Exercise interventions for patients with pediatric cancer during inpatient acute care: A systematic review of literature

Availability and adaption of exercise programs in pediatric oncology during the COVID-19 pandemic and beyond: a nationwide follow-up survey of providers in Germany

Background

The COVID-19 pandemic has presented major challenges to clinical practice and delivery of care programs throughout all health care systems. Exercise programs, that are implemented in most centers for pediatric oncology in Germany, are a relatively new care program however with high clinical impact and health benefits.

Objective

The impact and consequences of the pandemic on the delivery and availability of exercise programs in Germany for pediatric cancer patients and survivors are unknown. A national survey analyzed restrictions, challenges and novel approaches of exercise program delivery and scientific research.

Method

A two-stage online survey was distributed to providers of exercise programs (acute clinics, non-clinical institutions, rehabilitation facilities) via the established Network ActiveOncoKids. Data was collected during the pandemic in 2022 and 2023 using a combination of open and closed questions.

Results

In total, n = 27 (response rate: 82%) and n = 17 (response rate: 63%) providers participated in the first and second survey, respectively. Findings pointed out restrictions in 85% of all exercise programs in 2020 and 2021, with slight reductions in 2022. During pandemic, restrictions with major impact arose within exercise offers during follow-up and declined gradually. Whereas restrictions within the setting of acute therapy had medium or minor impact but persisted beyond. Delivery of provided exercise programs necessitated adaptions, including digital methods, supervised interventions from a distance and change of locations.

Discussion

The findings highlight the adaptability, the demand and the potential of exercise programs in pediatric oncology. We assume that exercise professionals have used the pandemic-related challenges to review and modify existing concepts and made adaptations according to local conditions and novel tools for the provision of exercise programs. Nevertheless, a conspicuous lack of exercise-related care has become evident in certain patients and survivors. Further expansion of programs is imperative to address and accommodate all pertinent needs.

Effect of Early Physical Therapy on Children of School Age With Hematological Cancer: A Quasi-Randomized Controlled Pilot Study

PURPOSE

Although physical therapy (PT) positively impacts exercise capacity and health-related quality of life (HRQOL) in children with hematological cancers, the optimal time for intervention is unknown. We compared the effects of PT administered before and after initial cancer treatment on the exercise capacity and HRQOL of children with hematological cancer.

METHODS

The participants were allocated to early (before initiating treatment) and late PT (after initiating treatment) groups. We evaluated exercise capacity using the 6-min walking distance (6MWD) test and HRQOL using the Pediatric Quality of Life Inventory.

RESULTS

Thirteen school children (7-13 years) were included. The early PT cohort had significant improvements in Pediatric Quality of Life Inventory but not 6MWD scores from admission to the completion of initial treatment; however, both scores reduced significantly in the late PT cohort.

CONCLUSIONS

Early rather than late PT during hospitalization might prevent reduced exercise capacity and improve HRQOL in children with hematological cancers.

Health policy considerations for combining exercise prescription into noncommunicable diseases treatment: a narrative literature review

Objectives

In this review, we aim to highlight the evidence base for the benefits of exercise in relation to the treatment of noncommunicable diseases (NCDs), draw on the Health Triangular Policy Framework to outline the principal facilitators and barriers for implementing exercise in health policy, and make concrete suggestions for action.

Methods

Literature review and framework analysis were conducted to deal with the research questions.

Results

Exercise prescription is a safe solution for noncommunicable diseases prevention and treatment that enables physicians to provide and instruct patients how to apply exercise as an important aspect of disease treatment and management. Combining exercise prescription within routine care, in inpatient and outpatient settings, will improve patients' life quality and fitness levels.

Conclusion

Inserting exercise prescription into the healthcare system would improve population health status and healthy lifestyles. The suggestions outlined in this study need combined efforts from the medical profession, governments, and policymakers to facilitate practice into reality in the healthcare arena.

Risk factors for overweight and obesity after childhood acute lymphoblastic leukemia in North America and Switzerland: A comparison of two cohort studies

BACKGROUND

After childhood acute lymphoblastic leukemia (ALL), sequelae include overweight and obesity, yet with conflicting evidence. We compared the prevalence of overweight and obesity between ≥5-year ALL survivors from the North American Childhood Cancer Survivor Study (CCSS) and the Swiss Childhood Cancer Survivor Study (SCCSS) and described risk factors.

METHODS

We included adult childhood ALL survivors diagnosed between 1976 and 1999. We matched CCSS participants (3:1) to SCCSS participants by sex and attained age. We calculated body mass index (BMI) from self-reported height and weight for 1287 CCSS and 429 SCCSS participants; we then compared those with siblings (2034) in North America and Switzerland (678) siblings. We assessed risk factors for overweight (BMI 25-29.9 kg/m2 ) and obesity (≥30 kg/m2 ) using multinomial regression.

RESULTS

We found overweight and obesity significantly more common among survivors in North America when compared with survivors in Switzerland [overweight: 30%, 95% confidence interval (CI): 27-32 vs. 24%, 21-29; obesity: 29%, 27-32 vs. 7%, 5-10] and siblings (overweight: 30%, 27-32 vs. 25%, 22-29; obesity: 24%, 22-26 vs. 6%, 4-8). Survivors in North America [odds ratio (OR) = 1.24, 1.01-1.53] and Switzerland (1.27, 0.74-2.21) were slightly more often obese than siblings. Among survivors, risk factors for obesity included residency in North America (5.8, 3.7-9.0); male (1.7, 1.3-2.3); attained age (≥45 years: 5.1, 2.4-10.8); Non-Hispanic Black (3.4, 1.6-7.0); low household income (2.3, 1.4-3.5); young age at diagnosis (1.6, 1.1-2.2). Cranial radiotherapy ≥18 Gray was only a risk factor for overweight (1.4, 1.0-1.8); steroids were not associated with overweight or obesity. Interaction tests found no evidence of difference in risk factors between cohorts.

CONCLUSIONS

Although treatment-related risk for overweight and obesity were similar between regions, higher prevalence among survivors in North America identifies important sociodemographic drivers for informing health policy and targeted intervention trials.

