Physical activity of pediatric patients with acute leukemia undergoing induction or consolidation chemotherapy

Exploring the role of pain on physical activity among youth with acute lymphoblastic leukemia using the biopsychosocial model

BACKGROUND

Engaging in physical activity (PA) throughout cancer treatment offers many benefits, but may be challenging due to cancer-related pain. Pain research in pediatric cancer has primarily focused on procedural pain, with fewer studies exploring how pain affects PA. The current study qualitatively investigated the impact of pain on PA in youth with acute lymphoblastic leukemia (ALL) using a biopsychosocial framework.

PROCEDURE

As part of a larger study, caregivers (N = 17) of a child diagnosed with ALL and on treatment for less than 1 year completed a semi-structured interview about perceptions of their child's health behaviors during ALL treatment. This secondary analysis focused specifically on discussions about pain and its impact on PA. We followed Braun and Clarke's (2006) six-step thematic analysis framework to identify themes of pain-related barriers to PA.

RESULTS

Key pain-related barriers endorsed by caregivers included: interactions among pain and treatment effects, caregiver distress around seeing their child in pain, and fear of interfering with medical equipment. Despite these barriers, caregivers found creative solutions to adapt activities for their child. Caregivers were reassured by PA advice from their medical team; however, advice varied between teams.

CONCLUSION

The relationship between pain and PA during ALL treatment is influenced by an intricate system of biological (e.g., treatment effects), psychological (e.g., parental distress), and social (e.g., communication among families and medical teams) factors. Future directions include identifying evidence-based PA recommendations and exploring family-team communication dynamics. This study also highlights a need to prioritize ALL pain management and involve caregivers in behavioral treatment protocols to improve PA.

Caregiver perceptions of child heath behaviors and weight during treatment for acute lymphoblastic leukemia

BACKGROUND

Changes in health behaviors and weight are common during the early phases of pediatric acute lymphoblastic leukemia treatment, and may negatively impact treatment tolerability. Given that ALL is most prevalent in children, caregivers play an essential role in shaping health behaviors during treatment. This study presents a qualitative analysis of semi-structured interviews with caregivers of youth in the early phases of ALL treatment.

PROCEDURE

Caregivers (N = 17, 95% female) of a child (M age = 6.76 years) diagnosed with ALL and on treatment for less than 1 year (M = 8.7 months since diagnosis) completed a semi-structured interview about perceptions of their child's nutrition, physical activity, sedentary time, and weight during ALL treatment. Thematic analysis followed Braun and Clark's six-step framework (2006). Two coders established reliability (alpha = .88) and used a multi-pass coding system to extract themes.

RESULTS

Caregivers' concerns around their child's weight during ALL treatment primarily centered around avoiding malnutrition. Weight gain during treatment was less of a concern and often viewed as protective. Caregivers reported encouraging their child to eat palatable, calorie-dense foods to mitigate risk for weight loss. Caregivers also expressed concern that children were less active and more sedentary due to treatment-related pain. Caregivers discussed health behaviors during treatment as being child-directed, rather than parent- or provider-directed.

CONCLUSION

Future interventions may consider strategies to engage in joint parent-child decisions and caregiver education around risks of excessive weight gain during treatment. Interventions should include anticipatory guidance and aim to support parents in developing skills to support their child's health behaviors during treatment.

Family Rules and Routines During the Early Phases of Pediatric Cancer Treatment: Associations With Child Emotional and Behavioral Health

OBJECTIVE

Consistent family rules and routines promote positive adaptation to stress and may be protective to child emotional and behavioral functioning. Few studies have quantified family engagement in these behaviors during pediatric cancer treatment or examined associations with child emotional and behavioral health.

METHODS

In this cross-sectional observational study, 86 primary caregivers of youth ages 2-14 years (M = 7.9) with an initial diagnosis of cancer within 16 weeks reported on their frequency of engagement in family rules and routines (e.g., sleep, schoolwork, and meal routines) before their child's cancer diagnosis and their current frequency of engagement in the same routines. Caregivers also reported demographics, psychosocial distress, and child emotional and behavioral health outcomes. Analyses examined demographic and psychosocial factors associated with engagement in rules and routines during cancer treatment, and associations with child emotional and behavioral health.

RESULTS

Families reported a lower frequency of engagement in rules and routines during cancer treatment, compared to before treatment (mean difference 0.8 SDs [95% confidence interval 0.7-1.1 SDs]). Caregiver factors associated with lower engagement in rules and routines during treatment included being married, having lower educational attainment, and higher levels of psychosocial distress. Families who engaged in higher levels of rules and routines during treatment reported fewer child externalizing and behavioral challenges. There was limited evidence of association between family rules and routines and child internalizing outcomes.

CONCLUSIONS

Results found that engaging in family rules and routines during cancer treatment was associated with fewer child behavioral challenges during treatment. Future directions include longitudinal examinations of family rules, routines, and child emotional/behavioral outcomes to examine directional impact over time.

Healthcare providers' promotion of physical activity among child and adolescent cancer survivors: strategies and challenges

PURPOSE

This study aims to investigate how healthcare providers (HCPs) promote physical activity (PA) to child and adolescent cancer survivors.

METHODS

Semi-structured interviews were conducted with HCPs (n = 16; women n = 12; men n = 4) who provide care for cancer survivor youth (age 3 to 18). Participants represented 7 professions, including child life specialists, oncologists, nurse practitioners, physical therapists, and social workers. A reflexive thematic analysis was conducted to explore the techniques that HCPs use to promote PA for this patient population and ways PA promotion can improve.

RESULTS

HCPs use five strategies to promote PA to cancer survivor youth: (1) broadening the definition of PA, (2) tailoring PA recommendations, (3) including families, (4) connecting patients to programming, and (5) promoting patient motivation.

CONCLUSIONS

This research highlights techniques that HCPs use to promote PA to young cancer survivors and reveals the need for additional ways to support HCPs to improve PA promotion for child and adolescent cancer survivors. While HCPs emphasized the importance of PA for this patient population, they navigate barriers that limit the quality of PA discussions.

