Physical activity for children with chronic disease; a narrative review and practical applications

Physical activity (PA), that is, any bodily movement produced by skeletal muscles that requires energy expenditure [1], is associated with many physiological and psychological health benefits across the lifespan. As such, multiple agencies including The Canadian Society for Exercise Physiology (CSEP), The American College of Sports Medicine (ACSM) and The World Health Organization (WHO) have published PA guidelines targeting all age groups including children, adults, and older adults [2–5]. For children aged 5–17 years, guidelines consistently recommend participating in at least 60 min of daily moderate–to-vigorous intensity PA (MVPA) daily [2], and clearly indicate that a greater volume of PA is associated with greater health benefit [6]. In fact, the emerging concept of using exercise as medicine implies that exercise can be used in a dose-dependent manner (akin to pharmaceutical drugs) to positively impact health outcomes for individuals with chronic diseases [7].

Both PA & exercise (i.e., purposeful and intentional PA) may impact chronic disease by preventing the development of new chronic diseases (such as in metabolic syndrome), by directly modifying the disease (disease reversal, such as in type 2 diabetes) and/or by helping to manage the symptoms associated with chronic disease (such as in arthritis or cancer) [8]. As such, clinical practice guidelines for a variety of chronic diseases include guidance on the dose of PA that should be prescribed to individuals affected by that disease. However, these clinical practice guidelines often focus on adults, while guidelines that address chronic diseases that primarily affect children often ignore PA. Although the published international PA guidelines indicate how much exercise is suggested for otherwise healthy children [2–4], pediatric disease-specific PA guidelines are lacking. As a result, clinicians remain unsure about the dose of PA or appropriate modes of PA to prescribe to their patients. While healthy children should strive to achieve the recommended PA guidelines of 60 min of daily MVPA, the optimal prescription for children with a chronic disease requires greater specificity as well as careful consideration of risks and benefits (Fig. 1). Similar to pharmacotherapy, the dose of PA (i.e., the frequency, type, intensity, and time) may change depending on the chronic disease, and the child’s health and fitness levels.

Cystic Fibrosis (CF) is an autosomal-dominant disease occurring in approximately 1:2500–4000 live births per year in Canada and the United States [10, 11], with a higher incidence in European countries [12]. CF involves abnormal expression or function of the CF transmembrane conductance regulator protein, which results in thicker mucus production and associated complications to multiple organ systems (especially digestive and respiratory) [13, 14]. Exercise capacity is reduced in pediatric CF due to multiple factors, including lung and cardiovascular function [15], peripheral skeletal muscle function [16], and poor nutritional status [15, 17, 18].

Individuals with CF increase their ventilation during exercise to adapt to the increased dead space in their lungs [19], and increased work of breathing diverts blood flow from the exercise muscles. Oxygen desaturation occurs in moderate-to-severe CF due to ventilation/perfusion mismatching. Investigators have found that ventilatory limitations to exercise mostly exist in patients with severe CF (the amount of air you can exhale from your lungs in one second [FEV₁] < 40% predicted), and that respiratory factors are not the primary exercise limitation in mild to moderate CF [20, 21]. Cardiovascular complications in CF are poorly described, but there is evidence for abnormalities in right ventricular systolic function [22] and diastolic function [23]. Both large artery [24] and endothelial microvascular dysfunction have been reported in CF, and may affect the peripheral skeletal muscles’ ability to direct blood flow to areas of increased demand during exercise. Indeed, impaired endothelial function is correlated with both workload and ventilation in CF patients at peak exercise [25].

Significant benefits of exercise and habitual PA have been documented for children with CF [29, 30] including improvements in cardiovascular endurance [31, 32], muscular strength [30, 33], quality of life [34, 35], and mucus clearance [36, 37].

