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Home-Based Rehabilitation Enhances Daily Physical Activity and Motor Skill in Children Who Have Undergone the Fontan Procedure

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Abstract

This randomized trial compared physical activity enhancing exercise prescription and education programs in 61 children (36 male) with single-ventricle physiology after Fontan. After Fontan, children are less active than recommended for optimal health. They are often geographically dispersed and unable to attend weekday programs. Participants, 5.9–11.7 years of age who were status 5.3 years post-Fontan, received 12-month, parent-delivered home programs to enhance physical activity, motor skill, fitness, and activity attitudes. Daily moderate-to-vigorous physical activity (MVPA) was measured at baseline and again at 6, 12, and 24 months. Secondary outcomes were gross motor skill, fitness, and activity attitudes. Gross motor skill (p = .01) was significantly greater at the end of the 2-year study period for both intervention groups combined. MVPA at 2 years was significantly greater (p = .03) than the predicted decrease with age. Spring season (85 ± 25 min), male sex (69 ± 21 min), greater baseline activity (0.3 ± 0.1 min/baseline minute), and better gross motor skill (1.1 ± 0.4 min/percentile) increased weekly MVPA in a multivariable repeated-measures regression model adjusted for intervention, maturation during the 2-year study, sex, season, and baseline activity. Benefits were not influenced by type of rehabilitation, compliance, or rural/urban location. Home-based, pediatric physical activity rehabilitation enhances physical activity, gross motor skill, exercise capacity, and physical fitness among preadolescent children after Fontan regardless of rural/urban location. Prescribed education and exercise programs are similarly effective for providing the important health benefits of daily physical activity. Enhanced gross motor skill is associated with increased MVPA despite exercise capacity limitations after Fontan. Rehabilitation attenuates the expected decrease in MVPA with age.

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Acknowledgments

The authors acknowledge the support of the families who participated in this research. The contributions of Laura Banks, Stephanie Wong, Gareth Smith, Susan Iori, Laura De Souza, Laura Fenwick, and Faith Bangawan to the data collection are also appreciated. This research project was supported by the Heart and Stroke Foundation of Ontario (Toronto, Ontario), Grant No. NA 5950. P.E.L. was supported by a Doctoral Research Award from the Canadian Institutes of Health Research (Ottawa, Ontario, Canada).

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Correspondence to Patricia E. Longmuir.

Appendices

Appendix 1: Sample of the Education Intervention

Focus of Activities for This Month

  1. 1.

    Learn about basketball

  2. 2.

    Evaluate the pros and cons of increasing daily physical activity

  3. 3.

    Learn more about T-ball and baseball.

  4. 4.

    Learn about endurance sports.

Week 1

Activity

Instructions

Quiz

Do you know the difference is between T-ball, softball, and baseball? See if you can figure out how the rules are different for each of these games. Hint: If you aren’t sure, you can find out about t-ball on the Web site at http://www.teeballusa.org/Kids.asp, and there is information about softball on the Web site at: http://www.momsguide.com/softball/sb1.html

Crossword

See if you can fit all of the words about baseball into the puzzle called “List Crossword for Baseball” (CWord List Baseball.doc)

Web site

Endurance is how tired you are when you keep doing something for a long time. For example, if you can jog for 5 or more minutes at a time, without resting, then your endurance is pretty good. Marathon and triathlon athletes have excellent endurance. Find out how you can increase your endurance using the F.I.T.T. principle by visiting the Web site at http://www.healthgoods.com/Education/Fitness_Information/Fitness_Short_Course/fitt_principle.htm

See if you can figure out 5 things you could do inside and 10 things you could do outside to improve your endurance

Drawing

Draw a picture of you playing basketball. What is the name of your team? Are you dribbling or taking a shot? See if you can make your picture fill up the entire piece of paper

Pictionary

Get at least three people (yourself plus two others) and choose one person to be the artist. The artist secretly picks one word from the list of words on the puzzles, On the word “go,” the artist tries to get someone to say the word that she/he chose by drawing a picture. The artist can’t say anything; he/she can only draw. The first person to say the word that the artist chose gets a point and becomes the artist for the next turn. The winner is the person with the most points when all of the words on the puzzle list have been drawn or when you are out of time

