Intensity of Physical Activity and Peak Oxygen Consumption in Patients With Heart Failure | Cardiology | JN Learning | AMA Ed Hub [Skip to Content]
Outline
Quiz
PDF
Lifestyle Behaviors

Effect of High-Intensity Interval Training, Moderate Continuous Training, or Guideline-Based Physical Activity Advice on Peak Oxygen Consumption in Patients With Heart Failure With Preserved Ejection FractionA Randomized Clinical Trial

Educational Objective
To learn the effect of differing modes of exercise on peak oxygen consumption (V̇o2) in patients with heart failure with preserved ejection fraction (HFpEF).
1 Credit CME
JAMA
February 9, 2021
Original Investigation
Stephan Mueller, MA1,2;
Ephraim B. Winzer, MD3;
André Duvinage, MD1,2;
Andreas B. Gevaert, MD, PhD4,5;
Frank Edelmann, MD6,7;
Bernhard Haller, Dr rer nat8;
Elisabeth Pieske-Kraigher, MD6,7;
Paul Beckers, PhD4,5;
Anna Bobenko, MD6,7;
Jennifer Hommel, MA3;
Caroline M. Van de Heyning, MD, PhD4,5;
Katrin Esefeld, MD1,2;
Pia von Korn, MSc1,2;
Jeffrey W. Christle, PhD1,9;
Mark J. Haykowsky, PhD10;
Axel Linke, MD3;
Ulrik Wisløff, PhD11;
Volker Adams, PhD3;
Burkert Pieske, MD6,7;
Emeline M. van Craenenbroeck, MD, PhD4,5;
Martin Halle, MD1,2;
for the OptimEx-Clin Study Group
Author Affiliations
  • 1Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
  • 2DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
  • 3Heart Center Dresden–University Hospital, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
  • 4Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium
  • 5Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
  • 6Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
  • 7DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
  • 8Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, Munich, Germany
  • 9Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California
  • 10Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
  • 11The Cardiac Exercise Research Group at Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
  • OptimEx-Clin Study Groupfor the
Read article on JAMA Network

MOC/CME Information

editorial comment icon
Editorial
Comment
 related articles icon
Related
Articles
 author interview icon
Interviews
 multimedia icon
Multimedia
Read Article Take Quiz
Key Points

Question  Is there a difference in change in peak oxygen consumption (V̇o2) among patients with heart failure with preserved ejection fraction (HFpEF) treated with differing modes of exercise?

Findings  This randomized clinical trial included 180 patients with HFpEF assigned to high-intensity interval training, moderate continuous training, or a control of guideline-based physical activity advice. At 3 months, the changes in peak V̇o2 were 1.1, 1.6, and −0.6 mL/kg/min, respectively. There was no statistically significant difference between high-intensity interval and moderate continuous training, and neither group met the a priori–defined minimal clinically important difference of 2.5 mL/kg/min compared with the guideline control.

Meaning  These findings do not support either high-intensity interval training or moderate continuous training compared with guideline-based physical activity for patients with HFpEF.

Abstract

Importance  Endurance exercise is effective in improving peak oxygen consumption (peak V̇o2) in patients with heart failure with preserved ejection fraction (HFpEF). However, it remains unknown whether differing modes of exercise have different effects.

Objective  To determine whether high-intensity interval training, moderate continuous training, and guideline-based advice on physical activity have different effects on change in peak V̇o2 in patients with HFpEF.

Design, Setting, and Participants  Randomized clinical trial at 5 sites (Berlin, Leipzig, and Munich, Germany; Antwerp, Belgium; and Trondheim, Norway) from July 2014 to September 2018. From 532 screened patients, 180 sedentary patients with chronic, stable HFpEF were enrolled. Outcomes were analyzed by core laboratories blinded to treatment groups; however, the patients and staff conducting the evaluations were not blinded.

Interventions  Patients were randomly assigned (1:1:1; n = 60 per group) to high-intensity interval training (3 × 38 minutes/week), moderate continuous training (5 × 40 minutes/week), or guideline control (1-time advice on physical activity according to guidelines) for 12 months (3 months in clinic followed by 9 months telemedically supervised home-based exercise).

Main Outcomes and Measures  Primary end point was change in peak V̇o2 after 3 months, with the minimal clinically important difference set at 2.5 mL/kg/min. Secondary end points included changes in metrics of cardiorespiratory fitness, diastolic function, and natriuretic peptides after 3 and 12 months.

