← Back to January 2016


Pediatric Cardiac "Prehab"


Monica Horn, RN, CCRN, CCTC
Mhorn@chla.usc.edu

Jessica Greim, PT, DPT
JGreim@chla.usc.edu
Children's Hospital Los Angeles
Los Angeles, CA, USA



Cardiac rehabilitation (rehab) programs are therapeutically guided efforts usually aimed at recovery after heart surgery or other functional restorations. A tolerance-limited version of this sort of therapy, a cardiac "prehabilitation" ("prehab"), may be instituted for waitlisted cardiac failure patients in order to prevent further deconditioning before heart transplantation. Unlike adult heart failure patients, infants and younger children may not be able to recognize or verbally express activity intolerance during physical therapy sessions. Trained-eyes monitoring the child and supervising individually measured/planned activity prevent syncopal events or sudden death.

Pediatric heart transplant referral diagnoses include severe heart failure from cardiomyopathies (dilated, hypertrophic, restrictive, left ventricular non-compaction, arrhythmogenic right ventricular dysplasia) and congenital cardiac malformations. These children may be maintained on intravenous inotropes or ventricular assist devices as inpatients if necessary.

The degree of heart failure and physiologic responses associated with these conditions may impair our ability to entirely treat the resultant debilitation. However, consistent carefully directed physical therapy sessions may effectively allow achievement of timely developmental milestones and promote maintenance of reasonable strength for faster recovery after transplant.

Infant
An infant's primary role should be growth and exploration. How can this be safely promoted in an infant that may have the desire to explore and interact, but whose cardiac reserve severely limits activity? Physical therapists (PTs) aim to facilitate an environment and positions from which they can explore.

Infants with limited experiences may not spontaneously reach out for tactile exploration of a toy. They may not lift up their lower extremities to discover their feet. This important precursor to rolling requires strength, but also causes an increase in intra-abdominal pressures, and therefore may require close monitoring when facilitating these movements. In fact, simply positioning an infant in upright can be taxing and poorly tolerated. However, given that a majority of life is intended to be spent upright, the benefits (opportunity to practice head control, reinforcing the visual and vestibular systems' orientation to the horizontal plane) make this goal a priority.

Another challenge presented to our young patients is bone growth and development. Wolff's law teaches us that bone development occurs in response to the forces exerted on them by gravity and the pull of muscles, for better or for worse. Infants' long bones, ribcage, and skull are particularly vulnerable. PTs can help minimize positional plagiocephaly and promote the proper recruitment of the core postural muscles that influence ribcage development and efficient breathing mechanics. We can provide modified opportunities for lower extremity weight bearing to enhance the gross motor development skill set and prime them for ongoing skill acquisition.

PTs educate caregivers on providing appropriate opportunities for safe movement experiences, which fosters the infant's ongoing desire to explore, in turn motivating our young patients to move themselves. Because when movement is limited, cognitive development is limited to only what is immediately available within reach or line of sight.

Toddler
A toddler or older infant may be on the cusp of acquiring the exciting new skill of walking. Ambulation is an incredible accomplishment for a typically developing child at home. In the hospital, multiple barriers stand in the way of new walkers: safety (typical toddlers fall 17 times per hour when learning to walk [1]), logistics and line management, insecurity in his environment, and energy expenditure. For brand-new walkers, limited energy from diminishing cardiac reserves may cause them to regress to a more energy efficient strategy such as crawling. Research shows that infants learning to walk will practice the equivalent distance of 7.7 football fields per day [1] before mastering this skill.

links imageAdd a heavy VAD, multiple lines, stranger anxiety, cardiac insufficiency, and limited opportunities for practice, and it seems incredible that these little ones are ever able to overcome these obstacles during their hospitalization! A PT must help the early walker safely strengthen, practice static and dynamic balance, weight shifting, and protective responses over and over.

Acquisition of a new skill such as ambulation is not energy efficient at all, and a failing heart can only give so much. PTs can help pace activity and carefully monitor for subtle physical and behavioral signs of intolerance, including worsening movement quality and compensations. Even once a child is mechanically compensated with a VAD, the logistical difficulties require a coordinated team of therapists, therapy aide, nurses, and child life specialists.

School-Age
Our school-age patients often present with an acute onset of cardiac insufficiency. Learning to balance their newfound restrictions with a safe activity level can be a tricky transition. Designed for adults, the Borg rating of perceived exertion (RPE) scale translates poorly for children, which despite our best efforts, gets misused as an inverted rating of perceived fun instead of exertion.

links imagePTs teach patients to monitor their body's response to activity, a crucial skill post-transplant, particularly given the transition from a neural to a hormonal mechanism for changes in heart rate. We prioritize the pending effects of surgery to focus activities on core control and stability, preventing substantial losses in strength (particularly throughout the trunk and lower extremities), and line management and safety.

We practice transfers, warm-up and cool-down periods, and sternal precautions in preparation for the acute and sub-acute post-operative period. This is a critical age group for promoting healthful behaviors and activity. Modeling this approach for families can help them transition what they've learned in the hospital to their home after discharge and set them up for success.

Teens/Betweens
Survivors of single ventricle physiology or other impairments early in life may eventually reach adolescence, perhaps after years of cardiac dysfunction. They may come to us with poor health habits or outlooks on exercise. Their deconditioning may have long preceded their hospitalization. They present with decreased lean muscle mass and poor posture, which inhibits full recruitment of their lungs for appropriate ventilation and contributes to early onset kyphosis or lower back pain.

A directed physical therapy program can target individualized issues, teach activity pacing, strengthen target muscle groups, and promote healthy attitudes towards activity. We aim to help adolescents discover a physical activity that they enjoy and can participate in post-transplant to build healthful, life-long habits.

Summary
Children somehow must just know they are supposed to seek opportunities to learn new skills and grow. They instinctively find new experiences and learn quickly...just watch a two year old figure out how to navigate a computer screen or master the television remote to watch a video.

links imageHelping them learn and grow while supporting their severe heart failure can be a challenging task for all involved, particularly the child. Poor cardiac output may result in irritability, developmental delay and feeding intolerance. Tangled intravenous inotrope lines, nasogastric feeding tubes and anticoagulation safety precautions pose barriers to their freedom to walk, run, and investigate all those really interesting things in their environments.

Depending on the resultant physiology of the child's particular cardiac disease process, exercise may provoke arrhythmias, increase already elevated venous pressure and intensify ischemia (cardiac or other organs) if not monitored and performed appropriately. Staff working with children must be alert to early, sometimes subtle, signs of exercise limitations such as shortness of breath, heart rhythm changes, dizziness and fatigue.

It is important to maintain some level of physical strength, even in the setting of heart failure, in order to advantage post-operative recovery. After all, those of us who work in pediatrics must confess: the truly inspiring reward after transplant is seeing that child who required many months of support finally be able to just take off and RUN like a kid! All that said, in many ways, this "Prehab" really pays off! ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Adolf K, Cole W. How do you learn to walk? Thousands of steps and dozens of falls per day. Psychol Sci. 2012; 23(11): 1387-1394



Share via:

links image    links image    links image    links image