There are few randomized controlled exercise intervention trials (EX-RCT) in pediatric patients with CF. Of these, one evaluated the difference between aerobic (70% peak heart rate for 30 min) versus resistance training (70% of peak workload, 5 sets of 10 repetitions) following hospital admission, and observed improved FEV₁ and maximal aerobic capacity (VO_2peak) following discharge [33]. Other hospital-based EX-RCTs include a 12-week treadmill training session, twice a week for 30 min at 60% of the peak heart rate achieved during exercise testing, and increases in VO_2peak but no changes in FEV₁ were observed [32]. A supervised 8 week combination of resistance training, cycle erogmetery, and active play three times per week improved VO_2peak [38], and when in combination with two days per week of inspiratory muscle training, improvements in inspiratory pressure were also observed relative to controls [39]. Finally, a three-year home exercise program of 20 min aerobic exercise, 3 days per week, resulted in a slower decline in percent predicted forced vital capacity and forced expiratory volume in 1 min [40].

Prior to engaging in a new exercise program, children with CF should undergo exercise testing to identify maximal heart rate, levels at which oxygen desaturation and ventilation limits occur, exercise-related bronchospasm, and response to therapy so that the safest exercise program can be designed [41]. A recent position statement suggests that exercise testing (such as The Godfrey Cycle Ergometer Protocol) provides essential guidance on prognosis in those with CF who are 10 years of age and older [41]. Engaging in exercise in warm environments should be done with caution as those with CF have a low tolerance to heat stress [42, 43]. Children with CF should be extra vigilant about replacing their fluid loss and electrolytes with exercise because compared to healthy children, patients with CF have higher concentrations of sodium in their sweat [43], lose more fluid, and underestimate their fluid needs [42]. In more severe cases of CF, heart rate and even oxygen saturation should be monitored during exercise sessions to ensure children are exercising within healthy physiological limits [44]. Care should also be taken in gym environments to prevent disease transmission and cross-contamination with other CF patients (wear gloves and clean equipment, don’t exercise in groups with other individuals with CF).

Asthma is defined as a heterogeneous disease characterized by chronic inflammation of the airways [47]. Symptoms such as wheezing, coughing, shortness of breath, chest tightness, and variable expiratory flow are used to establish a diagnosis [47]. The global prevalence of asthma among children is estimated to be 14% [48]. The prevalence varies by sex, such that males have a higher prevalence at a younger age, while females have a higher or similar prevalence post-puberty [49].

Asthma can be allergic or non-allergic in nature, and as such, acute bronchoconstriction can be provoked by a variety of triggers. The increase in ventilation associated with exercise is a trigger in approximately 90% of those with asthma [50]. There are two hypotheses that explain exercise-induced bronchoconstriction (EIBC): the osmotic and the thermal hypothesis. The osmotic hypothesis suggests that an increase in ventilation during exercise leads to an increase in water loss in the airways, triggering EIBC. The thermal hypothesis suggests that the increase in ventilation during exercise leads to cooling of the airways. The subsequent rewarming of the airways following exercise (reactive hyperemia) is thought to trigger EIBC [51]. EIBC likely occurs as a result of both the osmotic and thermal hypothesis.

EIBC can be prevented effectively by using a short-acting bronchodilator 15 min prior to exercise [52]. However, the perceived stigma associated with using medication means that children often do not take their medication prophylactically [53]. There are other ways in which EIBC can be prevented. For example, a high intensity or variable intensity warm-up [54]. Further, controlling for other triggers may reduce the severity of EIBC symptoms. For example, environmental factors such as cold-dry air exacerbate EIBC, thus, exercise can be performed in a warm-humid environment for prevention [55].

Regular aerobic exercise improves asthma symptoms and thus, asthma control levels. Studies have shown that exercise leads to fewer hospital visits, less medication use, less wheezing, less bronchial reactivity, and better quality of life [59–63]. However, it should be noted that regular exercise is not associated with improvements in lung function [64]. In other words, exercise can improve asthma control, but may not impact disease severity.

With regards to aerobic exercise, there are two main considerations for children with asthma; the mode of exercise and the intensity of exercise. The mode of exercise is important as some exercises are conducted in less asthmogenic environments than others. For example, swimming in an indoor pool provides a warm-humid environment i.e. one that is less asthmogenic than running outside on a cold-dry day. Swimming is therefore often recommended to children with asthma.

