Cardiac Rehabilitation and Exercise Training

  • Ana Ubeda-Tikkanen
  • Naomi S. GauthierEmail author


The benefits associated with cardiac rehabilitation in adults with acquired heart disease have been widely recognized and accepted. An increasing volume of data from studies in pediatric patients and adults with congenital heart disease has also demonstrated that exercise training is, for the vast majority of patients, safe and beneficial. The limited availability of age and diagnosis-appropriate programs, as well as other socioeconomic barriers, has impeded access to this valuable therapeutic modality.


Congenital heart disease (CHD) Cardiac rehabilitation Exercise training Pediatric CHD Adult CHD 


  1. 1.
    Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011;162(4):571–584 e572.PubMedCrossRefGoogle Scholar
  2. 2.
    Leon AS, Franklin BA, Costa F, Balady GJ, Berra KA, Stewart KJ, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association Scientific Statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111(3):369–76.PubMedCrossRefGoogle Scholar
  3. 3.
    Piepoli MF, Conraads V, Corra U, Dickstein K, Francis DP, Jaarsma T, et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail. 2011;13(4):347–57.PubMedCrossRefGoogle Scholar
  4. 4.
    Green DJ, O’Driscoll G, Joyner MJ, Cable NT. Exercise and cardiovascular risk reduction: time to update the rationale for exercise? J Appl Physiol (1985). 2008;105(2):766–8.CrossRefGoogle Scholar
  5. 5.
    Thijssen DH, Maiorana AJ, O’Driscoll G, Cable NT, Hopman MT, Green DJ. Impact of inactivity and exercise on the vasculature in humans. Eur J Appl Physiol. 2010;108(5):845–75.PubMedCrossRefGoogle Scholar
  6. 6.
    Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation. 1999;99(7):963–72.PubMedCrossRefGoogle Scholar
  7. 7.
    Dimmeler S, Zeiher AM. Exercise and cardiovascular health: get active to “aktivate” your endothelial nitric oxide synthase. Circulation. 2003;107(25):3118–20.PubMedCrossRefGoogle Scholar
  8. 8.
    Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873–934.CrossRefGoogle Scholar
  9. 9.
    Balfour IC, Drimmer AM, Nouri S, Pennington DG, Hemkens CL, Harvey LL. Pediatric cardiac rehabilitation. Am J Dis Child. 1991;145(6):627–30.PubMedGoogle Scholar
  10. 10.
    Longmuir PE, Turner JA, Rowe RD, Olley PM. Postoperative exercise rehabilitation benefits children with congenital heart disease. Clin Invest Med. 1985;8(3):232–8.PubMedGoogle Scholar
  11. 11.
    Rhodes J, Curran TJ, Camil L, Rabideau NC, Fulton DR, Gauthier NS, et al. Impact of cardiac rehabilitation on the exercise function of children with serious congenital heart disease. Pediatrics. 2005;116:1339–45.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Rhodes J, Curran TJ, Camil L, Rabideau NC, Fulton DR, Gauthier NS, et al. Sustained effects of cardiac rehabilitation in children with serious congenital heart disease. Pediatrics. 2006;118:e586–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Rhodes J, Ubeda TA, Jenkins KJ. Exercise testing and training in children with congenital heart disease. Circulation. 2010;122(19):1957–67.CrossRefGoogle Scholar
  14. 14.
    Takken T, Bongers BC, van Brussel M, Haapala EA, Hulzebos EHJ. Cardiopulmonary exercise testing in pediatrics. Ann Am Thorac Soc. 2017;14(Supplement_1):S123–8.CrossRefGoogle Scholar
  15. 15.
    Washington RL. Cardiac rehabilitation programmes in children. Sports Med. 1992;14(3):164–70.PubMedCrossRefGoogle Scholar
  16. 16.
    Opocher F, Varnier M, Sanders SP, Tosoni A, Zaccaria M, Stellin G, et al. Effects of aerobic exercise training in children after the Fontan operation. Am J Cardiol. 2005;95:150–2.PubMedCrossRefGoogle Scholar
  17. 17.
    Bradley LM, Galioto FM Jr, Vaccaro P, Hansen DA, Vaccaro J. Effect of intense aerobic training on exercise performance in children after surgical repair of tetralogy of fallot or complete transposition of the great arteries. Am J Cardiol. 1985;56(12):816–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Cordina RL, O’Meagher S, Karmali A, Rae CL, Liess C, Kemp GJ, et al. Resistance training improves cardiac output, exercise capacity and tolerance to positive airway pressure in Fontan physiology. Int J Cardiol. 2013;168(2):780–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Fredriksen PM, Kahrs N, Blaasvaer S, Sigurdsen E, Gundersen O, Roeksund O, et al. Effect of physical training in children and adolescents with congenital heart disease. Cardiol Young. 2000;10:107–14.PubMedCrossRefGoogle Scholar
