Effects of physical activity on heart rate variability in children and adolescents: a systematic review and meta-analysis

Chen, Hao; Xu, Jing; Xie, Hao; Huang, Yufen; Shen, Xin; Xu, Fei

doi:10.1590/1413-81232022275.10402021

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REVIEW • Ciênc. saúde coletiva 27 (05) • May 2022 • https://doi.org/10.1590/1413-81232022275.10402021 copy

Effects of physical activity on heart rate variability in children and adolescents: a systematic review and meta-analysis

Efeitos da atividade física na variabilidade da frequência cardíaca em crianças e adolescentes: uma revisão sistemática e meta-análise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The aim of the study was to investigate the effects of physical activity (PA) on heart rate variability (HRV) in children and adolescents. We conducted a research of Web of Science, PubMed, ScienceDirect, Springer-Link and EBSCO-host. The revised Newcastle-Ottawa Scale was used in an investigative analysis to assess bias risk. A total of 21 studies were included. Overall, medium-sized associations were found between PA and low frequency and high frequency in children and adolescents. High PA level had significantly higher standard deviation of RR intervals and root of the mean of the sum of the squares of differences between adjacent RR intervals in children and adolescents. The effects of PA on HRV were consistent in children and adolescents. Our systematic review and meta-analysis revealed medium-sized between PA and HRV in children and adolescents. Promoting children’s and adolescents’ participation in moderate-to-vigorous physical activity (MVPA) will increase parasympathetic nerve activity and decreased sympathetic nerve activity. Our findings support motivating children and adolescents to engage in more MVPA in their daily lives to improve autonomic nervous system function and promote cardiovascular safety.

Key words:
Physical activity; Heart rate variability; Autonomic nervous system; Children; Adolescents