Week 2

Activity

Instructions

Quiz

Quiz someone older than you (such as your mom or dad) about active living. Go to the physical activity Web site found at http://www.phac-aspc.gc.ca/pau-uap/paguide/quiz/question1.html. You ask the questions and see if the other person can get the right answer

Online game

Go to the Web site listed below and play the online “Shooting Hoops” game. See how many balls you can throw in the hoop. Get 10 in a row, and you are at the next level! Good Luck ☺

http://funschool.kaboose.com/funblaster/games/game_shooting_hoops.html

Word find

See if you can find all of the words about T-ball in the puzzle called “Word Search for T-Ball” (Word Search TBall.doc)

Jigsaw puzzle

Ask your mom or dad to cut up the picture that you drew last week of you playing basketball. Ask them to cut the picture into lots of different pieces that are different shapes. Once they have finished cutting up the entire puzzle, see if you can put it back together like a jigsaw puzzle

Stumblebum

Stumblebum is played like charades. One person chooses a word from the puzzle lists for baseball and T-ball, and then they must act out the word without saying anything until someone else guesses the word. The difference with Stumblebum is that before the person starts to act, he/she rolls one die. Depending on the number that is rolled, there is an action that the person must do the entire time that they are acting out the word. The list of actions is shown below. For example, if you chose a word to act out and then rolled a one, you would must do all of the acting while you are standing on one foot (see below). Get together with several players and give it a try

Roll a 1, and you must act out the word while standing on one foot

Roll a 2, and you must act out the word with your eyes closed

Roll a 3, and you must act out the word while making a fist with each hand

Roll a 4, and you must act out the word while keeping both knees bent at least 90º

Roll a 5, and you must act out the word while standing on your tippy toes

Roll a 6, and you must act out the word while keeping your legs crossed

The first person who guesses the chosen word gets to choose the next word and roll the die

Week 3

Activity

Instructions

Quiz

See if you can figure out which sports require more endurance and which sports require less endurance. For some sports, like running a marathon, you need to have a lot of endurance. You need a lot of endurance when the activity goes on for a long time and the athletes don’t have a chance to rest. There are also lots of sports that do not require a lot of endurance because the athletes are active for a short time and then they get to rest. Hockey is an example of a sport that does not require a lot of endurance. Look at the list of sports on the quiz called “Which are Endurance Sports?” See if you can figure out which 5 sports require the most endurance and which 5 sports require the least endurance. To see if you got the right answer, check out the “Kinds of Sports” web page on our research Web site: http://www.activefamilies.sickkids.ca

Make a word

This is a game for two or more players. You can play with your family or friends, and you can have as many people playing at once as you want. You will need 2 dice to play. Each player rolls the dice to see what number they get. You get one letter for each number that you roll. The letters you get are as follows:

2 = A or R

3 = E or S

4 = I or T

5 = O or L

6 = U or N

7 = D

8 = H

9 = C

10 = M

11 = Y

12 = wild card

Each person rolls the dice once and then passes them to the next player in turn. The first person to spell a word about playing T-ball or baseball wins

Quiz

Where can you play on a T-ball or baseball team near your house? See if you can find out where the teams play their games, how often the games occur, and how much it costs. Are there any teams for players your age that have not played before? Many leagues have rookie divisions in which all of the first-year players play together. Is there a rookie division in a league near you? To find out the information, check on the Internet, ask at the library, ask kids whom you know who play, or ask at your recreation centre

Story

Read a story about your favourite basketball player. The story can be a book from the library, a book that you own, or a story on the Internet

Crossword puzzle

See if you can fit all of the words about T-ball into the crossword puzzle called “List Crossword for T-Ball” (CWord List TBall.doc)

Week 4

Activity

Instructions

Online game

Go to the Web site listed below to play “Big League Bash.” See how far you can hit the ball. Good Luck!

http://www.nabiscoworld.com/Games/game_large.aspx?gameid=10101

T-ball or baseball game

Did you find out where the T-ball or baseball games are played near your house? See if you can plan to go and watch a game sometime this week. The game can be with players of any age; just find a game that you can go to watch

Pros and cons

Think about playing on a baseball team in the summer. Can you think of reasons why you would want to do that? Reasons why you would want to do that are called “pros.” See if you can think of at least 3 pros (reasons why you would want to play on a baseball team this summer.)