IMPLICATIONS FOR CANCER SURVIVORS

Further research should explore interventions to improve PA promotion and PA participation among child and adolescent cancer survivors. By understanding the perspectives of HCPs, patients, and their families, PA promotion strategies can be improved, and more programs that support both patients and practitioners may be developed.

Physical frailty deteriorates after a 5-day dexamethasone course in children with acute lymphoblastic leukemia, results of a national prospective study

BACKGROUND

Dexamethasone is important in the treatment for pediatric acute lymphoblastic leukemia (ALL) but induces muscle atrophy with negative consequences for muscle mass, muscle strength, and functional abilities. The aim of this study was to establish the effect of a dexamethasone course on sarcopenia and physical frailty in children with ALL, and to explore prognostic factors.

METHODS

Patients with ALL aged 3-18 years were included during maintenance therapy. Patients had a sarcopenia/frailty assessment on the first day of (T1) and on the day after (T2) a 5-day dexamethasone course. Sarcopenia was defined as low muscle strength in combination with low muscle mass. Prefrailty and frailty were defined as having two or ≥three of the following components, respectively: low muscle mass, low muscle strength, fatigue, slow walking speed, and low physical activity. Chi-squared and paired t-tests were used to assess differences between T1 and T2. Logistic regression models were estimated to explore patient- and therapy-related prognostic factors for frailty on T2.

RESULTS

We included 105 patients, 61% were boys. Median age was 5.3 years (range: 3-18.8). At T1, sarcopenia, prefrailty, and frailty were observed in respectively 2.8%, 23.5%, and 4.2% of patients. At T2, the amount of patients with frailty had increased to 17.7% (p = 0.002), whereas the number of patients with sarcopenia and prefrailty remained similar. Higher ASMM (odds ratio [OR]: 0.49, 95% CI: 0.28-0.83), stronger handgrip strength (OR: 0.41, 95% CI: 0.22-0.77) and more physical activity minutes per day (OR: 0.98, 95% CI: 0.96-0.99) decreased the risk of frailty at T2. Slower walking performance (OR: 2, 95% CI: 1.2-3.39) increased the risk. Fatigue levels at T1 were not associated with frailty at T2.

CONCLUSION

Physical frailty increased strikingly after a 5-days dexamethasone course in children with ALL. Children with poor physical state at start of the dexamethasone course were more likely to be frail after the course.

Physical fitness throughout chemotherapy in children with acute lymphoblastic leukaemia and lymphoma

Acute lymphoblastic leukaemia/lymphoma (ALL/LBL) and its treatment interfere with normal physical functioning. However, it remains unclear how physical fitness (PF) is affected throughout treatment for ALL/LBL. Sixty-two patients (2.1 to 18.3 years) treated for ALL/LBL underwent four physical tests at nine timepoints from baseline up to 6 months post-treatment. We assessed muscle strength of the quadriceps and tibialis anterior, standing broad jump test (SBJ) for functional mobility and six-minute walk test (6MWT) for endurance. One-sample t-tests were used to compare our results to the norm at each timepoint. Norm-referenced Z-scores were predicted based on time, risk group and age at diagnosis, using linear mixed models. Quadriceps strength, SBJ and 6MWT scores were significantly lower than norm values at all timepoints from diagnosis up to 6 months after maintenance therapy. Significant decreases over time were encountered for quadriceps strength and SBJ, mainly occurring after induction therapy (F = 3.568, p < 0.001 and F = 2.699, p = 0.008, respectively). Age at diagnosis was a significant predictor for tibialis anterior strength (F = 5.266, p = 0.025), SBJ (F = 70.422, p < 0.001) and 6MWT (F = 15.890, p < 0.001) performances, with lower results in adolescents at all timepoints. Six months after treatment, quadriceps strength, 6MWT and SBJ scores remained below expected levels.

CONCLUSION

The decreased quadriceps strength, functional mobility and endurance at all timepoints, with a large deterioration following induction therapy, suggest the need for early interventions, specifically in the adolescent population. The continued low results 6 months after therapy emphasise the importance of long-term rehabilitation.

WHAT IS KNOWN

•Acute lymphoblastic leukaemia is the most common type of cancer among children, with increasing survival rates due to therapeutic improvements. •Acute lymphoblastic leukaemia/lymphoma and its treatment can cause muscle weakness, neuromuscular toxicity and a decreased cardiopulmonary fitness. Together with physical inactivity, this can result in a decreased physical fitness.

WHAT IS NEW

•Quadriceps strength, functional mobility and endurance are decreased during treatment for acute lymphoblastic leukaemia/lymphoma. The lowest measurements are observed after induction therapy, suggesting the need for early interventions. •We observed continued lower results for quadriceps strength, functional mobility and endurance at the end of treatment, up to 6 months after therapy, supporting the need for long-term rehabilitation.

Integrative Neuromuscular Training in Adolescents and Children Treated for Cancer (INTERACT): Study Protocol for a Multicenter, Two-Arm Parallel-Group Randomized Controlled Superiority Trial

Background

Improved survival rates for children and adolescents diagnosed with cancer call for novel strategies for reducing short- and long-term treatment-related side effects. These include the physical and metabolic sequelae that are exacerbated by sedentary behavior and treatment-induced toxicities. We aim to investigate the effect of an integrative neuromuscular training intervention during the first 6 months of anti-cancer treatment primarily on muscle strength, and secondarily on exercise capacity, physical function, markers of metabolic syndrome, dysmetabolism, and health-related quality of life during and after ended treatment.

Methods

One hundred and twenty-seven children and adolescents, newly diagnosed with malignant and benign neoplasia, aged 6-17 years, and treated with chemotherapy or radiation will be randomized to either the intervention or the control arm of the study. The intervention group will, in addition to usual care, be offered a combination of 6 months of supervised physical exercise (integrative neuromuscular training) and home-based exercise. The active control group will, in addition to usual care, receive information along an unsupervised written home-based training program. All participants, including parents, will receive information about the importance of physical exercise during the course of cancer treatment, at the start of treatment, and in 5 monthly sessions. The primary outcome is measured in terms of isometric quadriceps muscle strength. Secondary outcomes include muscle strength and endurance, markers of metabolic syndrome and dysmetabolism, exercise capacity, physical function and activity, days of hospitalization, and health-related quality of life. Assessment will be conducted at treatment initiation (baseline), at 3 and 6 months after inclusion, and 1 month and 1 year after ended treatment. The primary endpoint for lower-body muscle strength is at 6 months after treatment initiation. The effects of the intervention will be evaluated through a constrained linear mixed model.