Pediatric oncohematological exercise program in hospital: clinical trial study protocol

Leukemias are the most common types of hematological cancers in children, and negatively impact functional capacity. There is evidence in the literature that therapeutic exercises can have a positive impact on functions. The aim of this study is to evaluate functional capacity, muscle strength, fatigue and quality of life through the application of a protocol of therapeutic exercises during pediatric leukemia hospitalization. Children will be allocated into two groups: one will carry out a protocol of therapeutic exercises, while the other will undergo conventional respiratory physiotherapy. The protocol is approved by the ethics and research committee of the host institution (No. 5.439.594). Results will be disseminated through peer-reviewed journal articles and conferences. Clinical trial registration: RBR-8sxnfyd (https://ensaiosclinicos.gov.br).

Inpatient Physical Therapy After Orthopedic Lower Extremity Surgery in Children With Cerebral Palsy

PURPOSE

To characterize and examine the variability in receipt of inpatient (IP) physical therapy after lower extremity (LE) orthopedic surgery for individuals with cerebral palsy (CP) across hospital-level (region, bed size) and individual characteristics (gender, age, race/ethnicity, insurance type, technology dependency, and surgical burden).

METHODS

We retrospectively analyzed physical therapy billing data of children with CP who had LE orthopedic surgery from October 1, 2015, through September 30, 2017, from the Pediatric Health Information Services (PHIS) database.

RESULTS

Seventy-five percent of individuals received IP physical therapy during the hospital stay. Individuals from the South and West and those who were technology dependent were less likely to receive IP therapy. Those at large hospitals, aged 11 to 14 years, and with a high surgical burden were more likely to receive therapy.

CONCLUSIONS

Results provide a starting point for future research on the discrepancies of acute physical therapy services in children diagnosed with CP. (Supplemental digital content video abstract available at: http://links.lww.com/PPT/A420).

Multidisciplinary Network ActiveOncoKids guidelines for providing movement and exercise in pediatric oncology: Consensus-based recommendations

BACKGROUND

Pediatric cancer leads to reduced participation in exercise and only few patients comply with national physical activity recommendations. Physically inactive behavior hinders motor development and increases physical and psychological adverse effects of therapy and incidence of sequelae. Currently, there is neither nationwide coverage nor uniform level of knowledge regarding exercise promotion. The objective of the guideline is to facilitate qualified exercise interventions through standardized procedures in addition to regular physiotherapy and overall avoid physical inactivity in pediatric cancer patients.

METHODS

This guideline addresses the multidisciplinary treatment team and informs physiotherapists and decision-makers in tertiary care hospitals and health insurance companies. The requirements of the Association of the Scientific Medical Societies in Germany were followed. Contents were based on best practice experience of experts, patient advocates, as well as on scientific evidence.

RESULTS

The guideline includes 11 recommendations. Recommendations 1-4 declare the relevance of implementing exercise interventions and address general framework conditions. Recommendations 5-11 focus on the design of exercise programs, prevention and safety issues, relative contraindications for specific training loads, and options to overcome barriers to exercise.

CONCLUSION

This guideline summarizes existing and established structures and evidence in the context of movement and exercise in pediatric oncology. It takes into consideration the rights, varying needs, and characteristics of children and adolescents as well as national and international experience in this field. In the future, relevant research gaps need to be addressed by high-quality intervention studies to provide the scientific background for a stronger evidence-based guideline.

Promoting positive physical activity behaviors for children and adolescents undergoing acute cancer treatment: Development of the CanMOVE intervention using the Behavior Change Wheel

Background

Increasing participation in physical activity has the potential to improve outcomes for children and adolescents with cancer during treatment and into survivorship. The aim of this study is to outline the theoretical process behind development of CanMOVE, a behavior change intervention designed to increase physical activity for children and adolescents with cancer.

Study design

This study followed a theoretical design process consistent with the Behavior Change Wheel to inform the design of a complex intervention.

Materials and methods

The three stages of the Behavior Change Wheel intervention design process include: (1) understanding physical activity behavior within the pediatric cancer setting, (2) identifying potential intervention functions, and (3) identifying appropriate behavior change and implementation strategies. Qualitative and behavior change literature relevant to the pediatric cancer treatment setting were used to inform each stage.

Results

An individualized and flexible approach to physical activity promotion that considers intrinsic factors specific to the child/adolescent and their environment is required. Fifteen behavioral change strategies were identified to form the intervention components of CanMOVE. Implementation strategies were identified to build motivation, opportunity and capacity toward increasing physical activity behaviors. Key intervention components of CanMOVE include standardized assessment and monitoring (physical activity, physical function, and health-related quality of life), provision of an activity monitor to both child/adolescent and parent, and one-on-one capacity building sessions with a healthcare professional. Capacity building sessions include education, goal setting, an active supervised physical activity session, barrier identification and problem solving, and action planning.

Conclusion

CanMOVE is a novel approach to physical activity promotion in the pediatric cancer treatment setting. The use of a theoretical intervention design process will aid evaluation and replication of CanMOVE when it is assessed for feasibility in a clinical setting. The design process utilized here can be used as a guide for future intervention development.

Therapeutic exercise interventions in pediatric survivors of brain cancer and other solid tumors: A scoping review

Background

Improved survival rates for children with solid tumors presents an ongoing challenge of how to maximize quality of survivorship and effectively manage the short- and long-term complications of disease and treatment. To gain an understanding of the extent and nature of research pertaining to therapeutic exercise interventions and identify knowledge gaps, we conducted a scoping review of exercise training studies conducted in pediatric survivors of brain cancer and other solid tumors.

Method

A systematic literature search was performed across four electronic databases. Papers were selected for full-text review if they included participants treated for brain cancer or other solid tumors, with at least 50% of participants aged ≤ 21 years, evaluated an exercise intervention ≥2-weeks in duration, and were published in an English, peer-reviewed journal. We included the following quantitative study designs; randomized controlled trials, non-randomized trials, and single-arm pre-test-post-test.

Results

Of the 7,482 citations identified, 17 papers met the inclusion criteria (presenting findings from eleven studies). Two studies were randomized controlled trials, five studies were non-randomized controlled trials, and four studies were a single-arm pre-test post-test design. Average age of participants ranged from 7.3-15.5 years, and time since diagnosis ranged from 3 to 70 months. Five studies included participants with brain tumors exclusively, three studies included other solid tumors, and three studies included a mixed sample (brain and other solid tumors). A wide range of exercise modalities were employed, including cycle ergometry, resistance training, sport, yoga, and active gaming. The length of the exercise program ranged from 3-40 weeks and frequency from 3-11 sessions per week. Exercise session duration ranged from 15-180 min, with most studies reporting 30-90-min sessions. Adherence ranged from 77 to 100%, with none of the studies reporting adverse events. Studies reported improvements in cardiorespiratory fitness, functional strength, physical activity, and quality of life.