  20. 20.
    Goldberg B, Fripp RR, Lister G, Loke J, Nicholas JA, Talner NS. Effect of physical training on exercise performance of children following surgical repair of congenital heart disease. Pediatrics. 1981;68(5):691–9.PubMedGoogle Scholar
  21. 21.
    Ruttenberg HD, Adams TD, Orsmond GS, Conlee RK, Fisher AG. Effects of exercise training on aerobic fitness in children after open heart surgery. Pediatr Cardiol. 1983;4(1):19–24.PubMedCrossRefGoogle Scholar
  22. 22.
    Sutherland N, Jones B, d’Udekem Y. Should we recommend exercise after the Fontan procedure? Heart Lung Circ. 2015;24(8):753–68.PubMedCrossRefGoogle Scholar
  23. 23.
    Minamisawa S, Nakazawa M, Momma K, Imai Y, Satomi G. Effect of aerobic training on exercise performance in patients after the Fontan operation. Am J Cardiol. 2001;88(6):695–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Moalla W, Maingourd Y, Gauthier R, Cahalin LP, Tabka Z, Ahmaidi S. Effect of exercise training on respiratory muscle oxygenation in children with congenital heart disease. Eur J Cardiovasc Prev Rehabil. 2006;13(4):604–11.PubMedCrossRefGoogle Scholar
  25. 25.
    Tikkanen AU, Oyaga AR, Riano OA, Alvaro EM, Rhodes J. Paediatric cardiac rehabilitation in congenital heart disease: a systematic review. Cardiol Young. 2012;22(3):241–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Therrien J, Fredriksen P, Walker M, Granton J, Reid GJ, Webb G. A pilot study of exercise training in adult patients with repaired tetralogy of fallot. Can J Cardiol. 2003;19(6):685–9.PubMedGoogle Scholar
  27. 27.
    Dua JS, Cooper AR, Fox KR, Graham SA. Physical activity levels in adults with congenital heart disease. Eur J Cardiovasc Prev Rehabil. 2007;14(2):287–93.PubMedCrossRefGoogle Scholar
  28. 28.
    Holloway TM, Chesssex C, Grace SL, Oechslin E, Spriet LL, Kovacs AH. A call for adult congenital heart disease patient participation in cardiac rehabilitation. Int J Cardiol. 2011;150(3):345–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Opotowsky AR, Rhodes J, Landzberg MJ, Bhatt AB, Shafer KM, Yeh DD, et al. A randomized trial comparing cardiac rehabilitation to standard of care for adults with congenital heart disease. World J Pediatr Congenit Heart Surg. 2018;9(2):185–93.PubMedCrossRefGoogle Scholar
  30. 30.
    Chan L, Chin LMK, Kennedy M, Woolstenhulme JG, Nathan SD, Weinstein AA, et al. Benefits of intensive treadmill exercise training on cardiorespiratory function and quality of life in patients with pulmonary hypertension. Chest. 2013;143(2):333–43.PubMedCrossRefGoogle Scholar
  31. 31.
    Fox BD, Kassirer M, Weiss I, Raviv Y, Peled N, Shitrit D, et al. Ambulatory rehabilitation improves exercise capacity in patients with pulmonary hypertension. J Card Fail. 2011;17(3):196–200.PubMedCrossRefGoogle Scholar
  32. 32.
    Mereles D, Ehlken N, Kreuscher S, Ghofrani S, Hoeper MM, Halank M, et al. Exercise and respiratory training improve exercise capacity and quality of life in patients with severe chronic pulmonary hypertension. Circulation. 2006;114(14):1482–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Grunig E, Ehlken N, Ghofrani A, Staehler G, Meyer FJ, Juenger J, et al. Effect of exercise and respiratory training on clinical progression and survival in patients with severe chronic pulmonary hypertension. Respiration. 2011;81(5):394–401.PubMedCrossRefGoogle Scholar
  34. 34.
    Arena R, Lavie CJ, Borghi-Silva A, Daugherty J, Bond S, Phillips SA, et al. Exercise training in group 2 pulmonary hypertension: which intensity and what modality. Prog Cardiovasc Dis. 2016;59(1):87–94.PubMedCrossRefGoogle Scholar
  35. 35.
    Becker-Grunig T, Klose H, Ehlken N, Lichtblau M, Nagel C, Fischer C, et al. Efficacy of exercise training in pulmonary arterial hypertension associated with congenital heart disease. Int J Cardiol. 2013;168(1):375–81.PubMedCrossRefGoogle Scholar
  36. 36.
    Falk B, Bar-Mor G, Zigel L, Yaaron M, Beniamini Y, Zeevi B. Daily physical activity and perception of condition severity among male and female adolescents with congenital heart disease. J Pediatr Nurs. 2006;21(3):244–9.PubMedCrossRefGoogle Scholar
  37. 37.