Discussion

This national randomized controlled study has the potential to provide new knowledge concerning the short- and long-term effects of a novel, inclusive approach for youth exercise programming (integrative neuromuscular exercise) in children and adolescents during anti-cancer treatment. Using a pragmatic, low-cost, and time-efficient training design, this intervention can be easily adapted to both hospital and home settings.

Clinical Trial Registration

ClinicalTrials.gov (NCT04706676), first released January 5, 2021.

24-Hour Movement Behaviors in Children with Chronic Disease and Their Healthy Peers: A Case-Control Study

Background: Time spent in 24-h movement behaviors is important to health and wellbeing in childhood, but levels of these behaviors in children with chronic disease are unknown. Methods: A case-control-study included 80 children with chronic disease; 20 with type 1 diabetes mellitus (T1DM), 20 with juvenile idiopathic arthritis (JIA), 20 with congenital heart disease (CHD), 20 with cystic fibrosis (CF); pair-matched individually for age, sex, and timing of measures with 80 healthy children. Habitual time spent in movement behaviors and step counts were all measured with an activPAL accelerometer over 7 days. Comparisons against recommendations and differences between the groups were made. Results: Time spent in physical activity and step counts/day were significantly lower in T1DM and CHD groups compared to controls. Only 20/80 children with chronic disease and 29/80 controls met step count recommendations. Sedentary time was significantly higher in children with CF compared to controls. Time spent asleep was slightly greater in children with chronic disease, significant only for the JIA group. Sleep disruption was consistently greater in those with chronic disease, reaching significance for T1DM, CHD, and CF groups. Conclusions: For some groups of children with chronic disease, 24-h movement behaviors may differ substantially from recommendations, and slightly but systematically from their healthy peers. Optimizing levels of 24-h movement behaviors should confer a number of benefits for child health, development, and wellbeing.

Dexamethasone-induced sarcopenia and physical frailty in children with acute lymphoblastic leukemia: Protocol for a prospective cohort study (Preprint)

Background

During treatment for pediatric acute lymphoblastic leukemia (ALL), children receive high doses of dexamethasone for its apoptotic effect on leukemia cells; however, muscle atrophy is a well-known serious side effect. Muscle atrophy (loss of muscle mass) accompanied by a decreased muscle strength may lead to a generalized impaired skeletal muscle state called sarcopenia. Loss of muscle mass is also an indicator of physical frailty, which is defined as a state of increased vulnerability that is characterized by co-occurrence of low muscle mass, muscle weakness, fatigue, slow walking speed, and low physical activity. Both sarcopenia and physical frailty are related to an increased risk of infections, hospitalizations, and decreased survival in children with chronic diseases.

Objective

This study aims to (1) estimate the occurrence of sarcopenia and physical frailty in children during ALL maintenance therapy, (2) evaluate the effect of administering dexamethasone, and (3) explore determinants associated with these outcomes.

Methods

This prospective study is being pursued within the framework of the DexaDays-2 study: a randomized controlled trial on neurobehavioral side effects in pediatric patients with ALL. A total of 105 children (3-18 years) undergoing ALL maintenance treatment at the Princess Máxima Center for Pediatric Oncology are included in this study. Sarcopenia/frailty assessments are performed before and just after a 5-day dexamethasone course. A subset of 50 children participating in the DexaDays-2 trial because of severe dexamethasone-induced neurobehavioral problems were assessed at 3 additional timepoints. The sarcopenia/frailty assessment consists of bioimpedance analysis (skeletal muscle mass [SMM]), handheld dynamometry (handgrip strength), Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (fatigue), Timed Up and Go Test (TUG; walking speed), and physical activity questionnaires. To evaluate potential change in sarcopenia/frailty components after a 5-day dexamethasone administration, a paired Student t test or Mann-Whitney U test will be used. Because of the presence of repeated measurements, generalized linear mixed models will be used to estimate the effect of dexamethasone on sarcopenia and frailty outcomes. Multivariable regression models will be estimated to investigate associations between the assessment scores and patient and treatment-related factors.

Results

Patient accrual started in 2018 and was finalized in spring 2021. From autumn 2021 onward final data analyses will be performed.

Conclusions

This first study combining parameters of sarcopenia and physical frailty is of importance because these conditions can seriously complicate continuation of ALL therapy, independence in physical functioning, reaching motor milestones, and participating in daily life activities. The results will provide knowledge about these complications, the association between dexamethasone treatment and muscle loss and other components of frailty, and therefore insights into the severity of this side effect. By exploring potential determinants that may be associated with sarcopenia and physical frailty, we may be able to identify children at risk at an earlier stage and provide timely interventions.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33517

Evaluation of the functional capacity and quality of life of children and adolescents during and after cancer treatment

Objective:

To evaluate the functional capacity and quality of life of children and adolescents during cancer treatment and post-treatment.

Methods:

Cross-sectional study of patients during cancer treatment and post-treatment, assessed by the 6-minute walk test (6MWT) and the Pediatric Quality of Life ™ questionnaire (cancer module).

Results:

Sixty-five patients, aged 11.2±3.5 years, mostly males (50.8%) and white (90.8%), with high incidence of hematological cancers (81.5%) participated in the study. The performance in the 6MWT was 23.1% inferior comparing the mean predicted and achieved (584.3±5 and 447.7±78.6 m, respectively). The percentage difference between the predicted and achieved 6MWT, and the different phases of cancer treatment were significantly different between patients in treatment (73.7±12.8) and post-treatment (84.5±9.1). When grouped by the different diagnoses, it was possible to observe that the distance covered by the patients with leukemia showed results closer to that predicted (80.7±11.7). Regarding the health-related quality of life questionnaire (HRQL), the child’s perception (78.0±14.56) was better than that reported by their parents (72.4±17.74). However, when we compared HRQL with the 6MWT, there was no association between them (p=0.597).

