176 | mup 4|2009|176-183|© Ernst Reinhardt Verlag München Basel Keywords: Psycho-educational riding/ vaulting, hippotherapy, equestrian sports for handicapped people, vaulting, riding, therapeutic riding, equine assisted therapy, physical activity and congenital heart disease, coordination, physical capacity of children with congenital heart disease Due to overprotective parents and the uncertainty of physicians and sports pedagogues about the physical stress tolerance many cardiac children suffer from a lack of movement experience. This can result in a deficiency of motor skills, body perception and movement coordination, but also in anxiousness, fear in movement situations, lack of self-confidence, a low level of social competence as well as in a limited scope of action (Sticker 2004, Bjarnason-Wehrens et al. 2007). Therapeutic riding, especially psycho-educational riding/ vaulting, but also hippotherapy and riding for handicapped people have a particularly positive effect on these misdevelopments. Schickendantz, Bjarnason-Wehrens, Sticker, Dordel, Drache, Sreeram Therapeutic Riding for Children with Congenital Heart Diseases Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases mup 4|2009 | 177 Schickendantz, Bjarnason-Wehrens, Sticker, Dordel, Drache, Sreeram Since 1994 the “Kölner Modellprojekt - Sport mit herzkranken Kindern“ (Cologne pilot project - Sports with cardiac children), a joint project of the “Institut für Kreislaufforschung und Sportmedizin“ (Institute for Research in Blood Circulation and Sports Medicine) and the “Institut für Rehabilitation und Behindertensport der Deutschen Sporthochschule Köln“ (Institute for Rehabilitation and paralympic Sports at the Cologne Sports University) as well as the “Department Psychologie der Universität zu Köln“ (Psychological Department at Cologne University) in cooperation with the “Clinic and Polyclinic for Children Cardiology at Cologne University), has been engaged in the rehabilitation of out-patient cardiac children. The focus is on which children with which cardiac defects should be allowed to do which kind of sports at which level of intensity. Within the scope of this project deficiencies in the physical, mental and social development of cardiac children and the impact of selective remedial sports education have been documented and their causes identified (Bjarnason-Wehrens u. a. 1999, 2000, 2007; Leurs 2001, 2004; Sticker 2001, 2004). Lack of movement, caused partly by overprotectiveness, partly by the ignorance and uncertainty of physicians and sports pedagogues / sports scientists involved, results in cascadelike deficiencies in motor skills and social competences (see illust. 1). On top of this cardiac children have a risk increased by the factor of ten of developing scoliosis (Herrera-Soto et al. 2007). Based on these experiencestherapeutic riding, mainly in the form of Psycho-educational riding / vaulting, have been included in the rehabilitation measures at the “Zentrum für Therapeutisches Reiten Johannisberg e. V.“ (Centre of Therapeutic Riding Johannisberg), since it is promising in providing intense support of the identified deficiencies. This is a new path in the rehabilitation of cardiac out-patient children. Active-dynamic sitting on horseback demands and supports posture and movement in a multi-faceted way. The posture is stabilised through many reactive muscle contractions. The muscle tone as the basis of motor skills is supported intensely (Bareiss 1996; Deppisch 1996, 1997, 2001). A beneficial factor is that children are usually highly motivated when it comes to dealing with horses. Self-confidence and self-esteem, realistic self-assessment, attention and the ability to Ill. 1: Coherence between overprotectiveness and lack of movement with children with congenital defects of the heart and large blood vessels near the heart Congenital cardiac defect Overprotectiveness Lack of movement fear, anxiousness limited action radius social isolation maybe limited capacity further overprotectiveness hindered psycho-social situation: self-concept, social behaviour, motivation and others lack of information, ignorance motoric deficiencies limitations of movement and perception experience 178 | mup 4|2009 Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases concentrate, so basically anything we would expect from a successful rehabilitation measure for these children, is fostered here. Cardiac patients Children with heartconditions are usually born with them. About one per cent of all newborns in Germany, which is about 6,000 children a year, are born with a heartcondition. These deficiencies and obstructions are located in the area of the heart and the large blood vessels near the heart, misconnections and combinations of these deformities down to the absence of whole parts of the heart can occur. On top of this there are malfunctions of the heartbeat’s orderliness (heartbeat being too fast or too slow) as the only abnormality, but also combined with another cardiac defect. Fortunately, most defects are harmless and are subject to spontaneuous healing, yet other babies or very young children need to be operated in order to survive. Usually, an operation like this is able to correct the cardiac defect, yet some children have to live on with remaining malfunctions having different effects on the children’s physical