Are there reasons why you would not want to play on a baseball team this summer? Reasons that you don’t want to do something are called “cons.”

See how many pros and how many cons you have. Do you have more pros or more cons? Can you think of ways to do things differently so that you have fewer cons?

Web site

Play the physical-activity matching game on this Web site: http://www.phac-aspc.gc.ca/pau-uap/paguide/child_youth/youth/index.html

Story

Read about Health Canada’s newest physical activity guidelines for youth. The information can be found in pages 1–4 of the “Family Guide to Physical Activity for Youth 10–14 Years of Age.” (YthFamilyGuideEnFinal.pdf)

Appendix 2: Sample of the Activity-Prescription Intervention

Focus of Activities for this Month

  1. 1.

    Enjoy hiking

  2. 2.

    Improve soccer skills (dribbling, trapping)

  3. 3.

    Increase leg strength

  4. 4.

    Learn Frisbee and disc golf

Week 1

Activity

How many times or how long

How many days

Instructions

Soccer pass with the inside of the foot

10 min

2 day/week

Practice passing a soccer ball with the inside of each foot. If you have a partner, practice passing the ball to your partner. Otherwise, you can practice passing the ball to a wall so it bounces back to you. When you pass the ball, try to kick the ball only with the inside of your foot (that’s the side of your shoe that touches the other foot when you stand with your feet together). See how many accurate passes you can make so that your partner (or you) doesn’t must move to get the ball. The first day, try to always pass the ball with the inside of your right foot. The second day, try to do all of the passes with the inside of your left foot. The third day, see if you can change feet with each pass (right, left, right, left, etc.)

Hiking

30 min

Total for the week

Go hiking with friends or family during the week. Try to go for a total of 30 min (either all at once or by adding up the time from different days). When you are hiking, see if you can keep moving for at least 10 min all at once

Frisbee wrist flick

5 min

3 day/week

Do you know how to throw a Frisbee? It’s all about flicking your wrist to make the disc spin. Start by making sure you are holding the disc properly. You should be holding the disc along the edge that is farthest away from you (the edge that is closest to your target). Your thumb should be on top of the disc, your index finger (the one you point with) along the edge of the disc, and the other three fingers curled underneath against the rim. You can use your other hand at the back of the disc if you need help to keep it level. Once you are holding the disc properly, see if you can wiggle your wrist back and forth. You must be able to wiggle your wrist to do the wrist flick. See if you can let go of the disc just as you flick your wrist forward. Don’t worry if the disc doesn’t go very far. It’s more important to get the flick right using just your wrist (not your entire arm)

Deep knee jumps

10 times/day

3 times/week

Jump as high as you can. Start and end with your legs bent and your fingers touching your ankles. Lift both hands above your head as you jump up. Try to do all 10 jumps in a row

Sit and stand

10 times/day

3 day/week

Find a chair or somewhere to sit that is approximately as high as your knees. Stand so the chair is behind you. Sit down on the chair and stand up again without using your hands or arms for support. Try to do as many in a row as you can up to 10

Chest trap for soccer

10 min

2 day/week

The chest trap may look difficult, but it’s the easiest trap to learn because you use the largest part of your body. To do the chest trap:

-Bend slightly at the waist

-Bend slightly backward at the waist if the ball is falling from above you. Bend slightly forward at the waist if the ball is rising up from the ground toward you

-Make your chest a concave surface just before making contact with the ball

-A concave surface is lower in the middle and greater at the sides. To make your chest concave, push your shoulders forward and pull your back backwards

-Make contact with the ball just below your collarbone

-Move your body so that the ball hits your chest on the solid bone in the middle of your chest just below your collarbone

-Cushion the ball with your chest so that it falls to your feet

-Draw your chest away from the ball slightly as it lands on you (the same way you cushion a ball that you catch with your hands)

Be careful not to accidentally touch the ball with your arms or shoulders. To better control the ball, try bending more at the waist. Don’t worry; the chest trap won’t hurt you unless you step in front of a hard shot

*Information from http://www.ehow.com/how_5202_trap-soccer-ball.html

Week 2

Activity

How many times or how long

How many days

Instructions

Soccer pass with the outside of the foot

10 min

3 day/week

Practice passing a soccer ball with the outside of each foot. If you have a partner, practice passing the ball to your partner. Otherwise, you can practice passing the ball to a wall so it bounces back to you. When you pass the ball, try to kick the ball only with the outside of your foot (that’s the side of your shoe that is far away from the other foot when you stand with your feet together). See how many accurate passes you can make so that your partner (or you) doesn’t must move to get the ball. The first day, try to always pass the ball with the outside of your right foot. The second day, try to do all of the passes with the outside of your left foot. The third day, see if you can change feet with each pass (right, left, right, etc.)