Results  Among 180 patients who were randomized (mean age, 70 years; 120 women [67%]), 166 (92%) and 154 (86%) completed evaluation at 3 and 12 months, respectively. Change in peak V̇o2 over 3 months for high-intensity interval training vs guideline control was 1.1 vs −0.6 mL/kg/min (difference, 1.5 [95% CI, 0.4 to 2.7]); for moderate continuous training vs guideline control, 1.6 vs −0.6 mL/kg/min (difference, 2.0 [95% CI, 0.9 to 3.1]); and for high-intensity interval training vs moderate continuous training, 1.1 vs 1.6 mL/kg/min (difference, −0.4 [95% CI, −1.4 to 0.6]). No comparisons were statistically significant after 12 months. There were no significant changes in diastolic function or natriuretic peptides. Acute coronary syndrome was recorded in 4 high-intensity interval training patients (7%), 3 moderate continuous training patients (5%), and 5 guideline control patients (8%).

Conclusions and Relevance  Among patients with HFpEF, there was no statistically significant difference in change in peak V̇o2 at 3 months between those assigned to high-intensity interval vs moderate continuous training, and neither group met the prespecified minimal clinically important difference compared with the guideline control. These findings do not support either high-intensity interval training or moderate continuous training compared with guideline-based physical activity for patients with HFpEF.

Trial Registration  ClinicalTrials.gov Identifier: NCT02078947

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Related Articles

  1. Diet vs Exercise in Obese Older Patients With HFPEF

  2. Sex Differences in Cardiometabolic Traits in Heart Failure With Preserved Ejection Fraction

  3. Effect of Praliciguat on Oxygen Consumption in Patients With Heart Failure With Preserved Ejection Fraction (HFpEF)

  4. Searching for the Optimal Exercise Training Regimen in Heart Failure With Preserved Ejection Fraction

See More

View All Featured

See More About

Cardiology Heart Failure Lifestyle Behaviors Physical Activity Heart Failure with Preserved Ejection Fraction
Article Information

Corresponding Author: Martin Halle, MD, Department of Prevention and Sports Medicine, Accredited Centre for Sports Cardiology/EAPC, School of Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Georg-Brauchle-Ring 56, D-80992 Munich, Germany (martin.halle@mri.tum.de).

Accepted for Publication: December 28, 2020.

Author Contributions: Mr Mueller and Dr Haller had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Mr Mueller and Drs Winzer, van Craenenbroeck, and Halle contributed equally.

Concept and design: Edelmann, Haller, Beckers, Christle, Linke, Wisløff, Adams, Pieske, Halle.

Acquisition, analysis, or interpretation of data: Mueller, Winzer, Duvinage, Gevaert, Edelmann, Haller, Pieske-Kraigher, Beckers, Bobenko, Hommel, Van de Heyning, Esefeld, von Korn, Christle, Haykowsky, Linke, Van Craenenbroeck, Halle.

Drafting of the manuscript: Mueller, Duvinage, Haller, Haykowsky, Halle.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Duvinage, Haller, Halle.

Obtained funding: Wisløff, Adams, Pieske, Halle.

Administrative, technical, or material support: Mueller, Gevaert, Edelmann, Beckers, Bobenko, Van de Heyning, von Korn, Christle, Linke, Wisløff, Adams, Halle.

Supervision: Mueller, Winzer, Edelmann, Pieske-Kraigher, Beckers, Van de Heyning, von Korn, Christle, Linke, Wisløff, Adams, Pieske, Van Craenenbroeck, Halle.

Conflict of Interest Disclosures: Dr Mueller reported receiving grants from Deutsche Forschungsgemeinschaft (DFG) through the TUM International Graduate School of Science and Engineering during the conduct of the study. Dr Winzer reported receiving personal fees from Novartis (honoraria for lectures and advisory board activities), Boehringer Ingelheim (honoraria for advisory board activities), and CVRX (honoraria for lectures) outside the submitted work. Dr Duvinage reported receiving grants from Novartis outside the submitted work. Dr Van de Heyning reported receiving speaker fees from Abbott, Daiichi Sankyo, and Edwards Lifesciences outside the submitted work. Dr Linke reported receiving speaker fees from Abbott, Medtronic, Edwards Lifesciences, AstraZeneca, Boston Scientific, and Novartis; grants from Edwards Lifesciences and Novartis; advisory board fees from Transverse Medical, Picardia, Edwards Lifesciences, and Heart Leaflet Technology; and stock options from Claret Medical and Transverse Medical, and being a co-owner of Dresden Cardiovascular Research Institute and Core Laboratories outside the submitted work. Dr Pieske reported receiving personal fees from Bayer Healthcare (steering committee, lectures), Merck (steering committee, lectures), Novartis (steering committee, lectures), Servier, AstraZeneca (lectures), Bristol-Myers Squibb (lectures), and Medscape (lectures) outside the submitted work. Dr Van Craenenbroeck reported receiving grants from the Flemish Research Funds (FWO) during the conduct of the study. Dr Halle reported receiving grants from the TUM International Graduate School of Science and Engineering during the conduct of the study and grants from Novartis (principal investigator of the Activity Study in HFrEF) and personal fees from Bristol-Myers Squibb, Berlin Chemie-Menarini, Novartis, Daiichi-Sankyo, AstraZeneca, Roche, Abbott (advisory board on exercise and diabetes), Sanofi, Pfizer, Boehringer Ingelheim, and Bayer outside the submitted work. No other disclosures were reported.