Researcher/region	Subject characteristics			Mixed factors	PA test tools, types and judgment standards							HRV test method/indicator			Main results
Researcher/region	Health status	Sample size	Age/BF%		Tool	1	2	3	4	5	Judgment criteria /CPM	Time Domain	Frequency domain	Non- linear
Blom et al., 2009 Stockholm, Sweden	Health	47G,24B	16.5 y	Heart rate; blood sugar	Subjective memories	√	×	×	×	×	1: Physical exercise and sweating	SDNN	LF; HF	No	First: 1 & SDNN: r = 0.28* 1 & LF: r = 0.35* 1 & HF: r= 0.26*	Twice: r = 0.37* r = 0.29* r = 0.30*
Buchheit et al., 2007 Eastern France	Health	42G,25B	11.5±0.8 y/18±3.3%	Sex; age; BF%	Accelerometer	×	√	√	×	×	3 > 4METs 2 > 6METs	RMSSD	LF; HF (0.15-0.5 Hz); HF/(LF+HF)	No	3 & HF: β? 2 & HF: β?
Cayres et al., 2015 Sao Paulo, Brazil	1) Health 2) Exerciseinactive	N =12	1) 12±1 y/31.5±13.6% 2) 11±1 y /28.9±19.4%	Sex; age; race; PHV; maturation; BF%	Pedometer	√	×	×	×	×		RMSSD		No	1 & RMSSD: r = 0.22* 1 & RMSSD: β = 0.042*
S. R. Chen et al., 2008 Taiwan	1) Type 1 diabetes 2) Health	1) 48G,45B 2) 50G,57B	1) 10.3±1.6 y 2) 10.4±1.6 y	No	PAQ-C questionnaire	√	×	×	×	×		No	LF; HF; LF/HF	No	1 & LF: R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.48 1 & HF: R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.44 1 & LF/HF: R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.12**
S. R. Chen et al., 2012 Taiwan	1) Overweight 2) Health	1) 44B,40G 2) 44B,43G	1) 10.8±1.6 y 2) 10.6±1.5 y	No	PAQ-C questionnaire	√	×	×	×	×		No	LF; HF	No	1 & LF: r = 0.62* 1 & HF: r = 0.49*
Farah et al., 2014 Pernambuco, Brazil	Health	1152B	16.6±1.2 y	Age; HRV test period	Subjective memories	√	×	×	×	×	1: > 5 h/w	RMSSD; SDNN	LF; HF; LF/HF	No	1 & SDNN: B = 1.14* 1 & RMSSD: B = 1.54* 1 & LF: B = -0.56* 1 & HF: B = 0.56* 1 & LF/HF: B = -0.03
Fiuza-Luces et al., 2018 Pernambuco, Brazil	1) Abdominal obesity 2) Non-abdominal obesity	1) N = 149 2) N = 933	1) 17±1 y 2) 17±1 y	Age; HRV test period; BMI; blood pressure	Subjective memories	√	×	×	×	×	1: > 5 h/w	No	LF; HF; LF/HF	No	Abdominal obesity 1 & RMSSD: B = 1.51** 1& LF/HF: B = -0.022	Non-abdominal obesity Β = 1.39 Β = -0.025
Gutin et al., 2000 United States, Georgia	Obesity	53G,26B	9.5±1 y	Sex; age; BF%; blood pressure; Race; Heart rate	Subjective memories	×	√	√	×	×	2: > 3.2 h/w 3: < 3.2 h/w	RMSSD	No	No	2 & RMSSD: r = -0.03 3 & RMSSD: r = 0.03
Gutin et al., 2005 United States, Georgia	Health	1) 171G 2) 133B	1) White: 16.2±1.1 y/29.3±7.5%; Negro: 16.3±1.3 y/30±7.9% 2) White: 16.4±1.3 y/18.6±8%; Negro: 16.0±1.1 y/17.9±11.6%	sex; age; blood pressure; Race; Heart rate; Tanner stage; BF%	Accelerometer	×	√	√	×	×	3: 3-6 METs 2: 6-9 METs	RMSSD	LF (0.05-0.15 Hz); HF; LF/HF	No	3 & RMSSD: β = 0.18* 3 & HF: β = ? 3 & LF/HF: β = -0.0018*
Herzig et al., 2017	Health	162B,147G	3.9±0.7 y	Heart rate; age	Accelerometer	√	×	√	×	×	1: ? 3: ?	RMSSD; SDNN	LF; HF	α1	Heart rate:1 & SDNN: β = -0.63 1 & RMSSD: β = -0.69 1 & α1: β = 0.49 3 & SDNN: β = -0.63 3 & RMSSD: β = -0.7 3 & α1: β = 0.49
Iwasa et al., 2005	Health	12G,17B	7.5±1.4 y	No	Pedometer	×	√	×	×	×	Rest: 0-0.5 kCal Walking: 1-3 kCal Quick walk: 4-6 kCal Vigorous exercise: 7-9 kCal	No	LF; HF; LF/HF	No	2 & HF: r = -0.66 2 & LF/HF: r = ?