    McCrindle BW, Williams RV, Mital S, Clark BJ, Russell JL, Klein G, et al. Physical activity levels in children and adolescents are reduced after the Fontan procedure, independent of exercise capacity, and are associated with lower perceived general health. Arch Dis Child. 2007;92(6):509–14.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Sothern MS, Loftin M, Suskind RM, Udall JN, Blecker U. The health benefits of physical activity in children and adolescents: implications for chronic disease prevention. Eur J Pediatr. 1999;158(4):271–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Watson A, Timperio A, Brown H, Best K, Hesketh KD. Effect of classroom-based physical activity interventions on academic and physical activity outcomes: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2017;14(1):114.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Alvarez-Bueno C, Pesce C, Cavero-Redondo I, Sanchez-Lopez M, Garrido-Miguel M, Martinez-Vizcaino V. Academic achievement and physical activity: a meta-analysis. Pediatrics. 2017;140(6):e20171498.PubMedCrossRefGoogle Scholar
  41. 41.
    Donnelly JE, Hillman CH, Castelli D, Etnier JL, Lee S, Tomporowski P, et al. Physical activity, fitness, cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197–222.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Wright CM, Duquesnay PJ, Anzman-Frasca S, Chomitz VR, Chui K, Economos CD, et al. Study protocol: the Fueling Learning through Exercise (FLEX) study – a randomized controlled trial of the impact of school-based physical activity programs on children’s physical activity, cognitive function, and academic achievement. BMC Public Health. 2016;16(1):1078.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Chaddock-Heyman L, Erickson KI, Holtrop JL, Voss MW, Pontifex MB, Raine LB, et al. Aerobic fitness is associated with greater white matter integrity in children. Front Hum Neurosci. 2014;8:584.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Kao SC, Westfall DR, Parks AC, Pontifex MB, Hillman CH. Muscular and aerobic fitness, working memory, and academic achievement in children. Med Sci Sports Exerc. 2017;49(3):500–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Pontifex MB, Saliba BJ, Raine LB, Picchietti DL, Hillman CH. Exercise improves behavioral, neurocognitive, and scholastic performance in children with attention-deficit/hyperactivity disorder. J Pediatr. 2013;162(3):543–51.PubMedCrossRefGoogle Scholar
  46. 46.
    Blumenthal JA, Smith PJ, Hoffman BM. Is exercise a viable treatment for depression? ACSMs Health Fit J. 2012;16(4):14–21.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41(1):15–28.PubMedCrossRefGoogle Scholar
  48. 48.
    Pate RR, Heath GW, Dowda M, Trost SG. Associations between physical activity and other health behaviors in a representative sample of us adolescents. Am J Public Health. 1996;86(11):1577–81.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Anonymous. Guidelines for cardiac rehabilitation and secondary prevention programs. 5th ed. Champaign: Human Kinetics; 2013.Google Scholar
  50. 50.
    Ubeda Tikkanen A, Nathan M, Sleeper LA, Flavin M, Lewis A, Nimec D, et al. Predictors of postoperative rehabilitation therapy following congenital heart surgery. J Am Heart Assoc. 2018;7(10):e008094.Google Scholar
  51. 51.
    Balady GJ, Ades PA, Bittner VA, Franklin BA, Gordon NF, Thomas RJ, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation. 2011;124(25):2951–60.PubMedCrossRefGoogle Scholar
  52. 52.
    Murphy NA, Carbone PS. Promoting the participation of children with disabilities in sports, recreation, and physical activities. Pediatrics. 2008;121(5):1057–61.PubMedCrossRefGoogle Scholar
  53. 53.
    Shields N, Synnot A. Perceived barriers and facilitators to participation in physical activity for children with disability: a qualitative study. BMC Pediatr. 2016;16:9.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Carver A, Timperio A, Crawford D. Playing it safe: the influence of neighbourhood safety on children’s physical activity. A review. Health Place. 2008;14(2):217–27.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Physical Medicine and Rehabilitation, Department of Pediatric RehabilitationBoston Children’s HospitalBostonUSA
  2. 2.Physical Medicine and Rehabilitation, Department of Pediatric RehabilitationSpaulding Rehabilitation HospitalBostonUSA
  3. 3.Physical Medicine and Rehabilitation, Department of Pediatric RehabilitationHarvard Medical SchoolBostonUSA
  4. 4.Cardiac Fitness Program, Department of PediatricsHarvard Medical SchoolBostonUSA
  5. 5.Department of CardiologyBoston Children’s HospitalBostonUSA

Personalised recommendations