performance. Doing sports is a problem for some children, since some have to take so-called blood thinners like Marcumar for long periods of time or have to undergo pace maker therapies. This development which can usually be seen before birth and often calls for heavy heart surgery during the child’s baby phase, is a reason for great concern to the parents, since the heart is one of the most important organs in the human body. One can understand the parents’ overprotectiveness, but this often results in secondary developmental disorders in the motor (reduced muscle strength, flexibility and body coordination) and psycho-social area (emotional instability, fear of social contacts, unrealistic self-concept, inappropriate social behaviour and an instable performance) (Sticker 2004; Schickendantz et al. 2009). Groups A and B: Children with healed defects and children with little remaining defects have full physical capacity can do sports without any limitations - Group C: with remaining defects significant for the heart‘s work inconspicuous with everyday stress - Healthy physical capacity, but inferior when doing sports through reduced ability to increase cardiac output No competitive sports, risk of overload! no sports with mainly static load (e. g. weight training); results in pressure increase within the pulmonary circula- tion and in a load of the right side of the heart (danger of lethal cardiac arrhythmia) Avoiding sports with a high risk of injury in case of pace maker therapies and therapies with Marcumar (blood thinner). Group D: Children with severe remaining defects sports only within specified limits - Some of them suffer from a lack of oxygen within their blood (cyanosis = skin, lips and fingernails turning blue), which will decrease even more when under physical stress During sports these children must be allowed to throw in breaks according to how they feel - Group E: Children with a vital danger in case of physical stress must be excluded from sports due to the risk of sudden cardiac death. Table 1: Groups of level of severity and physical capacity Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases mup 4|2009 | 179 Physical capacity of cardiac children A precondition for doing sports is that the physical performance can be increased. This is done through an increase of the pulse rate and the transported blood volume per heartbeat (increase of the cardiac output). With cardiac children both control mechanisms can be in greater or lesser disorder. The limitation of the physical performance of these children when doing sports depends on to which degree the ability of the cardiac output is affected. Under this aspect the children are assigned to different groups of severity in order to assess their physical capacity (see table 1; Schickendantz et al. 2007). Children with healed defects and children with remaining light defects (groups A and B) are capable of performing to the fullest and thus can do sports without any limitations. Children with remaining defects which are vital for the heart’s work (group C) are utterly normal when it comes to everyday activities, but they are inferior in terms of physical performance to healthy children when doing sports. They should not do any competitive sports in order to prevent an overload of the heart. Apart from that sports with a mainly static load (e.g. weight training) result in a pressure increase within the lung circulation and stress on the right side of the heart which can cause severe, even lethal cardiac arrhythmia with children suffering from remaining significant defects. When pacemakers and blood thinners like Marcumar are involved sports with a high risk of injury should be avoided. Children with severe remaining defects (group D) can only do sports within specified limits. Some of them suffer from a lack of oxygen within their blood (cyanosis = skin, lips and fingernails turning blue), which will decrease even more when under physical stress. They must be allowed to throw in breaks according to how they feel. Children with a vital jeopardy in case of physical stress (group E) are not necessarily limited in their physical performance, but they should abstain from doing sports due to the risk of sudden cardiac death. The majority of cardiac children, though, is capable of doing sports without any limitations. According to a survey of cardiac children just starting school in 2008 / 2009 at our heart centre (see illust. 2) 85% of them are capable of doing sports without any limitations! Therapeutic riding for cardiac children Sports lessons in children cardiac sports groups are usually carried out without any pressure to perform (brief running and ball games take turns with a training machine course). In addition, during sports lesson units the children find out “what they can do“, they gain security, they realise that other children are not able to do some exercise at all either or at least not in a perfect fashion. Apart from this, a focus is on body perception which is supposed to keep the children from stress overload (Bjarnason-Wehrens et al. 1999; Leurs 2004; Sticker 2004). Therapeutic riding promises an even more intense fostering of muscle functions and group A = 21 % group B = 64 % group C = 11 % group D = 2 % group E = 2 % Distribution - physical capacity Ill. 2: Physical capacity of cardiac children just