Conclusions:

Children and adolescents undergoing cancer treatment or post-treatment showed a 23% deficit in functional capacity. In relation to HRQL results, children’s perception was higher than that of their parents.

Daily Physical Activity in Children and Adolescents with Low Lumbar and Sacral Level Myelomeningocele

PURPOSE

Children with low lumbar and sacral level myelomeningocele are expected to be community ambulators. However, they do not always meet the expected ambulation level by the time they reach adulthood. The purpose of this study is to investigate daily activity energy expenditure and physical activity levels of these patients in daily routine.

MATERIALS AND METHODS

20 patients and 20 healthy peers were included in this case-control study. Omnidirectional accelerometer monitor was used for assessing activity energy expenditure, and daily durations spent in sedentary, light activity, and moderate to vigorous physical activity levels (NCT04186338).

RESULTS

Mean activity energy expenditure and moderate to vigorous physical activity duration were significantly lower in the patient group, while age was positively correlated with sedentary time and negatively correlated with light activity time.

CONCLUSIONS

In patients with myelomeningocele, increasing daily activity energy expenditure and moderate to vigorous physical activity and, especially as age progresses, decreasing the sedentary behavior may assist in providing the expected ambulation level. These patients should be encouraged to partake in regular exercise programs.

An evaluation of participation restrictions and associated factors via the ICF-CY framework in children with acute lymphoblastic leukemia receiving maintenance chemotherapy

Our aim was to determine impairments in physical functions, activity limitations, and participation restrictions with the International Classification of Functioning, Disability and Health version for Children and Youth (ICF-CY) framework in children with acute lymphoblastic leukemia (ALL) receiving treatment. Physical functions were assessed in terms of pain level, fatigue level, handgrip strength, and motor proficiency. Fine motor activities and lower extremity performance were assessed to determine activity limitations. Participation was assessed with a patient-reported questionnaire. Thirty children with ALL (mean age: 8.45 ± 3.33 years) were included. Pain and fatigue level were mild. Poor handgrip strength was found; their mean handgrip strength was 60% of the normative. Fifty-six percent of the children had below-average motor performance. Participation scores were considerably high, except for sport and physical functioning sub-score. Participation level was positively associated with bilateral coordination and duration after diagnosis, while negatively correlated with pain and fatigue level (p ˂ 0.05).Conclusion: The ICF-CY-based evaluation was useful to understand children's limitations in everyday life. Children with ALL need supportive interventions during treatments in terms of physical functioning and participation in activities. Children with ALL with higher pain and fatigue, poor bilateral coordination, and who were in earlier period after diagnosis had higher risk for participation restriction. What is Known: • Children with ALL had physical functioning limitations on treatments. • Participation restrictions were described in children with ALL off treatment. What is New: • The ICY-CY-based health and functioning evaluation allows health care professionals to globally determine limitations of everyday life in children with ALL on treatment. • Impairments in physical functions, pain severity, fatigue severity, and duration after diagnosis are associated with participation to everyday life in children with ALL on treatment.

Peak Oxygen Uptake and Exercise Capacity of Children Undergoing Leukemia Treatment

The aim of the study was to assess the exercise capacity (VO_2peak) of children undergoing leukemia treatment and to compare the results with healthy children. Furthermore, we assessed the influence of treatment methods on the level of exercise capacity and the increase in sedentary behaviors. The study comprised 21 children (12 boys and 9 girls) undergoing treatment for acute lymphoblastic leukemia (ALL) (n = 13) and acute myeloid leukemia (AML) (n = 8). The subjects were aged 7-13 years (mean age 10.7, SD 2.0 years). Cardiorespiratory fitness was assessed by using the ergospirometry test. Progressive Godfrey protocol was performed. The level of physical activity was assessed by using the questions from the Health Behavior in School-Aged Children (HBSC 2018) questionnaire. The study results showed that children undergoing leukemia treatment were characterized by a reduced level of exercise capacity. The measured value of VO_2peak in the group of treated children was, on average, 22.16 mL·kg^-1·min^-1. The mean values of VO_2peak predicted for this age group were 45.48 mL·kg^-1·min^-1 (SD, 3.8). The measured value of VO_2peak in the study group with the division into age groups was, on average, 21.21 mL·kg^-1·min^-1 in the group of children aged 7-10 years. In the group of children aged 11-13 years, this parameter was 22.64 mL·kg^-1·min^-1. Lack of physical activity and failure to meet the standards for the minimum level of weekly physical activity (MVPA index-moderate-to-vigorous physical activity) probably contribute to the deterioration in exercise capacity level of cancer-treated children.

Precision-based exercise as a new therapeutic option for children and adolescents with haematological malignancies

Children and adolescents with haematological malignancies (PedHM) are characterized by a severe loss of exercise ability during cancer treatment, lasting throughout their lives once healed and impacting their social inclusion prospects. The investigation of the effect of a precision-based exercise program on the connections between systems of the body in PedHM patients is the new frontier in clinical exercise physiology. This study is aimed at evaluating the effects of 11 weeks (3 times weekly) of combined training (cardiorespiratory, resistance, balance and flexibility) on the exercise intolerance in PedHM patients. Two-hundred twenty-six PedHM patients were recruited (47% F). High or medium frequency participation (HAd and MAd) was considered when a participant joined; > 65% or between 30% and < 64% of training sessions, respectively. The “up and down stairs'' test (TUDS), “6 min walking” test (6MWT), the “5 Repetition Maximum strength” leg extension and arm lateral raise test (5RM-LE and 5RM-ALR), flexibility (stand and reach), and balance (stabilometry), were performed and evaluated before and after training. The TUDS, the 5RM-LE and 5RM-ALR, and the flexibility exercises showed an increase in HAd and MAd groups (P < 0.05), while the 6MWT and balance tests showed improvement only in HAd group (P < 0.0001). These results support the ever-growing theory that, in the case of the treatment of PedHM, ‘exercise is medicine’ and it has the potential to increase the patient’s chances of social inclusion.