The intensity of exercise is important as it is directly related to the ventilatory response [65]. Thus, exercise that is performed at a lower intensity or allows for ventilation to recover, might be safer. The latter in particular is referring to HIIT, that is, exercise sessions that include bouts of near maximal exercise with intermittent recovery. Although counterintuitive, this form of exercise is well-tolerated in children with asthma as the brief intervals of high intensity exercise are followed by recovery intervals which allow ventilation to recover [66]. Generally, aerobic exercise is well tolerated in children with asthma, and is not expected to lead to adverse events if medication is available [67].

There is a lack of data on the acute response or chronic adaptations associated with anaerobic exercise, including resistance training, in children with asthma. Of the studies available, it appears that children with asthma have a lower anaerobic capacity than healthy children [68], and that anaerobic exercise induces mild airway obstruction [69]. Further research is needed in this area.

There are currently no recommendations for exercise in the National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma or the Global Initiative for Asthma Guidelines [71]. Exercise prescription in children with asthma requires guidance on medication use and avoidance of triggers. Specifically, children should be given an asthma action plan that includes information on warming up prior to exercise, use of short-acting bronchodilators prior to exercise, and tips on management of additional triggers such as wearing a face mask if exercising on a cold day outside. If appropriate guidance is provided, children with asthma can follow guidelines for healthy children of similar levels of fitness.

Congenital heart disease (CHD) refers to any type of inborn cardiac defect, of which moderate-severe defects are present in 6/1000 live births [73]. Medical advancements have improved the survival rates for patients with CHD. Approximately 90% of children with a repaired CHD defect will survive into adulthood [74]. The cause of exercise intolerance in children with CHD is multifactorial, resulting from external influences causing hypoactivity as well as hemodynamic limitations caused by their heart defect [75].

Exercise interventions have demonstrated some improvements in maximal exercise capacity in pediatric patients with CHD. A recent systematic review reported increases in VO_2peak averaging 8% in 621 children with CHD participating in regular aerobic exercise training programs [77], with no patients experiencing adverse exercise-related events. However, improvements in VO_2peak following aerobic and combined aerobic and resistance exercise interventions are equivocal, with some studies reporting no improvement [78], and others reporting an increase in VO_2peak of up to 19% [79]. For example, one study reported a 16% increase in VO_2peak following a 12-week exercise intervention (60 min facility-based intervention, 2 x per week, including 45 min of combined aerobic and resistance based activities) in 16 children with CHD [80]. This improvement was sustained 7 months following the program [80].

Exercise interventions are generally safe, feasible, and beneficial in children with CHD [81, 82], with the exception of those patients with heart rhythm disorders [75]. The patient’s cardiologist should be consulted regarding any PA or exercise restrictions prior to program implementation. CHD patients on anticoagulant therapy and with implanted devices (e.g. pacemakers) should avoid contact sports; exercise in a thermoneutral environment is also encouraged to prevent heat-related illness and negative cardiac responses [75, 82].

Regular clinical assessment of maximal exercise capacity in patients with CHD may be useful to monitor disease progression and evaluate safety guidelines for participation [83]. A maximal cardiopulmonary exercise test may have prognostic value, but may also be used to determine if any impairment in peak exercise performance exists or if an abnormal heart rhythm develops during exercise stress. Holter monitoring can be performed to examine any heart rhythm abnormalities over a 24 h or 48 h period. These clinical tests can be used to provide exercise clearance for children and adolescents with CHD.

We are currently experiencing a worldwide epidemic of obesity, with pediatric obesity levels on the rise [86–93]. Obesity is defined as an excessive nonessential adipose tissue accumulation [94], with body mass index (BMI) percentiles commonly used to classify obesity status in children (overweight: 85th to 95th percentile; obese: 95th to 99th percentile; severely obese ≥99th percentile) [95]. There are many complictions associated with obesity, one of which is type 2 diabetes [96–98]. Type 2 diabetes is a chronic metabolic disorder marked by hyperglycemia and results from an inadequate response to insulin [94]. In one study of children and adolescents in the United States, the overall unadjusted incidence rates of type 2 diabetes increased by 7.1% annually (from 9.0 cases per 100,000 youths per year in 2002–2003 to 12.5 cases per 100,000 youths per year in 2011–2012) [99].

