Sports

Sport is important for everyone, but especially for people with congenital heart disease

Sport has an important role in western societies and substantially improves most people’s quality of life. This notion is especially true for children: motor activity is essential for young children, fostering not only their motor development but also cognitive and socio-emotional progress. The term “psychomotor development” describes the strong interaction between different developmental areas. Self confidence in boys is often based on doing well in sports. Therefore, whenever possible, people with congenital heart diseases should be encouraged to exercise during their spare time, and especially during physical-education classes at school.

Recent studies support this idea: in a nationwide Norwegian survey of children with congenital heart defects, these children’s risk of suffering sudden cardiac death related to physical activity tended towards zero (1).

The situation is excellent in Germany; however, that is not the case in the rest of Europe, where a south to north gradient ranging from strict to moderate restrictions seems to be in place. Whereas patients with congenital heart disease are sometimes even forbidden to move in southern European countries, most are allowed to practise nearly any type of sport in northern European countries.

Sport recommendations tailored for each individual

To assess one’s cardiological status, postoperative results seem to be more important than the diagnosis itself. Therefore, a special classification system has been developed and approved by the German Association for Prevention and Rehabilitation (DGPR) and other expert committees. The decision to allow a patient to play sport should not be made on the basis of the heart defect itself, but rather on residual results after treatment. Since diagnosis and residual results vary between children, recommending specific sports types to everyone with a congenital heart disease does not seem appropriate. According to the Cologne working group, every child should be advised what type of exercise (eg, dynamic or static, long term or short term) to avoid, emphasising those that they are allowed to do.

Why are not all children allowed to do sport?

However, not all children and adolescents with congenital heart diseases are allowed to participate fully in sport activities for several reasons.

• The heart defect is so severe that sport must be forbidden, because physical activity could put their life in danger. This course of action is necessary only in exceptional cases, usually because of the over cautiousness of doctors, parents and teachers.
• The heart defect allows only partial participation in sport (eg, limited sport or no competitive sport, see table 3) because of the heart’s inability to adapt to physical strain. For example, taking anticoagulant drugs is incompatible with contact sports such as rugby. Additionally, wearing a pacemaker is incompatible with extreme stretching such as exercising on a hanging bar.
• The heart defect is not so severe, but parents, kindergarten or school teachers are too anxious to allow the child to exercise as much as they want. This creates a vicious circle between restriction and deteriorating ability in sports.

The vicious circle caused by limited physical activity

Parents, educators and teachers often tend to overprotect children with congenital heart disease because of apprehension or lack of information. This might stop children from experiencing physical activities and push them towards (social) isolation. A vicious circle could arise, involving reduced motor activity, motor deficits and psychosocial adaptation issues, such as low self esteem and further social isolation. The limited amount of action that derives could in turn further reduce physical activity. The vicious circle remains closed and hard to break.

Figure 1: Vicious circle - Reduced physical activity

Whether children and adolescents with congenital heart disease can practise sport is a personal choice. This decision mostly depends on:

• findings after cardiac surgery (and not the heart defect itself)
• the type of the strain rather than the type of sport; dynamic strain is generally more advisable than static strain is.

The motto should always be “allow sport as much as possible, restrict sport no more than necessary”.

Specialised and tailor-made sport groups

To offer safe extracurricular sport opportunities for children and adolescents with this disease, specialised sport groups have been established in about twelve German cities (as of October 2015). These groups are led by specialised trainers. Sport is mostly practised in a gym, but sometimes swimming, inline-skating, horse riding, sailing and climbing opportunities are offered. A doctor with an emergency kit is always present.

Such groups are especially helpful if sport classes offered at school have to be restricted because of substantial residual defects. They also have positive effects on children with only small postoperative residual defects, whose parents, teachers (and sometimes also doctors) are overprotective and restrict their physical activities more than is necessary. A multidisciplinary study with six groups including 76 children and adolescents undertaken in Cologne showed the motor and psychosocial benefits for participants of such groups. (1,2) This study highlights that the vicious circle between restricted physical activity and impaired motor coordination can be opened and turned into a positive circle.

Figure 3: Positive circle – Physical activity

The Cologne team noted how sport groups seem to have different functions for different age groups

• For preschool children, they had a preventive function, whereby emergence of deficits could be averted.
• For school children, they fulfilled more of a therapeutic function, since a large number of the participants had developmental deficits, particularly affecting motor coordination.

To the best of our knowledge, virtually no sport groups designed for children with congenital heart disease exist in other European countries. In Scandinavia and the Netherlands, several such groups had been established within the scope of studies over a limited period of time (3, 4, 5, 6).

Sport lessons at school

Sport teachers often do not know much about congenital heart disease. Therefore they might be worried and over concerned when a child with a heart condition takes part in their sport class. This could lead children to become excessively restricted, hence the vicious circle proceeds. To reduce the level of apprehension when instructing such children, parents and doctors should provide comprehensive information about the child’s condition. Teachers should try to integrate these children as much as possible during physical education classes to allow their normal psychomotor development.

Recommendations for teachers

Almost a fifth of all children and adolescents have physical or psychic impairments. Therefore every teacher has to cope with this challenging situation, especially during sport classes.  For children with congenital heart disease, the teacher has to collect precise information for each individual to adjust the physical-education programme to the child’s physical potential. The teacher needs to consider the risks involved with long-term treatment, for example, taking anticoagulant drugs or wearing a pacemaker. Therefore, it is essential to gain enough information about a specific heart disease and particularly on residual defects.

An attempt to defeat this challenge has to be made and to create a beneficial environment for children with heart diseases. Many possibilities exist to integrate them in sport lessons, for example by reducing what is expected from them, so that they can also participate.

Discretion is very important, for example when grading these children. Supported by parents and maybe also by doctors, the teacher should be creative in applying the freedom allowed.

Talk and reason with the whole class about how impaired children can be integrated. This action may enhance the social competence of all children. Considering impaired children as a possible enrichment to academic life enables us to see the bright side of this situation, which could have a positive effect on the child, its family, class mates and teachers in a wide range of situations.