Effects of a group-based physical activity program for pediatric patients with cancer on physical activity and symptom experience: A quasi-experimental study

AIMS

To examine the effects of a group-based physical activity intervention on improvement in physical activity and mitigation of symptom distress among pediatric patients with cancer.

METHODS

Based on convenience sampling, 57 pediatric patients with cancer admitted to the cancer center were included in the intervention group. The control group included 57 pediatric patients with cancer from two other hospitals matched to the patients in the intervention group by age, sex, and diagnosis. A group-based physical activity program was implemented among the children in the intervention group, whereas the children in the control group received standard care. Physical activity and symptoms were measured using the Children's Leisure Time Activities Study Survey-Chinese and using the Memorial Symptom Assessment Scale 10-18 at baseline and after the 12^th exercise session in both the intervention and control groups.

RESULTS

The repeated-measures analysis of variance showed that the main intervention effects on the decrease in light-intensity physical activity and increase in moderate-to-vigorous physical activity were significant between the two groups (P < .001). The group-based physical activity intervention could decrease the scores of psychological symptoms (P < .001), Global Distress Index (P < .001), and physical symptoms (P = .01) when comparing the difference between the two groups before and after the intervention. There was no significant difference in the number of symptoms or the total symptom experience score between the two groups.

CONCLUSION

These findings suggest that a group-based physical activity intervention can promote physical activity and relieve psychological and physical symptom distress among pediatric patients with cancer.

The Contribution of Motor Changes to Oral Mucositis in Pediatric Cancer Patients: A Cross-Sectional Study

This study aimed to investigate the contribution of motor changes to oral mucositis in children and adolescents with cancer undergoing antineoplastic treatment in a referral hospital. This was an observational, cross-sectional study with 70 patients aged 2 to 19 years, diagnosed with any type of cancer and treated in a pediatric hospital cancer ward from April to September 2017. A questionnaire related to the patients' socioeconomic and clinical conditions was used, followed by the Oral Assessment Guide and selected domains of the activity and participation section of the International Classification of Functioning, Disability, and Health tool. The data were collected by previously calibrated examiners (kappa index > 0.75) and analyzed using descriptive statistics and logistic regression (α = 5%). Children and adolescents aged 7 to 10 years were more likely to develop oral mucositis (OR: 3.62). In addition, individuals who had severe difficulty in maintaining a body position (OR: 14.45) and walking (OR: 25.42), and those diagnosed with hematologic cancers (OR: 6.40) were more likely to develop oral mucositis during antineoplastic treatment. Within the limitations of this study, it is concluded that motor changes may contribute to the occurrence of oral mucositis in pediatric cancer patients.

Physical Activity, the Childhood Cancer Symptom Cluster-Leukemia, and Cognitive Function: A Longitudinal Mediation Analysis

BACKGROUND

Children undergoing leukemia treatment report co-occurring symptoms of fatigue, sleep disturbances, pain, nausea, and depression as a symptom cluster. Physical activity (PA) is essential for development and may influence symptom severity. Children with leukemia are at risk of cognitive impairments from central nervous system therapies. Using a longitudinal parallel-process model, relationships among function and symptom clusters were explored.

OBJECTIVE

This study examined the longitudinal mediation effects of PA on cognition via a symptom cluster during leukemia treatment.

METHODS

Symptoms, PA, and cognitive function of 327 children aged 3 to 18 years were measured over 4 intervals during the first year of leukemia treatment. Children 7 years or older self-reported and parents reported for younger children. Parents completed cognitive function measurements for all children. The influence of the first time point and the subsequent change between all 4 time points of PA on the symptom cluster were explored. Analysis determined whether the symptom cluster mediated the effect of cognition over the treatment period.

RESULTS

Patients with a higher PA at time 1 reduced their symptom cluster severity over the measurements. However, when PA increased over the measurements, symptom cluster severity also increased. When the symptom cluster was more severe at time 1, cognitive function was lower at time 1, and cognitive function decreased over time. When symptoms became more severe over time, cognitive function declined.

CONCLUSIONS

The symptom cluster acted as a mediator between PA and cognition.

IMPLICATIONS FOR PRACTICE

Symptom management during treatment may be an additional strategy for protecting cognitive function.

Physical Activity and Quality of Life of Healthy Children and Patients with Hematological Cancers

The aim was to assess the level of physical activity and the quality of life of children undergoing cancer treatment, during and after the completion of the treatment. Eighty-eight children aged 11–15 were enrolled. Three groups of children were assessed, i.e., children undergoing cancer treatment (n = 30), children after cancer treatment (n = 28), and healthy children (n = 30). The level of physical activity in children was assessed using the questions from the Health Behavior in School-Aged Children (HBSC) questionnaire. The assessment of children’s quality of life was conducted using the KIDSCREEN-10 Index. The chi-square test was used to assess the statistical significance of the differences in the results between the study groups in the case of both HBSC and KIDSCREEN-10 questionnaires. Children undergoing cancer treatment did not perform any physical activity of at least 60 min (in total) per day, during the week. Therefore, they did not meet the recommendations related to the appropriate level of daily physical activity (Moderate-to-Vigorous Physical Activity; MVPA). Children after cancer treatment and healthy children significantly more frequently undertook physical activity. The quality of life of children with cancer is significantly lower and different from the quality of life of healthy children.

Kids Are Moving: A Physical Activity Program for Children With Cancer

Children undergoing cancer treatment are less active than healthy peers. Inactivity persists into survivorship, negatively influencing health and quality of life. Fatigue is one of the most prevalent symptoms during treatment yet children with increased physical activity (PA) have less fatigue. This pilot study evaluated the impact of coaching on PA and fatigue in children undergoing cancer treatment delivered by pediatric oncology nurse practitioners (NPs) during routine clinic visits. NPs used motivational interviewing during clinic visits to coach children and their families on strategies to increase PA at home. Self-report measures of PA and fatigue were completed at treatment months 2, 4, and 6. PA was also measured using actigraphy. Among 30 children ages 6 to 18 years, 7 had acute lymphoblastic leukemia (ALL), 11 had lymphoma, and 12 had solid tumors. Patterns of fatigue were different by disease group with trends to fatigue decreasing during treatment in the patients with ALL ( p = .09) and lymphoma ( p = .13) but increasing in those with solid tumors ( p = .06). Self-report PA was unchanged. Actigraph measurements remained stable for the group. NPs reported time challenges in implementing coaching during the clinic visit and in providing coaching continuity. The intensive, repeating chemotherapy cycles in solid tumor treatment may contribute to increasing fatigue. Treatment intensity decreases during ALL and lymphoma treatment, which may allow for improvement in fatigue. Inactivity persisted during treatment but did not progress. Future research is needed to evaluate more “dose-intensive” PA interventions in larger samples of specific disease groups.