Funding/Support: This trial was funded by the European Commission, Framework Program 7, grant No. EU-602405-2; the Deutsche Forschungsgemeinschaft (DFG) through the TUM International Graduate School of Science and Engineering (IGSSE); and the Flemish Research Funds (FWO) through a Senior Clinical Investigator grant to Dr van Craenenbroeck.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The OptimEx-Clin Study Group members are listed in Supplement 2.

Data Sharing Statement: See Supplement 3.

References
1.
Virani  SS , Alonso  A , Benjamin  EJ ,  et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics.   Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757 PubMedGoogle ScholarCrossref
2.
Ho  JE , Enserro  D , Brouwers  FP ,  et al.  Predicting heart failure with preserved and reduced ejection fraction: the International Collaboration on Heart Failure Subtypes.   Circ Heart Fail. 2016;9(6):e003116. doi:10.1161/CIRCHEARTFAILURE.115.003116 PubMedGoogle Scholar
3.
Chang  PP , Chambless  LE , Shahar  E ,  et al.  Incidence and survival of hospitalized acute decompensated heart failure in four US communities (from the Atherosclerosis Risk in Communities Study).   Am J Cardiol. 2014;113(3):504-510. doi:10.1016/j.amjcard.2013.10.032 PubMedGoogle ScholarCrossref
4.
Pandey  A , LaMonte  M , Klein  L ,  et al.  Relationship between physical activity, body mass index, and risk of heart failure.   J Am Coll Cardiol. 2017;69(9):1129-1142. doi:10.1016/j.jacc.2016.11.081 PubMedGoogle ScholarCrossref
5.
Kitzman  DW , Little  WC , Brubaker  PH ,  et al.  Pathophysiological characterization of isolated diastolic heart failure in comparison to systolic heart failure.   JAMA. 2002;288(17):2144-2150. doi:10.1001/jama.288.17.2144 PubMedGoogle ScholarCrossref
6.
Bonsu  KO , Arunmanakul  P , Chaiyakunapruk  N .  Pharmacological treatments for heart failure with preserved ejection fraction.   Heart Fail Rev. 2018;23(2):147-156. doi:10.1007/s10741-018-9679-y PubMedGoogle ScholarCrossref
7.
Fukuta  H , Goto  T , Wakami  K , Kamiya  T , Ohte  N .  Effects of exercise training on cardiac function, exercise capacity, and quality of life in heart failure with preserved ejection fraction.   Heart Fail Rev. 2019;24(4):535-547. doi:10.1007/s10741-019-09774-5 PubMedGoogle ScholarCrossref
8.
Haykowsky  MJ , Brubaker  PH , Stewart  KP , Morgan  TM , Eggebeen  J , Kitzman  DW .  Effect of endurance training on the determinants of peak exercise oxygen consumption in elderly patients with stable compensated heart failure and preserved ejection fraction.   J Am Coll Cardiol. 2012;60(2):120-128. doi:10.1016/j.jacc.2012.02.055 PubMedGoogle ScholarCrossref
9.
Angadi  SS , Mookadam  F , Lee  CD , Tucker  WJ , Haykowsky  MJ , Gaesser  GA .  High-intensity interval training vs. moderate-intensity continuous exercise training in heart failure with preserved ejection fraction: a pilot study.   J Appl Physiol (1985). 2015;119(6):753-758. doi:10.1152/japplphysiol.00518.2014PubMedGoogle ScholarCrossref
10.
Donelli da Silveira  A , Beust de Lima  J , da Silva Piardi  D ,  et al.  High-intensity interval training is effective and superior to moderate continuous training in patients with heart failure with preserved ejection fraction.   Eur J Prev Cardiol. 2020;27(16):1733-1743. doi:10.1177/2047487319901206 PubMedGoogle ScholarCrossref
11.
Fujimoto  N , Prasad  A , Hastings  JL ,  et al.  Cardiovascular effects of 1 year of progressive endurance exercise training in patients with heart failure with preserved ejection fraction.   Am Heart J. 2012;164(6):869-877. doi:10.1016/j.ahj.2012.06.028 PubMedGoogle ScholarCrossref