Hiking

30 min

Total for the week

Go hiking with friends or family during the week. Try to go for a total of 30 min (either all at once or by adding up the time from different days). When you are hiking, see if you can find an area where you can go hiking that has hills and trees

Trapping a soccer ball with your foot

10 min

3 day/week

You can use your foot to trap a ball that is rolling on the ground or a ball that is bouncing toward you

To trap a ball that is rolling on the ground:

-Lift your foot several inches off the ground

-Point your toes up and stop the ball with the bottom of your foot

To trap a bouncing ball:

-Judge where the ball will hit the ground

-closest to you, and move to that spot

-Turn your foot sideways, and lift your foot slightly off the ground

-Touch the ball with your instep just as the ball hits the ground

-Let the backspin on the ball roll the ball toward you

Remember, judging where and how the ball will bounce takes time to learn. Be patient. A good trap means you gained control of the ball. It doesn’t have to look pretty. One of the best ways to practice trapping the ball by kicking it against a wall

Wall sits

15 s

3 day/week

Stand with your back against the wall and your feet approximately 0.5 metres away from the wall (your feet should be away from the wall of the same distance as from the floor to your knees). Gradually slide your back down the wall until your thighs are parallel to the floor. Hold that “wall-sitting” position for 10 s and then relax. Remember to keep breathing in and out while you are holding the wall-sit position. You can even do this while you watch TV

Deep knee jumps

10 times/day

3 day/week

Jump as high as you can. Start and end with your legs bent and your fingers touching your ankles. Lift both hands above your head as you jump up

Frisbee throw

5 min

3 day/week

Now that you know how to do the wrist flick, actually throwing the Frisbee is pretty easy. Start by holding the disc with your thumb on top, index finger along the edge, and other fingers curled underneath. The hardest part is to keep your elbow close to your body to start, but still keep your wrist nice and loose for a good flick. Curl your wrist toward your body so that the Frisbee almost touches your belly button and your hand and arm are wrapped around the disc. Your index finger, the palm of your hand, and your forearm should all be touching the disc. Tilt the disc so that the side farthest from your body is slightly lower than the rest of the disc, and then flick your wrist forward in one smooth motion and let go of the disc. To make the disc go farther you use the weight of your body. Start with most of your weight on the foot farthest from your target. As you throw, take a step forward onto the other foot. Try not to make a big arm swing when you throw. Remember, it’s the wrist flick that makes the disc spin, and it’s the spin that makes the disc go farther

Week 3

Activity

How many times or how long

How many days

Instructions

Wall sits

15 s

3 day/week

Stand with your back against the wall and your feet approximately 0.5 metres away from the wall (your feet should be away from the wall of the same distance as from the floor to your knees). Gradually slide your back down the wall until your thighs are parallel to the floor. Hold that “wall-sitting” position for 15 s and then relax. Remember to keep breathing in and out while you are holding the wall-sit position. You can even do this while you watch TV

Double-leg trap

5 min

3 day/week

This week try the double-leg trap. The double-leg trap is a way to control the ball just as it bounces on the ground. To do the double-leg trap:

-Judge where the ball will hit the ground closest to you, and move to that spot

-Stand with your legs bent and your weight evenly distributed on both feet

-As the ball hits the ground, bend both knees over the ball so that it hits both of your shins as is starts to bounce up off the ground

-Straighten your legs as the ball hits to slow the ball’s momentum

Remember, judging where and how the ball will bounce takes time to learn. Be patient. A good trap means you gained control of the ball. It doesn’t have to look pretty. One of the best ways to practice trapping the ball is by kicking it against a wall

Hiking

30 min

Total for the week

Go hiking with friends or family during the week. Try to go for a total of 30 min (either all at once or by adding up the time from different days). When you are hiking, see if you can keep moving for at least 15 min all at once