Assessment of physical function in children with cancer: A systematic review

BACKGROUND

Appropriate selection of robust assessment tools is essential to monitor physical function in children with cancer during and after treatment. This systematic review aims to identify and critically appraise the measurement properties of physical function measures currently used for children with cancer.

PROCEDURE

Two systematic searches of seven electronic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), Medline, PubMed, PsychINFO, Sportsdiscus, EMBASE, and Allied and Complementary Medicine Database (AMED)] were completed to identify physical function measures used in children with cancer and to evaluate their measurement properties. Methodological quality and the adequacy of measurement properties specific to populations of children with cancer were critically appraised using the COSMIN framework to ascertain which measures have evidence to support their use in children with cancer.

RESULTS

One hundred and one physical function measures were identified across 154 studies. Measurement property data were available for 12 measures. The measurement properties of only two outcome measures were assessed in more than one study. Despite some positive measurement property data, there was no assessment tool that had consistent and adequate evidence overall to recommend its use in childhood cancer populations. Poor methodological quality of the included studies was the main limiting factor.

CONCLUSIONS

There is very limited population specific evidence to guide the selection of physical function measures in children with cancer. Further research into the reliability, validity and responsiveness of physical function measures in children with cancer is needed to provide a basis for more effective clinical assessment and management.

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.

Exercise program for children and adolescents with leukemia and lymphoma during treatment: A comprehensive review

An exercise program (EP) during cancer treatment seems to be a valid strategy against physiological and quality-of-life impairments, but scientific evidence of benefits among pediatric patients is still limited. This review summarizes the literature focused on randomized controlled trials of EP offered to patients during leukemia and lymphoma treatment. Studies published up to June 2017 were selected from multiple databases and assessed by three independent reviewers for methodological validity. The review identified eight studies, but several types of bias have to be avoided to provide evidence-based recommendations accessible to patients, families, and professionals.

Accelerometer measured levels of moderate-to-vigorous intensity physical activity and sedentary time in children and adolescents with chronic disease: A systematic review and meta-analysis

Context

Moderate-to-vigorous physical activity (MVPA) and sedentary time (ST) are important for child and adolescent health.

Objective

To examine habitual levels of accelerometer measured MVPA and ST in children and adolescents with chronic disease, and how these levels compare with healthy peers.

Methods

Data sources: An extensive search was carried out in Medline, Cochrane library, EMBASE, SPORTDiscus and CINAHL from 2000–2017.

Study selection: Studies with accelerometer-measured MVPA and/or ST (at least 3 days and 6 hours/day to provide estimates of habitual levels) in children 0–19 years of age with chronic diseases but without co-morbidities that would present major impediments to physical activity. In all cases patients were studied while well and clinically stable.

Results

Out of 1592 records, 25 studies were eligible, in four chronic disease categories: cardiovascular disease (7 studies), respiratory disease (7 studies), diabetes (8 studies), and malignancy (3 studies). Patient MVPA was generally below the recommended 60 min/day and ST generally high regardless of the disease condition. Comparison with healthy controls suggested no marked differences in MVPA between controls and patients with cardiovascular disease (1 study, n = 42) and type 1 diabetes (5 studies, n = 400; SMD -0.70, 95% CI -1.89 to 0.48, p = 0.25). In patients with respiratory disease, MVPA was lower in patients than controls (4 studies, n = 470; SMD -0.39, 95% CI -0.80, 0.02, p = 0.06). Meta-analysis indicated significantly lower MVPA in patients with malignancies than in the controls (2 studies, n = 90; SMD -2.2, 95% CI -4.08 to -0.26, p = 0.03). Time spent sedentary was significantly higher in patients in 4/10 studies compared with healthy control groups, significantly lower in 1 study, while 5 studies showed no significant group difference.

Conclusions

MVPA in children/adolescents with chronic disease appear to be well below guideline recommendations, although comparable with activity levels of their healthy peers except for children with malignancies. Tailored and disease appropriate intervention strategies may be needed to increase MVPA and reduce ST in children and adolescents with chronic disease.

Objectively measured versus self-reported physical activity in children and adolescents with cancer

Objective

Existing research recognizes low levels of physical activity in pediatric patients with cancer, but much uncertainty exists about their capability to self-reflect physical activity levels. The objective of this study was to compare results of subjective self-reports and objective accelerometers regarding levels of daily walking as well as moderate-to-vigorous physical activities.

Methods

Results of the objective assessment tool StepWatchTM Activity Monitor and self-reporting with a standardized questionnaire were compared in 28 children and adolescents during cancer treatment.

Results

The patients were 13.8±2.8 years of age and 3.4±2.0 months after cancer diagnosis. The Bland-Altman plots indicated a fairly symmetrical under- and over-estimation for daily minutes of walking with the limits of agreement ranging from -100.8 to 87.3 min (d = -6.7 min). Mean difference for moderate-to-vigorous physical activity was almost zero but limits of agreement are ranging from -126.8 to 126.9 min. The comparison for the days with at least 60 min of moderate-to-vigorous physical activity showed a marked difference with 3.0±2.6 self-reported days versus only 0.1±0.4 measured days.

Conclusions

These findings suggest that physical activity in pediatric cancer patients should preferably be assessed with objective methods. Greater efforts are needed to implement supervised exercise interventions during treatment incorporating methods to improve self-reflection of physical activity.