12.
Bobenko  A , Bartels  I , Münch  M ,  et al.  Amount or intensity? potential targets of exercise interventions in patients with heart failure with preserved ejection fraction.   ESC Heart Fail. 2018;5(1):53-62. doi:10.1002/ehf2.12227 PubMedGoogle ScholarCrossref
13.
Suchy  C , Massen  L , Rognmo  O ,  et al.  Optimising exercise training in prevention and treatment of diastolic heart failure (OptimEx-CLIN).   Eur J Prev Cardiol. 2014;21(2)(suppl):18-25. doi:10.1177/2047487314552764 PubMedGoogle ScholarCrossref
14.
Paulus  WJ , Tschöpe  C , Sanderson  JE ,  et al.  How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology.   Eur Heart J. 2007;28(20):2539-2550. doi:10.1093/eurheartj/ehm037 PubMedGoogle ScholarCrossref
15.
Piepoli  MF , Hoes  AW , Agewall  S ,  et al; ESC Scientific Document Group.  2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).   Eur Heart J. 2016;37(29):2315-2381. doi:10.1093/eurheartj/ehw106 PubMedGoogle ScholarCrossref
16.
Guazzi  M , Arena  R , Halle  M , Piepoli  MF , Myers  J , Lavie  CJ .  2016 Focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations.   Circulation. 2016;133(24):e694-e711. doi:10.1161/CIR.0000000000000406 PubMedGoogle ScholarCrossref
17.
Mezzani  A , Agostoni  P , Cohen-Solal  A ,  et al.  Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: a report from the Exercise Physiology Section of the European Association for Cardiovascular Prevention and Rehabilitation.   Eur J Cardiovasc Prev Rehabil. 2009;16(3):249-267. doi:10.1097/HJR.0b013e32832914c8 PubMedGoogle ScholarCrossref
18.
Beaver  WL , Wasserman  K , Whipp  BJ .  A new method for detecting anaerobic threshold by gas exchange.   J Appl Physiol (1985). 1986;60(6):2020-2027. doi:10.1152/jappl.1986.60.6.2020PubMedGoogle ScholarCrossref
19.
Spertus  J , Peterson  E , Conard  MW ,  et al; Cardiovascular Outcomes Research Consortium.  Monitoring clinical changes in patients with heart failure: a comparison of methods.   Am Heart J. 2005;150(4):707-715. doi:10.1016/j.ahj.2004.12.010 PubMedGoogle ScholarCrossref
20.
Edelmann  F , Gelbrich  G , Düngen  HD ,  et al.  Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise Training in Diastolic Heart Failure) pilot study.   J Am Coll Cardiol. 2011;58(17):1780-1791. doi:10.1016/j.jacc.2011.06.054 PubMedGoogle ScholarCrossref
21.
Yelland  LN , Sullivan  TR , Voysey  M , Lee  KJ , Cook  JA , Forbes  AB .  Applying the intention-to-treat principle in practice.   Clin Trials. 2015;12(4):418-423. doi:10.1177/1740774515588097 PubMedGoogle ScholarCrossref
22.
Tucker  WJ , Lijauco  CC , Hearon  CM  Jr ,  et al.  Mechanisms of the improvement in peak VO2 with exercise training in heart failure with reduced or preserved ejection fraction.   Heart Lung Circ. 2018;27(1):9-21. doi:10.1016/j.hlc.2017.07.002 PubMedGoogle ScholarCrossref
23.
Tucker  WJ , Nelson  MD , Beaudry  RI ,  et al.  Impact of exercise training on peak oxygen uptake and its determinants in heart failure with preserved ejection fraction.   Card Fail Rev. 2016;2(2):95-101. doi:10.15420/cfr.2016:16:2 PubMedGoogle Scholar
24.
Gevaert  AB , Beckers  PJ , Van Craenenbroeck  AH ,  et al.  Endothelial dysfunction and cellular repair in heart failure with preserved ejection fraction.   Eur J Heart Fail. 2019;21(1):125-127. doi:10.1002/ejhf.1339 PubMedGoogle ScholarCrossref
25.
Schmederer  Z , Rolim  N , Bowen  TS , Linke  A , Wisloff  U , Adams  V ; OptimEx study group.  Endothelial function is disturbed in a hypertensive diabetic animal model of HFpEF.   Int J Cardiol. 2018;273:147-154. doi:10.1016/j.ijcard.2018.08.087 PubMedGoogle ScholarCrossref