Soccer kick with the laces of your boot

5 min

3 day/week

Practice kicking a soccer ball using the laces of your soccer boot (your cleats or running shoes). If you have a partner, practice kicking the ball to your partner. Otherwise, you can practice kicking the ball at a target on a wall so that the ball bounces back to you. When you kick the ball, try to kick the ball only with the top of your shoe. Try to hit the ball with the top of your shoe instead of the end of your shoe because kicking with the end can hurt your toes. The best kick uses the part of your shoe at the bottom of your laces. If you kick with the top of the laces (where they are tied in a bow), the knot can make the ball go the wrong direction, so always try to use the area of the laces that is closest to your toes (without the bow). See how many accurate kicks you can make so that your partner (or you) doesn’t must move to get the ball. The first day, try to always kick the ball with your right foot. The second day, try to do all of the kicks with your left foot. The third day, see if you can change feet with each kick (right, left, right, left, etc.)

Disc golf

20 min

Total for the week

See if you can play a game of disc golf this week. Disc golf is played like ball golf, except it uses a flying disc. One point is counted each time the disc is thrown and when a penalty is incurred. The object is to acquire the lowest score (without cheating). You must be standing behind the tee line or behind where your last throw landed before throwing again. The person farthest from the hole throws first. On a professional disc golf course, the “hole” is a metal basket on a pole. The basket is usually one metre or more above the ground, and there are chains hanging down about the basket (to cushion the disc and allow it to drop into the basket). If you don’t have a real disc-golf course near your house, you can make your own by drawing circles on the ground or putting hoops or garbage cans around the course as holes

Week 4

Activity

How many times or how long

How many days

Instructions

Soccer thigh trap

5 min

3 day/week

A thigh trap is most useful when the ball is dropping toward you and is already below your waist. To trap the ball with your thigh:

-Raise your thigh to meet the ball

-Allow your thigh to move in the direction of the ball as you make contact

-Absorb the ball’s momentum

-Allow the ball to drop to your feet

The object of trapping the ball is to slow its momentum and change its direction

Remember, you want your leg to be a flexible surface that moves with the ball rather than a rigid surface that the ball will bounce off of

(http://www.ehow.com/how_5203_trap-soccer-ball.html)

Jumping up stairs

3 times

3 day/week

Jump up a flight of stairs one step at a time. Try to jump with both feet at the same time. Make sure that you hold onto the railing and go slowly and carefully. Start at the bottom and jump up one step at a time until you get to the top of the stairs. Then walk back down to the bottom and try it again

Soccer passes on the run

5 min

3 day/week

Practice passing the soccer ball to a partner (or the wall) with the inside and outside of each foot. To make it harder, try to run with the ball for a few steps before you pass it. On the first day, practice passing on the run with the inside of your right foot. On the second day, practice passing on the run with the inside of your left foot. On the third day, see if you can pass on the right while using a different foot for each pass

Hiking

40 min

Total for the week

Go hiking with friends or family during the week. Try to go for a total of 40 min (either all at once or by adding up the time from different days). When you are hiking, see if you can keep moving for at least 15 min all at once

Disc golf

20 min

Total for the week

See if you can play a game of disc golf this week. Disc golf is played like ball golf, except it uses a flying disc. One point is counted each time the disc is thrown and when a penalty is incurred. The object is to acquire the lowest score (without cheating). You must be standing behind the tee line or behind where your last throw landed before throwing again. The person farthest from the hole throws first. On a professional disc-golf course, the “hole” is a metal basket on a pole. The basket is usually one metre or more above the ground, and there are chains hanging down about the basket (to cushion the disc and allow it to drop into the basket). If you don’t have a real disc-golf course near your house, you can make your own by drawing circles on the ground or putting hoops or garbage cans around the course as holes

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Longmuir, P.E., Tyrrell, P.N., Corey, M. et al. Home-Based Rehabilitation Enhances Daily Physical Activity and Motor Skill in Children Who Have Undergone the Fontan Procedure. Pediatr Cardiol 34, 1130–1151 (2013). https://doi.org/10.1007/s00246-012-0618-8

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  • DOI: https://doi.org/10.1007/s00246-012-0618-8

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