Obesity and Metabolic Syndrome Among Adult Survivors of Childhood Leukemia

Treatment-related obesity and the metabolic syndrome in adult survivors of childhood acute lymphoblastic leukemia (ALL) are risk factors for cardiovascular disease. Both conditions often begin during therapy. Preventive measures, including dietary counseling and tailored exercise, should be initiated early in the course of survivorship, with referral to specialists to optimize success. However, among adults who develop obesity or the metabolic syndrome and who do not respond to lifestyle therapy, medical intervention may be indicated to manage underlying pathology, such as growth hormone deficiency, or to mitigate risk factors of cardiovascular disease. Because no specific clinical trials have been done in this population to treat metabolic syndrome or its components, clinicians who follow adult survivors of childhood ALL should use the existing American Heart Association/National Heart Lung and Blood Institute Scientific Statement to guide their approach.

Does socioeconomic status impact physical activity and sleep among children with cancer?

BACKGROUND

Compared with healthy children, pediatric oncology patients have impaired sleep and engage in less physical activity (PA). Socioeconomic status (SES) may be one determinant of PA and sleep among pediatric oncology patients.

PROCEDURE

Between November 12, 2009 and March 27, 2013, 50 pediatric oncology patients between the ages of 8 and 18 years were recruited from an urban children's hospital. PA and sleep were assessed by actigraphy and diaries over 7 days. Fatigue was assessed using the Fatigue Scale. SES was defined by primary payer status of insurance (state or private) and by Median Household Income (MHI) obtained from 2010 U.S. Census block data for residences. MHI was compared to Connecticut state median income ($67,000). Multivariate regression models examined the relationship between SES and PA, sleep and fatigue.

RESULTS

PA and sleep efficiency were strongly correlated (r = 0.31, P = 0.03). Children with state insurance had higher average PA (P = 0.004) than children on private insurance. There were no significant differences in PA or sleep efficiency by block MHI. The 7-day fatigue score was lower among the participants aged 8-12 years in the group with MHI less than $67,000 (P = 0.03), although there was no significant difference among participants aged 13-18 years in the group. There was no difference in mean fatigue scores by insurance status.

CONCLUSIONS

Participants on state insurance had higher PA than those with private insurance. Although block MHI did not influence PA or sleep efficiency among children with cancer, participants aged 8-12 years in a lower MHI block had less fatigue. Future research is needed to further understand how SES influences PA.

Juvenile competitive triathlete after cardiotoxic anthracycline therapy for Acute Myeloid Leukemia

OBJECTIVE

The treatment of Acute Myeloid Leukemia (AML) leads to several functional limitations. Especially cardiac burden following cardiotoxic chemotherapy, which limits exercise and competitive sport in the long-term survivors.

SUBJECT AND METHODS

We report on a young female amateur triathlete born in 1997, who was diagnosed with AML at the age of fifteen. She had chemotherapy with a cumulative dose of about 1000 mg/m² anthracyclines and allogeneic stem cell transplantation which was successful, but she suffered from cardiotoxic systolic heart failure with a left ventricular ejection fraction (LVEF) <55 % and an impaired peak oxygen uptake of 23.2 ml/min/kg and 53 % of predicted, respectively. After medical examination and counselling with a sport scientist she started a tailored training of aerobic exercise. She was evaluated at regular intervals which resulted in increasing the training load and volume. Eventually her training hours was stepwise increased to 12 h training per week, which includes high intensity intervals.

RESULTS

Within almost 3 years, her exercise performance improved tremendously. Workload doubled from 2.1 W/kg to 4.2 W/kg, peak oxygen uptake increased from 23.2 ml/min/kg to 49.1 ml/min/kg and from 53 to 135 %, respectively. Moreover, she participated in several competitions. However, LVEF remains almost unchanged.

CONCLUSION

With the right training and under medical surveillance competitive exercise with an anthracycline-damaged heart is still achievable. Moreover, competitive training and exercise seems to be safe and feasible.

Use of accelerometry to investigate physical activity in dogs receiving chemotherapy

OBJECTIVES

To perform a preliminary study to assess whether single-agent palliative or adjuvant chemotherapy has an impact on objectively measured physical activity in dogs.

METHODS

Fifteen dogs with neoplasia (treatment group) wore ActiGraph™ accelerometers for 5-day periods before, during and after receiving single-agent adjuvant or palliative chemotherapy. Mean 5-day total physical activity and time spent in three different intensities of activity (sedentary, light-moderate and vigorous) before, during and after receiving chemotherapy were compared to a group of 15 healthy dogs (control group). Results were also compared within the treatment group across time.

RESULTS

Prior to chemotherapy, treated dogs tended to be less active than control dogs. Treatment group dogs were slightly more active at restaging than they were prior to treatment but had similar activity levels to control dogs. Marked effects of chemotherapy on physical activity were not detected. Physical activity was slightly lower in treated dogs during chemotherapy when compared to control dogs but there was a slight increase in physical activity of treated dogs during chemotherapy when compared with pretreatment recordings. There was little change in the mean 5-day total physical activity between treated dogs during chemotherapy and at restaging but a mild decrease in time spent sedentary and increase in time spent in light-moderate activity at this comparison of time points.

CLINICAL SIGNIFICANCE

Single-agent adjuvant or palliative chemotherapy had minimal impact on physical activity levels in dogs with neoplasia.

Impairments of Lower Extremity Muscle Strength and Balance in Childhood Cancer Patients and Survivors: A Systematic Review

This review aims to summarize the evidence for impairments of muscle strength and balance during and after treatment for childhood cancer. Thirty-two articles, identified in scientific databases by means of a structured search for investigations of muscle strength and balance in pediatric cancer patients and survivors, are evaluated. A summary of results is given with respect to matching reporting items to provide a qualitative analysis of the evidence. The majority of the studies reached a level 3 rating according to Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 levels of evidence. Muscle strength and balance seem to be impaired in varying degrees depending on the diagnosis, treatment received, and time elapsed between treatment and evaluation. Drawing specific conclusions from the identified studies is difficult because of heterogeneous study samples and methods of research. Individual targeted exercise therapy programs during treatment and follow-up of childhood cancer could help to prevent and further diminish impairments of muscle strength and balance function among childhood cancer patients and survivors.