starting school 2008/ 2009 (n = 63) 180 | mup 4|2009 Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases body coordination together with a significant increase of self-confidence and, being an animalsupported therapy, a positive development of social competence. For the majority of children psycho-educational riding is the right supportive measure. Being carried on horseback in three different gaits combined with different exercises (see pictures 1, 2 and 3) results in the children becoming proud and gaining selfconfidence, especially at faster paces. The other children of the group accompany the exercises with and next to the horse with running and catching games. That way movement coordination, especially balance and body perception as well as muscle performance (strength and flexiblity) and posture are trained. Involving small training devices such as balls and rings fosters concentration and coordination skills. Regarding cardiovascular stress psychoeducational riding / vaulting is an interval sport at a medium intensity almost without any static load. Thus it is even suitable and handable for children of group D suffering from severe remaining defects. Preparing the supportive measure and the final treatment of the horse with all the required care measures after each session train the sense of responsibility and social competence. It might make sense for children with more severe motor skills limitations to deploy hippotherapy (see picture 4). Since this therapy only has the horse walking on a rope no significant cardiovascular stress occurs. This is why it is even suitable for children which are not allowed to do any sports at all. Here, these children experience movements which they will not have with any other physiotherapeutic measure. At the end of the psycho-educational riding / vaulting the children can switch to equestrian sports for handicapped people or, in case of unrestrained physical capacity, get involved in “regular“ equestrian sports. Safety instructions When integrating a child with a heart-condition in a psycho-educational Pictures 1, 2 and 3: Psycho-educational riding/ vaulting for children with a congenital heart disease - several exercises on horseback Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases mup 4|2009 | 181 riding/ vaulting group the pedagogues definitely need information about the severity of the heart defect and any maybe problematic parts of the supportive measure. The children’s cardiologist in chargeshouldexplainthesepointsindividuallywithin the scope of a detailed phyiscal capacity attestation in order to clarify any open questions. In order to do so the parents need to give their approval. The presence of a paediatrician is only required within the scope of children heart sports groups. Any “escape routes“ should be known in case a bleeder child has hurt itself. Here, even minor injuries should be taken seriously since internal bleedings may be undetected at first. Wearing a riding helmet within the scope of children heart sports groups is mandatory, even with vaulting. When integrating children with a heart defect in other therapy groups this should made dependend on possible bleeding risks. Up to now neither with therapeutic riding nor with other events carried out by children heart sports groups any emergencies have occurred. Still it makes sense for employees of horse riding centres dealing with cardiac children within the scope of a therapy to regularly refresh their first aid knowledge and to lay down a rescue plan for emergency cases, e.g. for evacuating horses (and dogs) in case an ambulance comes rushing in with flashing beacons and noisy sirens or in case a helicopter is about to land. Final remarks Even for children suffering from a heart-condition therapeutic riding is an important out-patient rehabilitation measure that can and should be carried through at a larger scale. It is also important that children which are otherwise not allowed to do any sports get the opportunity to make extensive movement experiences with hippotherapy. Still it needs to be proved within the scope of scientific studies to which extent therapeutic riding has an impact on the psychosocial and psychomotor development. The studies dealing with therapeutic riding for cardiac children (unpublished) can only be Picture 4: Hippotherapy with cardiac children 182 | mup 4|2009 Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases Issues of scientific studies regarding: “Therapeutic Riding for cardiac children“ rare disease with a wide variability range required number of probands can only be reached in a multi- centric way randomisation, blinding and forming control groups is not possible selecting suitable and valid test methods is difficult special logistics required for standardised realisation of - test examinations and therapy particular cost intensity regarding - therapy costs costs of medical care - Financing extensive scientific studies and evaluations (personnel and material costs) Ill. 3: Difficulty of scientific studies within the field in question considered as pilot studies, although they point out the positive effect as a tendency. A study considering all scientific standards based on this pilot study was not able to be made due to financial issues; unfortunately, this problem often occurs when it comes to studies dealing with rare diseases with a wide variability range (see illust. 