Conclusions

A small number of mostly low methodological quality studies have examined the effects of therapeutic exercise in pediatric survivors of solid tumors. Although limited, the extant literature supports the feasibility and safety of therapeutic exercise interventions for pediatric survivors of brain cancer and other solid tumors.

Movement behaviours in paediatric cancer survivors during recovery and school weeks

Purpose

Paediatric cancer survivors (PCS) are a high-risk population, who can suffer from late effects of their treatment, such as metabolic syndrome, cardiovascular conditions, secondary tumours. Optimal movement behaviours (e.g., limited sedentary behaviour [SB] and sufficient physical activity [PA]) can reduce the side effects or avoid late effects of their treatment. The aims of this study were to analyse movement behaviours and meeting the recommendation of 60 minutes of moderate-to-vigorous physical activity (MVPA) a day in Czech PCS, and to compare their movement behaviours during recovery and school weeks in relation to gender, age, and cancer type.

Methods

Twenty-six PCS aged 7-15 years in remission stage took part in the cross-sectional study. Movement behaviours were measured with Actigraph wGT3X+ accelerometers worn 24 hour/day for 20 consecutive days covering recovery week (13 days at recovery camp) and school week (7 days). Based on cancer types, the PCS were categorized into haematological malignancy or solid tumours group.

Results

In the PCS, movement behaviours differed between recovery and school weeks. During recovery week, the PCS showed less SB (451.8 vs. 552.3 min/day, p < 0.001) and spent more time on light PA (350.3 vs. 255.1 min/day, p < 0.001), moderate PA (73.2 vs. 37.4 min/day, p < 0.001), and vigorous PA (10.3 vs. 4.0 min/day p < 0.001) than during school week. The PA recommendation was met by 77% (n = 20) PCS during recovery week, but only by 15% (n = 4) individuals during school week.

Conclusions

The PCS recorded higher levels of PA and lower levels of SB during recovery week than during school week. If provided with appropriate conditions, PCS in the remission stage are able to reach the PA level recommended for the healthy population. Recovery week can be a suitable platform for gaining experience that PCS are able to meet the recommended PA level and could be an integral part of reconditioning and resocialization programmes for PCS after the completion of their treatment.

Motor Functioning and Intelligence Quotient in Paediatric Survivors of a Fossa Posterior Tumor Following a Multidisciplinary Rehabilitation Program

BACKGROUND

Short- and long-term consequences after treatment for childhood fossa posterior tumors are extensively reported in the literature; however, papers highlighting physical function throughout rehabilitation and its correlation with Intelligence Quotient (IQ) are sparse. This study aims to describe the physical functioning and IQ of these survivors, their progression during rehabilitation, and the association with histopathological tumor classification. Additionally, the correlation between gross motor functioning and cognitive functioning was investigated.

METHODS

This retrospective single-center cohort study included 56 children (35 (62.5%) males and 21 (37.5%) females, with an average age of 6.51 years (SD 4.13)) who followed a multidisciplinary program at the Child Rehabilitation Centre, Ghent University Hospital in the period from 2005 to 2020. Descriptive statistical analysis was performed with the use of non-parametric tests and linear regression to determine the relationship between gross motor functioning and IQ.

RESULTS

This report shows impaired motor and intelligence performance in children with a fossa posterior tumor. Although multidisciplinary rehabilitation is beneficial, it is not able to counteract the further decline of several motor skills and intelligence during oncological treatment, more specifically in children with a medulloblastoma. A correlation between gross motor function and total IQ was found.

CONCLUSION

Pediatric survivors of a fossa posterior tumor experience impaired physical and intellectual functions, with more decline during oncological treatment despite simultaneous multidisciplinary rehabilitation.

Whole-body vibration training for inpatient children and adolescents receiving chemotherapy for first cancer diagnosis: an exploratory feasibility study

Whole-body vibration (WBV) is a feasible and potentially beneficial exercise strategy for managing neuromuscular impairments like decreased strength or flexibility, mobility limitations and bone health in pediatric cancer survivors. However, as starting rehabilitation as early as possible is recommended to preserve physical function, this study investigated the feasibility of WBV for patients receiving cancer treatment for first cancer diagnosis. Eleven patients (various types of cancer, ages 7–17) participated in the supervised WBV intervention concomitant to acute cancer treatment, which involved chemotherapy. Training was implemented as part of a general exercise program and offered 3 days per week during hospitalization (warm-up, four progressive training exercises comprising 60–120 s, 21–27 Hz, 2 mm peak-to-peak-displacement). Feasibility, which was defined as the absence of WBV-related serious adverse events leading to study dropout, was primarily evaluated. Training documentation was additionally analyzed. As a main result, no serious adverse events leading to study dropout were reported. However, two incidents of bleeding (adverse events) were observed in patients with bleeding tendencies and low platelets (thrombocytes < 30,000/μL). After adjusting the platelet count threshold for WBV participation to 30,000/μL, no further incidents occurred. Moreover, due to WBV-related side effects like physical exhaustion, 11% of all training sessions had to be stopped and another 11% required reductions in the vibration load. Patients participated in 48% of the planned sessions. While main reasons for non-attendance were medical issues (35%), only few WBV sessions were missed, not completed or needed modifications due to motivational issues. Consequently, WBV seems to be feasible for inpatient pediatric patients receiving chemotherapy for first cancer diagnosis, given a sufficiently high platelet count of at least 30,000/μL. Although WBV tolerance and training motivation appear high, patient’s reduced medical condition during hospitalization can negatively impact training progression and attendance. Future research is required to confirm our findings on feasibility and to assess efficiency of WBV training for pediatric cancer patients receiving cancer treatment.