Krishnan et al., 2009	Health	101G,107B	G: 9.0±0.3 y/ 22% B: 9.0±0.3 y/ 27%	Boys and girls analysed in separate models; Heart rate	Single-axis accelerometer	×	√	√	√	×	4 < 1000 cpm 3 < 2500 cpm 2 > 2500 cpm	RMSSD; SDNN	LF; HF	No	1& SDNN: r = 0.356 1 & RMSSD:r =0.364
Michels et al., 2013 Northern Belgium	Health	N = 460	G: 8.0±0.3 y /18.4±3% B: 8.1±0.4 y/15.7±2%	Boys and girls analysed in separate models; Age; Heart rate; BF%; Timepoint	Single-axis accelerometer	×	√	√	√	×	3 > 2296 cpm 2 > 4012 cpm	RMSSD; SDNN	LF; HF; LF/HF	No	B: 3 & SDNN: β = 0.13 3 & RMSSD: β = 0.17* 3 & LF: β = 0.12 3 & HF: β = 0.16* 3 & LF/HF: β = -0.06	G β = 0.11 β = 0.10 β = 0.14 β = 0.06 β = -0.12
Nagai & Moritani, 2004	1) Health and obese children 2) Normal exercise 3) Not exercise normally 4) Exercise overweight 5) Overweight without exercise	1) 576B,504G 2) 23B,1G/ 3) 23B,1G/ 4) 8B,16G/ 5) 8B,16G	1) ? 2) 9.6±1.3 y 3) 9.5±1.4 y 4) 9.4±1.8 y 5) 9.3±1.7 y	No	Sports practice	×	×	×	×	×	Exercise group: > 3 h/w	No	LF; (0.03-0.15 Hz); HF (0.15-0.5 Hz)	No	Exercise VS. no exercise health LF; HF* obesity LF; HF**
Radtke et al., 2013a	1) Health 2) High exercise volume 3) Inactive	1) 29G,20B 2) 14G,9B 3) 26G,11B	11±1.0 y	No	Subjective memories	×	×	×	×	×	3: > 3 h/w	No	LF; HF	α1	B 3 & LF: R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.59 (P?) 3 & HF: R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.64 (P?) 3 & α1: R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.64 (P?)	G R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.06(P?) R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.06(P?) R²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.= 0.06(P?)
Radtke et al., 2013b	Health	28G 24B	14.5±0.7 y 14.5±0.7 y	Sex; age;Tanner stage; Sum of skinfolds	Accelerometer	×	√	√	×	×	3 > 3000 cpm 2 > 5200 cpm	RMSSD	No	No	3 & RMSSD: β = 0.448* 2 & RMSSD: β = 0.011
Sharma et al., 2015	1) Health 2) Non-athletes 3) Athletes	1) 250B,189G 2) 205B,155G 3) 45B,34G	13.5±0.6 y	No	Sports practice	×	×	×	×	×	Sports group: National athletes	RMSSD	LF; HF	No	Exercise VS. no exercise G: SDNN; RMSSD; LF; HF B: SDNN; RMSSD; LF; HF
Subramanian et al., 2019	1) Health 2) Non-athletes 3) Athletes	1) ? 2) 30B 3) 30B	10-19 y	No	Sports practice	×	×	×	×	×	Sports group: National athletes	RMSSD; SDNN	LF; HF; LF/HF		Exercise VS. no exercise SDNN; RMSSD; LF; HF; LF/HF*
Tornberg et al., 2019/ Finland		3395B	18±1 y	Blood pressure; coffee; smoking	Subjective memories	×	×	×	×	×	Low = < 0.5 h/w Medium = 0.5-2 h/w High = 2-4 h/w Top => 4 h/w	RMSSD; SDNN	LF; HF	No	1 & RMSSD: β = 0.09* 1 & LF: β = 0.14* 1 & HF: β = 0.11* (top; high; medium) VS low SDNN; RMSSD; LF; HF; LF/HF
Veijalainen et al., 2019 Finland		185B 192G	7.7±0.4 y 7.6±0.4 y	PHV; BF%; CRS	Accelerometer	√	√	√	√	√	5: ≤ 1.50 METs 4: 1.51-4.00 METs 3: 4.01-7.00 METs 2: > 7.00 METs	RMSSD; SDNN	LF; HF	No	1 & SDNN: β = 0.22 1 & RMSSD: β = 0.26* 1 & LF: β = 0.15 1 & HF: β = 0.23 1 & LF/HF: β = 0.20
Vinet et al., 2005	Health	20B		No	Sports practice	×	×	×	×	×	Sports group: > 6 h/w	RMSSD	LF; HF		Exercise VS. no exercise	SDNN; RMSSD; LF; HF; LF/HF

Bias category	Score	Comment content	Evaluation criteria (0 to 3 points)
Selection bias	3 points	selection	This domain contained one subdomain regarding the source of the population. Low risk of bias was considered when random sampling was used and a high risk of bias was considered when a convenience sample was used without explanation of the recruitment procedures undertaken.
Design bias	3 points	sample size	Low risk of bias was considered when the study provided an appropriate power analysis for sample size calculation, and when the study controlled for important confounders using appropriate statistical methods.
Design bias	3 points	confounders
Statistical bias	3 points	statistical approach	Low risk of bias was considered when an appropriate statistical approach was used, and the authors properly described how missing cases were handled. Studies not mentioning missing cases were considered to have a low risk of bias.
Statistical bias	3 points	missing data
Result bias	3 points	PA test	Low risk of bias was considered when the exposures were objectively measured and sufficient details provided to enable the measurement to be replicated by the reader. In addition, the appropriate subdomain for the measurement of HRV was duplicated. In this case, a low risk of bias was considered when studies presented sufficient details of the procedures taken before and during the measurement of HRV according to published guidelines [11].
Result bias	3 points	HRV test

Sample characteristics		Effect size statistics^†				Heterogeneity statistics			Publication bias classic fail-safe N
Sample characteristics		k	r	SE	s²	95% CI	Z	Q	I²
SDNN	Child	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	350	0.34	0.01	0.00	(0.25, 0.43)	6.62	0.44	0.00	28
RMSSD	Child	486	0.22	0.03	0.03	(0.13,0.30)	4.75	12.54	76.07	12
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
HF	Child	400	0.52	0.32	0.26	(0.45, 0.59)	11.41	58.24	96.57	49
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	542	0.46	0.14	0.17	(0.39, 0.53)	11.54	66.75	94.01	87
LF	Child	341	0.66	0.01	0.00	(0.60, 0.71)	15.12	1.37	27.05	N/A
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	513	0.58	0.06	0.06	(0.52, 0.63)	14.92	22.43	86.63	183

Sample characteristics N₁		Effect size statistics^†				Heterogeneity statistics
Sample characteristics N₁		N₁	N₂	MD	95% CI	P	Z	I²2 Mendenhall E, Kohrt BA, Norris SA, Ndetei D, Prabhakaran D. Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations. Lancet 2017; 389(10072):951-963.	P
SDNN	Child	1452	2007	22.83	(7.89, 37.77)	0.00	3.00	97.47	0.00
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	1482	2037	22.45	(9.37, 35.5)	0.00	3.36	96.01	0.00
RMSSD	Child	90	369	28.35	(15.26, 41.44)	0.00	4.25	55.07	0.11
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	120	399	28.08	(17.50, 38.66)	0.00	5.20	24.82	0.22
HF	Child	90	369	569.61	(-154, 1293.24)	0.12	1.54	80.84	0.02
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	120	399	602.78	(0.47, 1205.08)	0.05	1.96	64.42	0.03
LF	Child	90	369	309.69	(95.44, 523.94)	0.00	2.83	0.00	0.39
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	120	399	309.96	(96.24, 523.68)	0.00	2.84	0.00	0.59
LF/HF	Child	1373	1647	0.33	(-0.31, 0.97)	0.31	1.02	92.90	0.00
	Adolescent	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Child and adolescent	1403	1677	0.31	(-0.18, 0.80)	0.22	1.23	84.58	0.00

Inclusion study	Selection bias	Design bias		Statistical bias		Result bias		Total score
Inclusion study	Subject source	Sample size	Confounding factors	Statistical methods	Missing data	HRV test	PA test
Blom et al., 2009	0	1	1	2	1	3	1	9
Buchheit et al., 2007	3	1	3	3	1	2	1	14
Cayres et al., 2015	1	1	3	3	3	3	0	14
Chen et al., 2008	1	2	0	2	2	2	1	10
Chen et al., 2012	0	1	0	2	0	3	1	7
Farah et al., 2014	0	2	2	3	3	3	1	14
Farah et al., 2018	2	2	3	2	1	2	1	13
Gutin et al., 2000	0	1	3	3	3	1	1	12
Gutin et al., 2005	0	3	3	3	3	3	2	17
Herzig et al., 2017	3	2	2	2	2	3	3	17
Iwasa et al., 2005	0	0	0	1	3	1	1	6
Krishnan et al., 2009	2	2	0	2	1	2	2	11
Michels et al., 2013	3	2	3	3	3	3	2	19
Nagai & Moritani, 2004	0	0	0	2	3	1	0	6
Radtke et al., 2013a	0	1	3	3	1	1	0	9
Radtke et al., 2013b	0	0	3	3	2	1	3	12
Sharma et al., 2015	0	2	0	1	0	1	0	4
Subramanian et al., 2019	1	2	0	2	3	3	1	12
Tornberg et al., 2019	2	3	2	3	2	2	2	16
Veijalainen et al., 2019	2	2	3	3	2	3	3	18
Vinet et al., 2005	0	0	0	2	3	1	0	6

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[1] Collaborations

H Chen: conceptualization, methodology, analyses, writing-original and edited drafts. J XU: methodology, analyses, writing-original and edited drafts. H Xie: writing-original draft, editing. Y Huang and X Shen: supervision, editing. F Xu: conceptualization, writing-review and editing, funding acquisition.