Cardiorespiratory fitness and physical activity in children with cancer

Purpose

This study assessed cardiorespiratory fitness (CRF), physical activity (PA), and sedentary behavior (SB), as well as factors associated with these outcomes in children during or shortly after cancer treatment.

Methods

Cross-sectionally, CRF data, obtained by the cardiopulmonary exercise test, and PA and SB data, obtained by an accelerometer, were assessed in children with cancer (8–18 years old). Linear regression models were used to determine associations between CRF, PA, or SB and patient characteristics.

Results

Among 60 children with cancer, mean age 12.6 years, 35 boys, 28 % were during cancer treatment. CRF, reported as the z score of VO_2peak, showed that 32 children had a VO_2peakz score which was −2 below the predicted value. CRF was significantly associated with PA and SB: each additional activity count per minute resulted in 0.05 ml/kg/min VO_2peak increase and each additional minute sedentary reduced VO_2peak by 0.06 ml/kg/min. Multiple linear regression models of PA and SB showed that decreased activity was significantly associated with higher age, being fatigued, being during childhood cancer treatment (p < 0.001), or having a higher percentage of fat mass. The multiple linear regression model showed that lower CRF was significantly associated with increased fatigue, being during cancer treatment, having a higher percentage of fat mass, and lower belief of own athletic competence (p < 0.001).

Conclusion

This study revealed that children during or shortly after cancer treatment have low CRF scores. The most inactive children had a higher fat mass, were fatigued, older, and during childhood cancer treatment. Unexpectedly, treatment-related factors showed no significant association with activity behavior.

Motor performance in children and adolescents with cancer at the end of acute treatment phase

Reduced motor performance may particularly limit reintegration into normal life after cessation of treatment in pediatric cancer patients. This study aimed at analyzing motor performance at the end of the acute treatment phase and reveals potential risk factors for motor deficits. A childhood cancer population with different tumor entities was assessed with the MOON test, which allows for comparison with age- and gender-matched reference values of healthy children, at the end of the acute treatment phase. Forty-seven patients were tested at 7.0 ± 2.6 months after diagnosis. Significant reductions of motor performance affected muscular explosive strength (P < 0.001), handgrip strength (P < 0.001), muscular endurance of legs (P = 0.035), hand-eye coordination (P < 0.001), static balance (P = 0.003), speed (P = 0.012), and flexibility (P < 0.001). Loss of upper extremity coordination did not achieve statistical significance. Associations between single motor deficits and the tumor entity, age, body mass index, and inactivity during treatment were revealed, whereas no associations were found for gender and vincristine application.

CONCLUSION

Overall, motor performance was low in the patient group studied. We recommend that individualized exercise interventions to attenuate motor deficits and promote physical activity are needed during cancer treatment in order to enhance motor performance and improve social participation during and after cancer therapy.

Assessment of physical performance using the 6-minute walk test in children receiving treatment for cancer

BACKGROUND

The study of physical performance in children with cancer is emerging as an important variable in symptom research. Studies have shown that children with cancer experience deficits in physical performance during treatment that may be present years after therapy.

OBJECTIVE

The aim of this study was to determine if distance on the 6-minute walk test (6MWT) changed in children during the first 3 cycles of cancer treatment and to compare the distances walked with healthy norms.

METHODS

This is a secondary data analysis of 19 boys and 10 girls, aged 6 to 17 years, who were newly diagnosed with cancer and were part of a larger study that measured changes in fatigue and physical performance during the first 3 cycles of chemotherapy. Participants performed the 6MWT between days 15 and 29 of the first and third cycles of chemotherapy.

RESULTS

Pediatric cancer patients did not have a significant change in the distance walked at cycle 3 of chemotherapy compared with cycle 1. When compared with 2 different normative data sets for healthy children, most children with cancer performed significantly below their peers.

CONCLUSIONS

Children had poor strength and endurance after 3 cycles of chemotherapy even when their disease was responding to treatment. Interventions are needed to promote rehabilitation and maintenance of physical performance, as both are important to quality of life and ongoing child development.

IMPLICATIONS FOR PRACTICE

Children receiving cancer treatment who are ambulatory may appear to be functioning normally but are in fact severely deconditioned compared with their healthy peers.

Nutritional status and dietary intake of children with acute leukaemia during induction or consolidation chemotherapy

BACKGROUND

The assessment of nutritional status among paediatric patients is important for the planning and execution of nutritional strategies that strive to optimise the quality of life and growth among sick children. The present study aimed to evaluate the nutritional status and dietary intake among children with acute leukaemia.

METHODS

This cross-sectional study included 53 paediatric patients aged 3-12 years old, who were diagnosed with either acute lymphoblastic leukaemia or acute myelogenous leukaemia and were undergoing chemotherapy treatments (induction or consolidation phase). Patients were matched for sex, age (±6 months) and ethnicity with healthy children as controls. Weight, height, body mass index, waist circumference, mid-upper arm circumference, triceps skinfold thickness, mid-upper arm muscle area and fat area were determined. Dietary intake was assessed using 3-day food records.

RESULTS

Anthropometric variables were generally higher among patients compared to controls, although the differences were not statistically significant (P > 0.05). The prevalence of overnutrition among patients according to body mass index-for-age, waist circumference-for-age, mid-upper arm circumference-for-age and triceps skinfold-for-age were 24.5%, 29.1%, 17.0% and 30.2%, respectively. Mean energy [5732 ± 1958 kJ (1370 ± 468 kcal) versus 6945 ± 1970 kJ (1660 ± 471 kcal), P < 0.01], protein (50.0 ± 19.7 g versus 62.3 ± 22.3 g, P < 0.01) and fat (43.6 ± 18.9 g versus 58.3 ± 16.7, P < 0.001) intakes of patients were significantly lower than controls.

CONCLUSIONS

The prevalence of being overweight and obesity in children with acute leukaemia was higher despite lower energy intake compared to controls. Studies assessing physical activity, the complex interaction and the effects of treatment drugs are warranted to better manage malnutrition among paediatric patients.