A Bout of High-Intensity Interval Training (HIIT) in Children and Adolescents during Acute Cancer Treatment-A Pilot Feasibility Study

Low- and moderate-intensity exercise is safe and feasible during childhood cancer treatment. The feasibility of a bout of high-intensity interval training (HIIT) in this population has not been analyzed to date. Pediatric cancer patients aged between 6 and 18 years were selected based on clinical conditions to perform ten sets of 15 s HIIT (>90% of estimated maximal heart rate (HRmax)) and 1 min active recovery on a bicycle ergometer within the first three chemotherapy courses. We assessed safety and feasibility criteria and the following parameters: perceived exertion rate, heart rate, and lactate and adrenaline concentrations. Out of 212 eligible patients, 11 patients aged 13.9 ± 3.6 years (n = 7 ♂) with lymphoma, leukemia, rhabdomyosarcoma, nephroblastoma, and synovial sarcoma completed the bout of HIIT without serious adverse events. During exercise, patients reached a BORG value maxima of 16 ± 1.2, and their heart rates rose from 78 ± 17 beats per minute (bpm) at rest to 178 ± 12 bpm after exercise (90 ± 6% estimated HRmax). The power-to-weight ratio was 2 ± 0.5 W/kg (watt per kilogram). Blood lactate concentrations increased from 1.09 ± 0.50 mmol/L (millimole per liter) at rest to 5.05 ± 1.88 mmol/L post-exercise. Our preliminary data suggest that HIIT is applicable only in a small number of childhood cancer patients. Individually adapted exercise protocols for patients with multiple impairments are needed.

Effects of strength exercise interventions on activities of daily living, motor performance, and physical activity in children and adolescents with leukemia or non-Hodgkin lymphoma: Results from the randomized controlled ActiveADL Study

OBJECTIVES

Pediatric patients with cancer experience impairments in muscle strength and physical activity (PA) that may reduce autonomy during hospitalization. To determine the effects of strength exercise interventions on the accomplishment of activities of daily living (ADLs), motor performance, and PA in children with leukemia or non-Hodgkin lymphoma, we randomly allocated patients (4-18 years) immediately after diagnosis into two exercise groups.

METHODS

The intervention group (IG; n = 21) received a specific strength training combined with a standard care exercise program, whereas the control group (CG; n = 20) was provided standard care exercise program without any targeted muscle strengthening. After the baseline visit, participants were followed-up three times until intensive treatment cessation. We assessed physical function limitations using the Activities Scale for Kids© (ASK) and Functional ADL Screen. Secondary outcomes were PA levels using accelerometer and motor performance as measured by MOON-test (motor performance in pediatric oncology-test).

RESULTS

In both groups, ADL accomplishment had significantly increased (p < 0.05). However, no significant between-group differences for ASK outcome were noted. Motor performance was reduced in all motor abilities.

CONCLUSIONS

Both exercise interventions were effective to maintain ADLs and motor performance during intensive treatment. In comparison, regular strength exercise interventions in the course of therapy tended to be more beneficial with regards to muscular explosive and endurance strength.

Bewegungsförderung während der kinderonkologischen Akuttherapie

Hintergrund

Obwohl Studien zeigen, dass Bewegungsinterventionen während der stationären kinderonkologischen Akuttherapie sicher durchführbar sind und positive Effekte haben, fehlt es an einer flächendeckenden sporttherapeutischen Versorgung.

Ziel der Arbeit

Die vorliegende Publikation analysiert Daten zur Teilnahme, zu Hindernissen und zur Gestaltung eines stationären Sportprogramms mit den Zielen, Hinweise für die Etablierung weiterer Sportangebote zu generieren und die Bewegungsförderung während der pädiatrisch-onkologischen Akuttherapie zu verbessern.

Material und Methoden

Die Daten wurden zwischen September 2015 und August 2019 im Rahmen eines stationären Sportprogramms für onkologisch erkrankte Kinder und Jugendliche im Alter zwischen 2 und 22 Jahren erhoben.

Ergebnisse

In das Sportprogramm wurden 63 Kinder und Jugendliche für durchschnittlich 26 Wochen eingebunden. Die Teilnehmer*innen absolvierten 14,83 ± 12,25 von 28,17 ± 20,05 angebotenen Einheiten (Teilnahmequote: 56 %). Medizinische Gründe waren die häufigste Ursache, weshalb eine Trainingseinheit nicht wahrgenommen wurde. Nur 10 % der Einheiten wurden aus mangelnder Motivation abgelehnt. Die Dauer der Trainingseinheiten betrug ca. 25 min. Die Intensität lag im leichten bis moderaten Bereich.

Diskussion

Die Ergebnisse belegen das Interesse der Betroffenen an einem stationären Bewegungsangebot. Die Vielfalt der Trainingsinhalte unterstreicht die Bedeutung einer individuellen Adaptation der Sporttherapie. Gleichzeitig wird die Notwendigkeit eines „Minimalprogramms“ mit sehr leichten Intensitäten hervorgehoben. Optimierungsmöglichkeiten bestehen u. a. in einer höheren zeitlichen Flexibilität des Angebotes sowie der Ergänzung um ein selbstständiges Training mithilfe eines Bewegungsplanes.

The international Pediatric Oncology Exercise Guidelines (iPOEG)

Physical activity (PA) and exercise are safe and beneficial for children and adolescents affected by cancer. Yet, this population is not active enough to receive benefits. PA guideline and recommendation statements can support individual behavior and practice change. The purpose of this project was to develop the international Pediatric Oncology Exercise Guidelines (iPOEG), comprised of guideline and recommendation statements, to promote PA among children and adolescents affected by cancer. Guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to the iPOEG network (n = 9 core team members, n = 122 expert consensus committee members). Surveys included closed- and open-ended items informed by a literature synthesis and an in-person meeting. Responses were analyzed using descriptive statistics and content analysis. Consensus was defined as ≥ 80% agreement. Response rates to online surveys ranged from 82% to 91%. The iPOEG network agreed on four guideline and five recommendation statements, which highlight that movement is important for all children and adolescents affected by cancer. These statements are generic in nature as more research is still required to provide specific guidance on the frequency, intensity, time, and type of PA for this population. Nevertheless, the iPOEG statements represent available evidence and expert opinion, collectively suggesting that it is time for children and adolescents affected by cancer to move more.

Physical activity is safe and beneficial for children and adolescents affected by cancer. Yet, most are not active enough to receive benefits. Guideline and recommendation statements can help change individual behavior and practice. To develop such statements, guideline development procedures, stakeholder engagement strategies, and the Delphi technique were used. Four online surveys were distributed to an international network (n = 131 experts). Surveys asked closed- and open-ended questions informed by a literature synthesis and an in-person meeting. Findings from the online surveys resulted in the international Pediatric Oncology Exercise Guidelines statements, which highlight that it is time for children and adolescents affected by cancer to move more.