Several pathophysiological adaptations that may affect exercise tolerance emerge in the cardiac, respiratory, endocrine, and musculoskeletal systems as a result of obesity. Cardiac pathophysiologic adaptations may include increases in cardiac output, blood pressure, and cardiac hypertrophy. Respiratory pathophysiologic adaptations may also occur and include an increased ventilation frequency, and decreased respiratory muscle efficiency [100], which may result in a greater metabolic demand. Musculoskeletal pathophysiologic adaptations may include intramyocellular fat accumulation, impaired phosphorus energy metabolism, and increased stress and pain in weight-bearing, lower-body joints [101].

Exercise interventions represent an important clinical strategy for the prevention of obesity and co-morbidities in adolescents [107, 108]. In particular, aerobic exercise interventions have been shown to significantly decrease adiposity [109–112], improve cardiometabolic risk [113, 114], increase muscle mass [115, 116], and improve cardiorespiratory function [117, 118] in obese adolescents. Anaerobic activities are also not restricted for children with obesity (for example, during play). A recent study determined that HIIT (12 intervals at 120% of maximal aerobic running speed, 6 min in total) is more effective at reducing skinfold thickness than low intensity interval training (16 intervals at 100% of maximal aerobic running speed, 8 min in total) [119]. In comparison, a recent systematic review and meta-analysis of 40 studies reported that resistance exercise has minimal effects on body composition, but moderate to large effects on muscular strength [120].

Pediatric patients with type 2 diabetes reportedly perform as much as 60% less MVPA than peers without diabetes [121]. Nassis and colleagues explored the effectiveness of a 12-week aerobic exercise training program (40 min of aerobic exercise performed 3 times weekly) on insulin concentration (via 2 h oral glucose tolerance test) in overweight adolescent girls [122]. They reported a decline in insulin concentration independent of changes in body mass, suggesting that moderate levels of aerobic exercise may have a positive effect on insulin sensitivity. Likewise, in a study of 22 adolescent males, a 45% increase in insulin sensitivity was observed following a 16-week resistance training program (1 h of resistance training performed 2 x per week) [123]. Therefore, moderate levels of exercise (2 h per week), independent of exercise modality, may be associated with significant improvements in insulin sensitivity and resistance in youth with Type 2 Diabetes [124].

Pediatric patients with obesity can accumulate PA amounts in shorter exercise bouts throughout each day with the focus on rate of perceived exertion and target heart rate (as opposed to performance based outcomes like speed), particularly if the child is previously sedentary and physiologically deconditioned. PA progressions should be implemented as physiological adaptations are noted [6]. Modifications can be considered where obesity-related pathophysiological adaptations impair cardiopulmonary function during intensive exercise. A prolonged warm-up may be recommended to allow the obese child to reach a comfortable steady-state [126]. Non-weight bearing activities such as cycling or swimming may be advised for obese children due to the increased risk of osteoarthritis in weight bearing joints [127].

For children with type 2 diabetes, The American Academy of Pediatrics has recommended an integrated clinical treatment approach, emphasizing a combination of medication (such as Metformin) as well as diet and PA modifications to achieve glucose control [128]. Most pediatric patients with type 2 diabetes should perform at least 60 min of daily PA [2]. Older adolescents or those with greater exercise intolerance may not be able to safely perform this amount of PA initially, however, as described above they should work on accumulating short bouts of PA on a daily basis. In fact, exercise training involving aerobic intervals and/or resistance training may actually enable individuals with low cardiorespiratory fitness to achieve a moderate level of PA. Care should be given to ensure that children with type 2 diabetes and carefully monitor their blood sugar before and after exercise bouts, with the aim to maintain a controlled blood sugar status.

Juvenile Idiopathic Arthritis (JIA) is a common chronic disease that presents during childhood; in fact, JIA affects one in every 1000 children and teenagers in Canada [135, 136], and close to 300,000 children in the United States [137]. JIA is an autoimmune disease that results in joint-specific inflammation that can lead to damage of bone and cartilage [135].

The use of exercise as medicine in children with JIA has been investigated in some non-randomized and EX-RCTs. In 2008, Tim Takken and co-workers published a Cochrane review on exercise therapy in JIA [142]. They identified three eligible EX-RCTs representing 212 children with JIA, that employed an exercise therapy protocol [143]. Pooled outcome measures included functional ability, quality of life, and aerobic fitness. These authors reported that all outcome measures improved with exercise; while these improvements were clinically meaningful, the improvements did not reach statistical significance in their analyses [142]. However, the evidence is limited by the low number of EX-RCTs, as well as the large variety in the type of exercise prescribed and outcomes assessed in the published trials. Perhaps most importantly, none of the exercise interventions evaluated in the review reported adverse events; therefore, exercise appears to be safe in children with JIA [142].

Since the Cochrane review article, new data has emerged that provides further, support for the effectiveness of exercise in JIA. An EX-RCT of 48 children ages 8–13 years old, who participated in a 14-week cognitive behavioral intervention to increase PA levels, reported improvements in self-reported and objective PA measures as well as improvements in exercise capacity within the intervention group that persisted to three months post intervention [143]. The control group experienced a decline in exercise capacity over the same time period, however the differences between the experimental and control groups were not statistically significant [143]. School absences also decreased and physical education participation increased significantly in the exercise group, while school absences increased in the control condition [143]. A recent non-randomized controlled exercise intervention reported similar findings. In this study, 30 patients with JIA and 20 age matched healthy controls were prescribed aerobic walking (4 days per week) and active and passive range of motion exercises for 8 weeks. The exercise program significantly improved physical parameters in children with JIA including VO_2peak which changed from 32.5 ± 6.6 ml/kg/min at baseline to 35.3 ± 7.9 ml/kg/min post intervention [138].

The data indicates that exercise programs, both aerobic and strength training, are safe and feasible in children with JIA. The evidence for the efficacy of these programs is limited, but currently supports small positive effects of PA participation on exercise capacity, muscle strength, school attendance and participation in physical education in this cohort.

Ideally, children with JIA should be followed by a multidisciplinary team involving primary care physicians, as well as physiotherapists and qualified exercise professionals, when returning to activities, especially high loading sports, as children with JIA may have changes to neuromuscular function that increase their chance of injury [146]. Furthermore, there are multiple subtypes and severities of JIA, some of which can result in organ inflammation including the heart. Therefore, children should be cleared by a physician to ensure that there are no cardiovascular complications with exercise (and if there are, make appropriate exercise accommodations).

There are several contraindications to participation in PA in children with JIA that have been noted in the literature and should be considered. Children with JIA should not participate in physical activities when they are febrile, exercise should be conducted within pain limits, and should include activities that do not exacerbate joint pain [141, 147]. Following a flare-up of JIA, reintroduction to exercise should be progressive and gradual [141]. Children with moderate to severe knee or hip pain should not participate in high impact or vigorous physical activities [148]. Contact sports in children with severe bone loss or spinal arthritis should be avoided [141, 147] due to fracture or spinal cord injury risk. Although exercise has been demonstrated to improve bone health in JIA [149], it is also important to approach impact/weight bearing exercise in a progressive nature to avoid micro- or larger fractures. As well, appropriate eye protection and dental protection should be considered for those with uveitis or temperomandibular joint disease in contact sports [141].

Pediatric cancer is the number one cause of disease-related mortality in individuals under the age of 20 [152], and nearly 1000 new cases of childhood cancer are diagnosed annually in Canada alone [153]. As treatments have become increasingly effective, 5-year survival rate has improved to ~ 85% [154], however, significant morbidity is experienced during survivorship as a consequence of disease treatment [155–157].

The disease course is characterized by aberrant cell growth and division causing dysfunction of tissues and organ systems as dysfunctional cancerous cells replace healthy, functional cells [158]. Treatment includes surgical resection of the tumour, local or full body radiotherapy, chemotherapy, or a combination of these treatments. Chemotherapy and radiotherapy are both nonspecific, cytotoxic treatments and are largely responsible for long-term health and functional consequences of pediatric cancer, including exercise intolerance [156, 157, 159].

Exercise interventions reliably demonstrate improved aerobic fitness and muscle strength in pediatric cancer patients during treatment and off treatment during early survivorship [161, 170, 171]. Exercise programs vary in exercise type, duration, patient population, and treatment phase, resulting in varied reports of changes in fitness outcomes. A 12-month home-based nutrition and fitness intervention for leukemia patients aged 4–10 years old, was tested against usual care and resulted in increased self-reported PA levels and cardiovascular fitness at 6 months and 12 months [172]. While this program was successful, other home-based programs have shown small or null effects [173, 174]. Conversely, hospital-based programs are reliably successful at achieving fitness gains in participants. For example, a 12-week aerobic intervention performed for 30 min 3 times per week under the supervision of a physiotherapist or a parent resulted in increased aerobic fitness during induction phase of chemotherapy for acute lymphoblastic leukemia [175].

Due to the variable degree of exercise intolerance in pediatric cancer patients, an individualized assessment of general fitness abilities should be conducted by an exercise professional who has knowledge of expected side-effects of their treatment regimen. For patients on treatment who may be immunosuppressed, care should be taken to ensure all equipment is sterilized to avoid risk of infection. Children with platelet counts below 10,000 per μL should not exercise [161]. Overall, pediatric cancer patients should strive to achieve national PA guidelines [2], however this may need to be done in smaller and more frequent doses to accommodate the acute side-effects of treatment. Fatigue is a common side-effect of treatment, and this should be taken into consideration. If possible, programs should be supervised by an exercise professional, as home-based programs are less reliably efficacious.

It is evident that children with the chornic diseases reviewed herein can benefit from PA and exercise interventions for the same reasons as healthy children, in addition to disease-specific benefits. Overall, exercise appears to be a safe and efficacious intervention across the chronic diseases reviewed, as long as disease specific and individual needs are carefully considered. It is important to note that the current review is a narrative review of the literature, not a systematic review. As such, there is greater potential for bias, as the quality of published data was not assessed. Thus, our practical applications for exercise should be used as a starting point in determining the use of exercise as medicine in pediatric chronic disease rather than as specific guidelines. While a position statement (endorsed by The Canadian Paediatric Society and the Canadian Academy of Sport Medicine) was created for some pediatric chronic diseases [141], there is still a lack of high quality data to make recommendations at this time. This narrative review is a necessary first step towards filling a gap in the literature in the area of exercise as medicine in pediatric chronic disease and is critical, since producing high quality data and evidence-informed recommendations may take several years.

We examined five common pediatric chronic disease areas in this paper including respiratory, congentical heart, metabolic disease, systemic inflammatory/autoimmune, and cancer. We chose to include these categories of chronic diseases because they are prevalent pediatric diseases [9], however our list of included diseases is not exhaustive and there are many other chornic diseases that were not included in the current review. We focused our manuscript on the benefits of PA on physiological outcomes within the context of chronic disease; we did not evaluate the effects of PA on psychological or social outcomes. These are important future considerations as well.

Children with chronic disease present with specific pathophysiologies that each uniquely contribute to exercise tolerance. International PA guidelines suggest that children should accumulate 60 min of daily MVPA; but these guidelines do not consider disease-specific factors that contribute to exercise intolerance in chronic diseases, and are non-specific. Comprehensive chronic disease PA guidelines are necessary, as they consider the safety of exercise, the dose, frequency, intensity, time and type of exercise on a per-disease basis. PA suggestions, such as the ones presented in this manuscript, provide a staring point that may help inform clinicians and health care teams working with pediatric chronic disease cohorts on how to appropriately use exercise as medicine. Based on literature reviewed, it appears that regular exercise is beneficial for children with CF, asthma, CHD, obesity, type 2 diabetes, JIA, and cancer. We provide our practical applications of PA with the understanding that high quality, EX-RCTs are still needed in many disease areas, to help determine the best exercise program to provide the most effective and safe improvements. There remains a large gap in the literature regarding PA/exercise suggestions and recommendations in pediatric chronic disease. This area of research should be a continued priority globally as PA/exercise is a powerful tool to improve health.