3). Bibliographical references Bareiss, H. J. (1996): Therapeutische Mensch- ■ Pferd-Interaktion (TMPI). Grundzüge eines ganzheitlichen und mehrdimensionalen Strukturmodells. Praxis der Psychomotorik 21, 93-99 Bjarnason-Wehrens, B., Dordel, S., Leurs, S., ■ Lawrenz, W., Sticker, E. J., Schickendantz, S., Mennicken, U., Rost, R. (1999): Das Kölner Modellprojekt „Sport mit herzkranken Kindern“. In: Bräutigam, M., Starischka, S., Swoboda, J. - Institut für Sport und seine Didaktik der Universität Dortmund (Hrsg.): Sport - Lehrer - Studium: Bewährtes erhalten und Neues tun. Dortmunder Schriften Sport 9. SFT, Erlensee, 27-45 Bjarnason-Wehrens, B., Dordel, S., Leurs, ■ S., Schickendantz, S., Lawrenz, W., Sticker, E. J., Mennicken, U., Rost, R. (2000): Sport mit herzkranken Kindern - Das Kölner Modellprojekt. Forschung, Innovation, Technologie I, 14-22 Bjarnason-Wehrens, B., Dordel, S., Schicken- ■ dantz, S., Krumm, C., Bott, D., Sreeram, N., Brockmeier, K. (2007): Motor development in children with congenital cardiac diseases compared to their healthy peers. Cardiology in the Young 17, 487-498 Deppisch, J. (1996): Das Pferd als Medium mo- ■ totherapeutischer Intervention für hyperaktive Kinder. In: Passolt, M. (Hrsg.): Mototherapeutische Arbeit mit hyperaktiven Kindern. Ernst Reinhardt, München / Basel, 167-193 Deppisch, J. (1997): Hippopädagogik - eine ■ neue Anwendungsdisziplin der Motopädagogik. Motorik 19, 39-49 Deppisch, J. (2001): Pferde bewegen die ■ Motopädagogik. In: Fischer, K., Holland-Moritz, H. (Red.): Mosaiksteine der Motologie. Karl Hofmann, Schorndorf, 283-194 Herrera-Soto, J. A., Vander Have, K. L., Barry- ■ Lane, P., Myers, J. L. (2007): Retrospective study on the development of spinal deformities following sternotomy for congenital heart disease. Spine 32, 1998-2004 Leurs, S., Dordel, S., Lawrenz, W., Schicken- ■ dantz, S., Sticker, E. J., Bjarnason-Wehrens, B. (2001): Kölner Modell „Sport mit herzkranken Kindern“. Konzept und Organisation des Projekts. In: Bjarnason-Wehrens, B., Dordel, S. (Hrsg.): Motorische Förderung von Kindern mit angeborenen Herzfehlern. Academia, Sankt Augustin, 70-78 Leurs, S. (2004): Die kardiale Leistungsfähig- ■ keit, der motorische Entwicklungsstand und die psychosoziale Situation herzkranker Kinder und Jugendlicher sowie deren Beeinflussbarkeit durch eine Kinderherzgruppe. Dissertation Deutsche Sporthochschule Köln Schickendantz, S., Sticker, E. J., Dordel, S., ■ Bjarnason-Wehrens, B. (2007): Bewegung, Spiel und Sport mit herzkranken Kindern. Sport and Physical Activity in Children with Congenital Heart Disease. Deutsches Ärzteblatt 104, A-563 / B-494 / C-476 Sticker, E. J. (2001): Kinderherzsportgruppen ■ in Deutschland. In: Bjarnason-Wehrens, B., Dordel, S. (Hrsg.): Motorische Förderung von Kindern mit angeborenen Herzfehlern. Academia, Sankt Augustin, 89-100 Sticker, E. J. (2004): Sport macht stark - auch ■ bei angeborenem Herzfehler, Ergebnisse einer interdisziplinären Follow-up-Studie zur Entwicklungsoptimierung. Shaker, Aachen Schickendantz et al. - Therapeutic Riding for Children with Congenital Heart Diseases mup 4|2009 | 183 Dr. med. Sabine Schickendantz after studying medical science she underwent a further training to become a paediatrician and children’s cardiologist, currently working at the Klinik und Poliklinik für Kinderkardiologie, Herzzentrum at the University of Cologne Prof. Dr. Birna Bjarnason-Wehrens Sports scientist, since 1991 working at the Institut für Kreislaufforschung und Sportmedizin of the Deutsche Sporthochschule in Cologne. Main fields of activity: cardiologic rehabilitation phases II and III; gender specific differences; physical activity and workout during prevention; secondary prevention and rehabilitation of cardiovascular diseases, physical activity and workout with children and teenagers with congenital heart defects. Prof. Dr. Elisabeth Sticker Certified psychologist, studied to become a teacher at primary and secondary schools (1971-1974), studied psychology (1975-1980), conferral of doctorate (1983), teaching and research activities at the University of Bonn (1983-1987), Cologne (1997-2002) and Siegen (from 2008, interim professor Pedagogical Psychology), state doctorate (2002), Head of project Giftedness Cologne (PHK) at the Schulpsychologischer Dienst of the city of Cologne (2004-2008) Dr. rer. nat. Sigrid Dordel Certified sports teacher, since 1971 at the Deutsche Sporthochschule Cologne focusing on movement, playing and sports during prevention, specified conditions and progress of normal and defected motor development as well as effectiveness of motor intervention Marion Drache Communication scientist M.A., Public Relations consultant, foundation consultant, riding coach C, instructor equestrian sports for handicapped people Prof. Dr. med. Narayanswami Sreeram 1993-1996 paediatric cardiologist at the Birmingham Children’s Hospital (GB), 1997- 2002 Professor for Paediatric Cardiology at the University Medical Center Utrecht (NL), since 2003 senior consultant at the Klinik und Poliklinik für Kinderkardiologie, Herzzentrum, at the University of Cologne Contact: Dr. med. Sabine Schickendantz · Kinderkardiologie · Herzzentrum der Universität zu Köln · Kerpener Str. 62 · 50937 Köln Germany· e-mail: sabine.schickendantz@medizin.uni-koeln.de The authors