Adverse Events During Supervised Exercise Interventions in Pediatric Oncology-A Nationwide Survey

Objectives: Exercise interventions during and after treatment for pediatric cancer are associated with beneficial physical, psychological, and social effects. However, valid data about adverse events (AEs) of such interventions have rarely been evaluated. This retrospective study evaluates AEs that occurred during supervised oncological exercise programs for pediatric cancer patients and survivors. Methods: This Germany-wide study used a self-administered online survey focusing on general program characteristics and AEs retrospectively for 2019. The questionnaire included (a) basic data on the offered exercise program, (b) AEs with consequences (Grade 2-5) that occurred in 2019 during an exercise intervention, (c) number of Grade 1 AEs, (d) safety procedures as part of the exercise programs, and (e) possibility to give feedback and describe experience with AEs in free text. Results: Out of 26 eligible exercise programs, response rate of program leaders was 92.3% (n = 24). Representatives working for Universities (n = 6), rehabilitation clinics (n = 3), acute cancer clinics (n = 12), and activity camps (n = 3) participated. In total, 35,110 exercise interventions with varying duration were recorded for 2019. Six AEs with consequences (Grade 2-3) occurred during exercise interventions after cancer treatment resulting in an incidence of 17 per 100,000 exercise interventions (0.017%). No life-threatening consequences or death were reported and no serious AE occurred during acute cancer treatment. Grade 1 AE occurred with a frequency of 983, corresponding to an incidence of 2,800 per 100,000 interventions (2.8%). Most frequent Grade 1 AE were muscle soreness, circulatory problems, and abdominal pain. The most frequent preventive safety procedures at the institutions were regular breaks, consultations with the medical treatment team, and material selection with low injury potential. Conclusions: Supervised exercise interventions for pediatric cancer patients and survivors seem to be safe and AEs with consequences comparatively rare when compared to general childhood population data. Occurrence of grade 1 AEs was common, however, causality was probably not evident between AEs and the exercise intervention. Future research should standardize assessment of AEs in clinical practice and research, and prospectively register and evaluate AEs that occur in the context of exercise interventions in pediatric cancer patients and survivors.

Positive Impact of Organized Physical Exercise on Quality of Life and Fatigue in Children and Adolescents With Cancer

Background: Cancer and its treatment can cause serious health issues that impair physical and mental well-being in children and adolescents. Exercise may be a valid strategy for managing some symptoms, including fatigue. In the light of our experience, we provide further justification for including exercise as part of routine childhood cancer care. Methods: Forty-four children and adolescents who had solid cancers not contraindicating their movement were invited to join an in-hospital 6-week supervised exercise program, and asked afterwards to complete validated quality of life and fatigue scales. The program consisted of personalized workout sessions of aerobic, resistance and flexibility exercises. The results obtained on the scales were compared between 21 patients who engaged in the exercise program (GYM group) and 23 who refused (No-GYM group), examining the different dimensions of health-related quality of life (physical, emotional, cognitive, social) and fatigue (general, sleep/rest, cognitive) in the two groups. Results: Being diagnosed with cancer initially prompted all but one of the respondents to drop-out of previous routine exercise or sports although their continuation had not been contraindicated. After 6 weeks of exercise, the GYM group's scores for quality of life and fatigue showed a statistically significant better perceived emotional functioning, and a trend toward a better social functioning than in the No-GYM group. Conclusion: We suggest that exercise improves the satisfaction of children and adolescents with cancer with their physical, mental and social functioning. We would emphasize the potential benefits of general practitioners discussing and recommending exercise for their young patients with cancer.

Feasibility and Acceptability Findings of an Energy Balance Data Repository of Children, Adolescents, and Young Adults with Cancer

Cancer patients suffer changes in energy balance (EB), the combination of energy intake (nutrition) and energy expenditure (physical activity (PA)), which may influence cancer-related morbidity, mortality, and quality of life. Significant gaps remain in our understanding of the frequency and magnitude of these EB changes. Herein, we report on the feasibility and acceptability of a longitudinal repository of EB outcomes in children, adolescents and young adults (AYA) with cancer along the cancer continuum to fill these gaps. This EB repository includes PA, nutrition, and physical function (PF) parameters. PA data were gathered through activity trackers. Nutritional data were gathered through food diaries and micronutrient labs. PF was assessed with validated objective and patient-reported measures. Feasibility was achieved with >50% enrollment of eligible patients (n = 80, Mage = 18.1 ± 7.5); 26 were children with cancer and 54 were AYAs with cancer. An 88.75% retention rate indicated acceptability. Despite COVID-19 disruptions, >50% of participants provided completed data for PA and micronutrient labs as of April 2020. Food diaries and PF data collection experienced disruptions. Methodological adaptations are in progress to minimize future disruptions. Overall, our findings demonstrate that prospective EB assessments are feasible and acceptable among children and AYAs with cancer.

Body Composition in Pediatric Solid Tumors: State of the Science and Future Directions

Sarcopenia (severe skeletal muscle wasting) and sarcopenic obesity (skeletal muscle wasting in the setting of excess fat) have been increasingly recognized as important prognostic indicators in adult oncology. Unfavorable changes in lean and adipose tissue masses manifest early in therapy and are associated with altered chemotherapy metabolism as well as increased treatment-related morbidity and mortality. Existing literature addresses the role of body composition in children with hematologic malignancies; however, data is lacking among solid tumor patients. Advances in imaging techniques for quantification of tissue compartments potentiate further investigation in this highly understudied area of pediatric oncology. The following review presents an in-depth discussion of body composition analysis and its potential role in the care of pediatric solid tumor patients. Integration of body tissue measurement into standard practice has broad clinical implications and may improve quality of life and treatment outcomes in this at-risk population.

Children's physical activity behavior following a supervised physical activity program in pediatric oncology

BACKGROUND

The theory of planned behavior (TPB) model and its components have been applied to comprehend the adoption of physical activity along with informational and motivational parameters. Thus, the first aim of this exploratory study was to explore the evolution of children's physical activity levels over a supervised physical activity program. The second aim was to describe the evolution of TPB measures, self-reported fitness and self-esteem in the physical domain to better understand children's physical activity behavior over the course of the physical activity program.

METHODS

A total of 16 children (8 boys and 8 girls) with cancer answered psychosocial questionnaires before and after a supervised physical activity program to explore the TPB measures, self-reported fitness, self-esteem in the physical domain and their daily physical activities.

RESULTS

A significant increase of 13.8 min/day [95% CI (16.7; 10.8); p < 0.0001; d = 1.4] of daily MVLPA was observed between the time before (9.3 ± 9.1 min/day) and after (23.1 ± 10.8 min/day) the physical activity program. We found that the physical activity program positively impacted children's TPB measures (mean in attitude, identity, facilitating factors, self-confidence and intention) and MVLPA levels. The TPB model explained 36.2% of the variance in MVLPA by injunctive norms after the physical activity program.

CONCLUSION

This study highlighted the need to provide children with physical activity support as soon as the cancer is diagnosed and showed that children's physical activity behaviors were facilitated by familial support measured by injunctive norms.

The impact of cancer on theory of planned behavior measures and physical activity levels during the first weeks following cancer diagnosis in children

BACKGROUND

The theory of planned behavior (TPB) is used to document children's health behaviors linked to their physical activity. The TPB model and its components have been applied to comprehend the adoption of physical activity along informational and motivational parameters. Thus, this exploratory study aims to assess the evolution of children's physical activity levels (MVLPA) during the first weeks of their cancer, in addition to documenting the evolution of the TPB measures, self-reported fitness, and self-esteem in the physical domain to better understand children's physical activity behavior.

METHODS

A total of 16 children (8 boys and 8 girls) with cancer answered psychosocial questionnaires at the diagnosis of cancer (time 1) and at 6 to 8 weeks (time 2) to assess the TPB measures, self-reported fitness, self-esteem in the physical domain, and their daily physical activities.

RESULTS

A significant decrease of 41.2 min/days of daily MVLPA was observed between the time at cancer diagnosis (50.5 ± 32.8 min/days) and 6 to 8 weeks after the first interview (9.3 ± 9.1 min/days). We found that the time after the diagnosis of cancer negatively impacted children's TPB measures (mean in attitude, injunctive norms, identity, facilitating factors, self-confidence, and intention) and MVLPA levels. The TPB model explains 40% of the variance in MVLPA by the injunctive norms during the first weeks following cancer diagnosis in children.

CONCLUSION

The findings of this study highlight the negative impacts of cancer on children's TPB measures, self-reported fitness, and self-esteem in the physical domain and self-reported MVLPA levels over 4 to 6 weeks following the diagnosis. These findings help to better understand the effect of cancer diagnosis on children's physical activity behavior.

The effect of exercise and motor interventions on physical activity and motor outcomes during and after medical intervention for children and adolescents with acute lymphoblastic leukemia: A systematic review

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) experience detrimental effects on motor function during and after chemotherapy. The objective of this systematic review was to evaluate the effect of exercise and motor interventions on physical activity and motor outcomes of children with ALL during and after chemotherapy.

METHODS

Ten databases were searched. Nineteen studies were included: 11 randomized clinical trials (RCT), 2 controlled clinical trials (CCT), and 6 cohort studies.

RESULTS

Participants included 508 children with ALL. Between-group results from RCTs and CCTs supported that exercise and motor intervention improved: fatigue during acute chemotherapy; physical activity, range of motion (ROM), strength, bone mineral density, aerobic capacity, and fatigue during maintenance chemotherapy; functional mobility, ROM, strength, and aerobic capacity during post-treatment survivorship; and participation, physical activity, ROM, strength, and coordination during multiple-phase interventions.

CONCLUSION

Low quality evidence supports the efficacy of motor and exercise interventions for children and adolescents with ALL.

Exercise as a Potential Intervention to Modulate Cancer Outcomes in Children and Adults?

Exercise is recommended for the healthy population as it increases fitness and prevents diseases. Moreover, exercise is also applied as an adjunct therapy for patients with various chronic diseases including cancer. Childhood cancer is a rare, heterogeneous disease that differs from adult cancer. Improved therapeutic strategies have increased childhood cancer survival rates to above 80% in developed countries. Although this is higher than the average adult cancer survival rate of about 50%, therapy results often in substantial long-term side effects in childhood cancer survivors. Exercise in adult cancer patients has many beneficial effects and may slow down tumor progression and improve survival in some cancer types, suggesting that exercise may influence cancer cell behavior. In contrast to adults, there is not much data on general effects of exercise in children. Whilst it seems possible that exercise might delay cancer progression or improve survival in children as well, there is no reliable data yet to support this hypothesis. Depending on the type of cancer, animal studies of adult cancer types show that the exercise-induced increase of the catecholamines epinephrine and norepinephrine, have suppressive as well as promoting effects on cancer cells. The diverse effects of exercise in adult cancer patients require investigating whether these results can be achieved in children with cancer.

The health behaviour status of teenage and young adult cancer patients and survivors in the United Kingdom

PURPOSE

The primary aim of this study was to investigate the health behaviour status of teenage and young adult (TYA) cancer patients and survivors; the secondary aim was to determine if TYA cancer patients and survivors health behaviour differs to general population controls.

METHODS

Two hundred sixty-seven young people with cancer (n =83 cancer patients receiving active treatment: n =174 cancer survivors, 57.1% >1 year since treatment completion) and 321 controls completed a health and lifestyle questionnaire which included validated measures of physical activity (PA) (Godin Leisure Time Exercise Questionnaire), diet (Dietary Instrument for Nutrition Education, DINE), smoking status, and alcohol consumption (AUDIT-C).

RESULTS

General population controls and cancer survivors were more likely to meet current (PA) recommendations (p <0.001) than TYA cancer patients undergoing treatment (54.8% vs 52.3% vs 30.1%, respectively). Less than 40% of young people with cancer and controls met fat intake, sugar intake, fibre intake or current fruit and vegetable recommendations. TYA cancer survivors were more likely to report binge drinking than controls (OR=3.26, 95% CI 2.12-5.02, p <0.001). Very few young people with in the study were current smokers. The majority of TYA cancer patients and survivors reported a desire to make positive changes to their health behaviour.

CONCLUSION

Consideration should be given to whether existing health behaviour change interventions which have demonstrated positive effects among the general TYA population could be adapted for young people with cancer.

Short-Term Consequences of Pediatric Anti-cancer Treatment Regarding Blood Pressure, Motor Performance, Physical Activity and Reintegration Into Sports Structures

Background: Cardiovascular diseases in childhood cancer survivors are known late sequelae following treatment. Arterial stiffness, pulse wave velocity (PWV) and central systolic blood pressure (cSBP) are potential predictors to assess the status of cardiovascular health. Frequent inpatient stays and reduced physical activity (PA) during treatment can lead to noticeable impairments regarding motor skills and physical performance. The present study examined parameters of cardiovascular health, motor performance and the status of integration into sports structures shortly after cessation of treatment. Methods: A cross-sectional, monocentric study was conducted from April to June 2019. Participants (6-18 yrs, mixed cancer entities) during maintenance therapy and follow-up care were recruited. Peripheral and central systolic/diastolic blood pressure (pSBP, pDBP, cSBP) and PWV were assessed using the Mobil-O-Graph®. The MOON test (MOtor performance in pediatric ONcology) was used to scale motor performance. PA levels and status of integration into sports structures were assessed with a questionnaire referring to the KiGGS study. All measured data were compared to published reference values. Results: Forty participants (11.3 ± 3.8 years, 50% female) were recruited 1.6 ± 1.8 years post-treatment. PSBP (z-score: 0.87 ± 0.67, p = 0.003), pDBP (0.83 ± 1.94, p = 0.033) and cSBP (≥8 years: 0.60 ± 1.29, p = 0.011) were significantly increased compared to reference values. PWV was also elevated, but not significantly. Motor performance was reduced in almost all motor abilities. Thirty-six percent of the examined group did not participate in physical education at school to the full extent. Only 17% reported 1 hour of daily moderate-to-vigorous PA as recommended for children and adolescents by the World Health Organization. Half of the participants were active sports club members before treatment, but one third did not resume their former membership. Conclusion: Increased cardiovascular parameters and impaired motor performance shortly after cessation of treatment, physical inactivity, and low rates of integration into regular sports programs highlight the support needed. Young cancer patients should receive early support in coping with physical limitations preferably soon after diagnosis. Motor deficits could be reduced by applying targeted interventions. Furthermore, a regular sports therapy program during in- and outpatient care could increase engagement in PA to possibly counteract risk factors and improve cardiovascular health.

Exploring the feasibility and acceptability of a mixed-methods pilot randomized controlled trial testing a 12-week physical activity intervention with adolescent and young adult cancer survivors

Background

Adolescent and young adult (AYA) cancer survivors (i.e. individuals diagnosed with cancer between 15 and 39 years and who completed treatment) may benefit from physical activity. Yet, few researchers have explored the effects of physical activity on physical and psychological outcomes among AYA cancer survivors. A pilot study exploring the feasibility and acceptability of a physical activity intervention and proposed trial methods to inform a definitive randomized controlled trial (RCT) is therefore necessary to fill this gap.

Methods

A two-arm, mixed-methods pilot RCT was conducted. Participants were randomized to a wait-list control group or a 12-week physical activity intervention comprised of 4 weekly aerobic and strength training sessions (intervention group). Feasibility measures included: number of AYA cancer survivors referred/self-referred, eligible, and recruited, retention to the trial (i.e. assessment completion), adherence to the physical activity intervention, and percentage of missing data for baseline (week 0), mid- (week 6), and post-intervention assessments (week 12). The acceptability of trial methods (all participants) and the intervention (intervention group only) was assessed via qualitative interviews post-intervention.

Results

Over a 12-month period, 31 AYA cancer survivors were referred/self-referred and 16 were eligible and consented to participate. Retention to the trial was 94% and adherence to the physical activity intervention ranged from 50 to 92%. With the exception of the assessment of aerobic capacity and directly measured physical activity behaviour, there were no missing data. Participants generally reported being satisfied with the trial methods and intervention; however, issues related to delivery of the physical activity intervention were identified.

Conclusions

The methods and intervention piloted require modification and further pilot testing in advance of a definitive RCT. Recruitment strategies identifying a greater number of younger AYA cancer survivors who have different types of cancers and who lack motivation to participate in physical activity-based studies should be explored. Refining the assessments of directly measured physical activity behaviour and aerobic capacity and incorporating behavioural support into the intervention may improve feasibility and acceptability. This study highlights the value of doing pilot work and provides critically useful data that can be used to refine studies seeking to assess causation and optimize physical activity interventions for AYA cancer survivors.

Trial registration

clinicaltrials.gov, NCT03016728. Registered January 11, 2017.

The effect of an active video game intervention on physical activity, motor performance, and fatigue in children with cancer: a randomized controlled trial

Objective

To evaluate the effect of active video games in promoting physical activity and motor performance, and reducing fatigue in children with cancer. A randomized controlled trial was conducted. The intervention included playing Nintendo Wii™Fit (Nintendo Co., Ltd., Kyoto, Japan) for 30 min/day for 8 weeks. Physical activity was estimated with accelerometers, physical activity diaries and questionnaires. Movement-ABC2 and PedsQL™ were used to examine motor performance and fatigue. Intervention experiences and fidelity were examined with an interview.

Results

Participants (n = 36 children with cancer, 3–16 years-old) were randomly assigned to the intervention and control groups. The median [min–max] accelerometer counts/h (500 [131–1130] vs 385 [116–1012], p = 0.63) and physical activity min/day (34 [0–150] vs 23 [0–260], p = 0.95) did not differ between the groups. Change between the pre-test and post-test regarding motor performance and fatigue was similar in both groups (motor performance p = 0.77; fatigue p = 1.00). Participants experienced playing active video games meaningful, but the intervention was not followed completely as instructed. Overall, the physical activity levels were low and one fourth of the children had or were at risk of having movement difficulties.

Trial registration: ClinicalTrials.gov identifier: NCT01748058 (October 15, 2012)

Effects of multimodal exercise on clinical status and patient-reported outcomes in children undergoing hematopoietic stem cell transplantation

There are limited data available regarding effectiveness of exercise training in children undergoing hematopoietic stem cell transplantation (HSCT). We aimed to investigate effects of multimodal exercise program on clinical status and patient-reported outcomes including pain, fatigue, depression, and quality of life (QOL) level of children and their parents' QOL level. Twenty-six children undergoing HSCT participated in this study. Clinical status, pain, fatigue, depression, and QOL level of children were assessed three times: before HSCT, at discharge, and one month later. For intervention group (IG, n = 15), multimodal exercise program was performed five days a week, throughout hospitalization and children were advised to continue exercise program at home. For control group (CG, n = 11), being active as much as possible was advised. The number of painful day and pain intensity was significantly lower in IG than in CG during hospitalization (p < .05). Depression level decreased in IG at the time points (p ˂ .05); however, there was no significantly difference between groups. The QOL level was higher in IG than CG only at control measurements (p ˂ .05). In addition, QOL level of the parents decreased in both groups (p ˂ .05). There was no statistically difference between groups in terms of other clinical variables. The multimodal supervised exercise program has positive effects on children's pain and QOL level. Exercise program was also well tolerated by children during hospitalization. In addition, QOL levels of the parents were also negatively affected during hospitalization, and interventions aiming to increase QOL level of the parents should be considered.

Exercise during preoperative therapy increases tumor vascularity in pancreatic tumor patients

The efficacy of chemotherapy is reduced by dysfunctional tumor vasculature, which may limit chemotherapy delivery to tumors. Preclinical studies have shown that moderate aerobic exercise improves tumor vascular function and increases chemotherapy efficacy in mouse models, but the effect of exercise on human tumor vasculature has not yet been determined. Here, we demonstrate that exercise remodels the tumor vasculature, accelerates the regression, and delays the regrowth of pancreatic ductal adenocarcinoma in a patient-derived xenograft mouse model treated with gemcitabine. By evaluating pancreatic adenocarcinoma specimens from patients treated with preoperative chemotherapy or chemoradiation therapy, we also demonstrate for the first time that tumor vascular remodeling occurs in association with exercise in humans. Future studies will evaluate whether exercise-induced vascular remodeling improves gemcitabine or other chemotherapy efficacy in patients, as this study evaluated only changes in tumor vascular structure.

Sport activities and exercise as part of routine cancer care in children and adolescents

The burden of morbidities affecting cardiovascular and musculoskeletal systems, metabolism, and psychosocial health in young patients with cancer is high. It is alarming that patients and survivors of childhood cancer are less physically active than their healthy peers, since exercise may improve many of these conditions significantly and is associated with reduction in all-cause mortality in the general population. Systematic integration of exercise programing into cancer care remains an exception, above all in children. Pediatric oncologists may contribute to a culture shift towards educating patients and stakeholders on the benefit of exercise and sports for children and adolescents with cancer.

Whole-body vibration in children with disabilities demonstrates therapeutic potentials for pediatric cancer populations: a systematic review

PURPOSE

Low levels of physical activity often observed in pediatric oncology might be attributed to various functional deficits, especially those of the lower limbs as these affect gait, mobility, and, consequently, physical activity. In the past few years, whole-body vibration (WBV) has emerged as a new therapy modality for improving physical functioning. Although WBV is increasingly applied in children with disabilities, its impact on lower limb function in pediatric cancer patients and survivors has not yet been investigated.

METHODS

To establish whether there is evidence that WBV may be beneficial for pediatric cancer patients and survivors, this review summarizes current data on WBV studies among children with disabilities and extracts relevant information for the pediatric cancer population. Two independent reviewers performed a systematic literature search following the PRISMA guidelines.

RESULTS

Nine studies were included in the analysis. Results demonstrate that WBV is a safe, highly compliant, and effective approach in cohorts of children with disabilities. The largest effects of WBV were observed in lower extremity muscle mass and strength, balance control, gait, and walking ability. Furthermore, we were able to develop first recommendations for WBV protocols.

CONCLUSIONS

WBV seems to be feasible and effective for improving parameters that may be relevant to the pediatric cancer population. Efforts are needed to conduct first WBV interventions in children with cancer proving the effects. The developed recommendations for WBV protocols might help to implement these intervention studies.

Testing physical function in children undergoing intense cancer treatment-a RESPECT feasibility study

BACKGROUND

The physical function of children with cancer is reduced during treatment, which can compromise the quality of life and increase the risk of chronic medical conditions. The study, "REhabilitation, including Social and Physical activity and Education in Children and Teenagers with cancer" (Clinicaltrials.gov: NCT01772862) examines the efficacy of multimodal rehabilitation strategies introduced at cancer diagnosis. This article addresses the feasibility of and obstacles to testing physical function in children with cancer.

METHODS

The intervention group comprised 46 males and 29 females aged 6-18 years (mean ± SD: 11.3 ± 3.1 years) diagnosed with cancer from January 2013 to April 2016. Testing at diagnosis and after 3 months included timed-up-and-go, sit-to-stand, flamingo balance, handgrip strength, and the bicycle ergometer cardiopulmonary exercise test (CPET).

RESULTS

Of the 75 children, 92% completed a minimum of one test; two children declined testing and four were later included. Completion was low for CPET (38/150, 25%) but was high for handgrip strength (122/150, 81%). Tumor location, treatment-related side effects, and proximity to chemotherapy administration were primary obstacles for testing physical function. Children with extracranial solid tumors and central nervous system tumors completed significantly fewer tests than those with leukemia and lymphoma. Children with leukemia demonstrated reduced lower extremity function, that is, 24% reduction at 3 months testing in timed-up-and-go (P = 0.005) and sit-to-stand (P = 0.002), in contrast with no reductions observed in the other diagnostic groups.

CONCLUSION

Children with cancer are generally motivated to participate in physical function tests. Future studies should address diagnosis specific obstacles and design testing modalities that facilitate physical function tests in this target group.

Feasibility and effects of a home-based intervention using activity trackers on achievement of individual goals, quality of life and motor performance in patients with paediatric cancer

OBJECTIVES

Supervised exercise interventions during inpatient care are feasible. The objective was to evaluate the usability of activity trackers and centralised monitoring to conduct a home-based exercise intervention during cancer treatment. The primary endpoint and confirmatory analysis was achievement of individual goals for daily steps, compared (A) in the intervention group (IG) over time and (B) between the IG and control group (CG). Secondary endpoints included achievement of goals for active minutes and effects on motor performance and health-related quality of life (hrQoL).

METHODS

Forty patients treated for paediatric cancer (14.7±3.9 years) were included. The IG received a 6-8 week intervention during acute treatment (T1) and a 2-week intervention in transition to aftercare (T2). The CG only received the intervention at T2. Baseline tests to assess motor performance and physical activity were conducted prior to every intervention.

RESULTS

In the primary confirmatory analysis, the IG significantly improved achievement of individual step goals (p=0.04) whereas group analyses did not reveal significant differences. Achievement of active minutes remained low (p=0.23). IG scored higher in hrQoL than CG (p<0.01) and percentage of children scoring below normative value in strength tests was higher in CG. Of all participants, 94% rated the intervention as meaningful and 80% as motivational.

CONCLUSIONS

Results of this study indicate that this intervention for home stays with centralised supervision is feasible and leads to increased achievement of individual step goals. Despite the positive effects on hrQoL, further strategies are needed to increase positive effects on motor performance.