26.
Bowen  TS , Rolim  NP , Fischer  T ,  et al; Optimex Study Group.  Heart failure with preserved ejection fraction induces molecular, mitochondrial, histological, and functional alterations in rat respiratory and limb skeletal muscle.   Eur J Heart Fail. 2015;17(3):263-272. doi:10.1002/ejhf.239 PubMedGoogle ScholarCrossref
27.
Kitzman  DW , Brubaker  P , Morgan  T ,  et al.  Effect of caloric restriction or aerobic exercise training on peak oxygen consumption and quality of life in obese older patients with heart failure with preserved ejection fraction: a randomized clinical trial.   JAMA. 2016;315(1):36-46. doi:10.1001/jama.2015.17346 PubMedGoogle ScholarCrossref
28.
Ellingsen  Ø , Halle  M , Conraads  V ,  et al; SMARTEX Heart Failure Study (Study of Myocardial Recovery After Exercise Training in Heart Failure) Group.  High-intensity interval training in patients with heart failure with reduced ejection fraction.   Circulation. 2017;135(9):839-849. doi:10.1161/CIRCULATIONAHA.116.022924 PubMedGoogle ScholarCrossref
29.
Piercy  KL , Troiano  RP , Ballard  RM ,  et al.  The physical activity guidelines for Americans.   JAMA. 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854 PubMedGoogle ScholarCrossref
30.
O’Connor  CM , Whellan  DJ , Lee  KL ,  et al; HF-ACTION Investigators.  Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial.   JAMA. 2009;301(14):1439-1450. doi:10.1001/jama.2009.454 PubMedGoogle ScholarCrossref
31.
Kitzman  DW , Brubaker  PH , Morgan  TM , Stewart  KP , Little  WC .  Exercise training in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial.   Circ Heart Fail. 2010;3(6):659-667. doi:10.1161/CIRCHEARTFAILURE.110.958785 PubMedGoogle ScholarCrossref
32.
Kitzman  DW , Brubaker  PH , Herrington  DM ,  et al.  Effect of endurance exercise training on endothelial function and arterial stiffness in older patients with heart failure and preserved ejection fraction.   J Am Coll Cardiol. 2013;62(7):584-592. doi:10.1016/j.jacc.2013.04.033 PubMedGoogle ScholarCrossref
33.
Gary  RA , Sueta  CA , Dougherty  M ,  et al.  Home-based exercise improves functional performance and quality of life in women with diastolic heart failure.   Heart Lung. 2004;33(4):210-218. doi:10.1016/j.hrtlng.2004.01.004PubMedGoogle ScholarCrossref
34.
Alves  AJ , Ribeiro  F , Goldhammer  E ,  et al.  Exercise training improves diastolic function in heart failure patients.   Med Sci Sports Exerc. 2012;44(5):776-785. doi:10.1249/MSS.0b013e31823cd16a PubMedGoogle ScholarCrossref
35.
Edelmann  F , Wachter  R , Schmidt  AG ,  et al; Aldo-DHF Investigators.  Effect of spironolactone on diastolic function and exercise capacity in patients with heart failure with preserved ejection fraction: the Aldo-DHF randomized controlled trial.   JAMA. 2013;309(8):781-791. doi:10.1001/jama.2013.905 PubMedGoogle ScholarCrossref
36.
Solomon  SD , McMurray  JJV , Anand  IS ,  et al; PARAGON-HF Investigators and Committees.  Angiotensin-neprilysin inhibition in heart failure with preserved ejection fraction.   N Engl J Med. 2019;381(17):1609-1620. doi:10.1056/NEJMoa1908655 PubMedGoogle ScholarCrossref
37.
Fleg  JL , Cooper  LS , Borlaug  BA ,  et al; National Heart, Lung, and Blood Institute Working Group.  Exercise training as therapy for heart failure.   Circ Heart Fail. 2015;8(1):209-220. doi:10.1161/CIRCHEARTFAILURE.113.001420 PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Privacy Policy|Terms of Use
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue