Analysis of handwriting of children during treatment for acute lymphoblastic leukemia

Upper-limb dysfunction in cancer survivors with chemotherapy-induced peripheral neurotoxicity

INTRODUCTION

Upper-limb symptoms are often reported in the context of chemotherapy-induced peripheral neurotoxicity (CIPN), but objective quantification of functional deficits is often lacking. We examined and compared a range of neurophysiological and functional assessments of the upper-limb in the assessment of CIPN severity.

METHODS

Cross-sectional assessment of neurotoxic chemotherapy-treated patients was undertaken using patient-reported and clinically-graded CIPN measures. Upper-limb functional assessments comprised of assessing fine motor skills, sensory perception, and neurophysiological measures of the median nerve. Group comparisons between participants who reported absence or presence of upper-limb functional deficits were investigated.

RESULTS

60 participants who were 11.5 (IQR = 4.0-26.0) months post-neurotoxic chemotherapy treatment reported CIPN. 65% (n = 39) reported upper-limb CIPN symptoms. Reduction in fine motor skills, sensory perception and median nerve SNAP amplitudes were associated with higher CIPN severity. Participants who self-reported presence of upper-limb functional deficits had worse CIPN severity across all measures, compared to participants who reported no upper-limb functional deficits.

CONCLUSIONS

Participants who reported upper-limb symptoms and functional deficits had worse CIPN severity and quality-of-life. There is a high burden of upper-limb dysfunction long after neurotoxic chemotherapy treatment cessation. Focus on research into supportive care and rehabilitation options to improve upper-limb function is warranted to improve patient quality-of-life.

Impairments in fine motor skills in children with Acute Lymphoblastic Leukaemia. A cross-sectional study

AIM

We evaluated fine motor skills; precision, motor integration, manual dexterity, and upper-limb coordination according to sex and risk stratification in children with Acute Lymphoblastic Leukaemia (ALL).

METHODS

We evaluated twenty-nine children in the maintenance phase aged 6 to 12 years with the Bruininks-Oseretsky Test of Motor Proficiency-second edition (BOT-2), and sex and age-specific norm values of BOT-2 were used to compare our results.

RESULTS

We found lower scores on the upper-limb coordination subtest, p = 0.003 and on the manual coordination composite, p = 0.008, than normative values. Most boys performed "average" on both the subtests and the composites, but girls showed lower scores with a mean difference of 7.69 (95%CI; 2.24 to 3.14), p = 0.009. Girls' scale scores on the upper-limb coordination subtest were lower than normative values, with mean difference 5.08 (95%CI; 2.35 to 7.81), p = 0.006. The mean standard score difference in high-risk patients was lower than normative on the manual coordination composite, 8.18 (95%CI; 2.26 to 14.1), p = 0.015. High-risk children also performed below the BOT-2 normative on manual dexterity 2.82 (95%CI; 0.14 to 5.78), p = 0.035 and upper limb coordination subtest 4.10 (95%CI; 1.13 to 7.05), p = 0.028. We found a decrease in fine motor precision in children with a higher BMI, rho= -0.87, p = 0.056 and a negative correlation between older age and lower manual dexterity, r= -0.41 p = 0.026; however, we did not find any correlation with the weeks in the maintenance phase.

CONCLUSIONS

Fine motor impairments are common in children with ALL in the maintenance phase; it is important to identify these impairments to early rehabilitation.

Comparative Analysis of Cognitive, Motor, and Visual-Motor Functions in Pediatric Acute Lymphoblastic Leukemia Survivors With and Without Allogeneic Hematopoietic Stem Cell Transplantation

OBJECTIVE

Hematopoietic stem cell transplantation (HSCT) is an effective treatment for pediatric high-risk acute lymphoblastic leukemia (ALL) survivors. Still, both the disease and treatment often impair cognitive and motor functions, and HSCT is a risk factor for long-term deficits. The study aimed at investigating the effect of HSCT on cognitive, motor, and visual-motor functions. Two groups were enrolled: The first group received HSCT treatment, and the second group did not.

METHOD

Sixty-five ALL survivors participated in the study (ages: 7-17). Twenty-one of participants who underwent HSCT comprised the first group. We implemented tests from Cambridge Neuropsychological Test Automated Battery, Wechsler Intelligence Scale for Children, and Test of Memory and Learning to estimate cognitive functions, Bruininks-Oseretsky Test of Motor Proficiency to estimate motor functions, and Beery-Buktenica Developmental Test to estimate visual perceptual and visual motor functions. As independent variables for analysis we chose group (HSCT+/-), age at diagnosis, and current age.

RESULTS

MANCOVA test demonstrated significant effect of current age on cognitive functions (partial η2 = 0.55) and significant effect of HSCT treatment on motor functions (partial η2 = 0.19). Current age also had moderate effect on visual-motor functions (partial η2 = 0.11). Significant differences were found in most cognitive, motor, and visual-motor tests' results between the two groups, with HSCT+ group demonstrating poorer performance.

CONCLUSIONS

This study has several limitations, including small sample size, potentially mismatched groups, imbalanced gender ratio. Still, the findings underline the importance of considering late effects of HSCT, and age when designing rehabilitation programs.

Oncological Children and Well-Being: Occupational Performance and HRQOL Change after Fine Motor Skills Stimulation Activities

Cancer children experience long periods of hospitalization, which are associated with limited performance in several developmental domains and participation restrictions in age appropriate occupations. Fine motor abilities represent building blocks in performing daily life skills and have been found to be closely connected with later academic success. Moreover, medical and psychological sequelae for cancer inpatients may result in diminished daily activities functioning, poor perceived health related quality of life (HRQOL), and increase the likelihood of long-term impairments. This study examines the variations in the occupational performance of children hospitalized for acute lymphoblastic leukemia (ALL) after their participation to a stimulation program designed to enhance fine motor skills. Parents reported significant gains in children's motor functioning, a slight improvement in overall occupational performance related to an increase in the area of productivity and self-care, and a better quality of life perception following the stimulation activities. Feasibility of the stimulation program in a health care setting are discussed evaluating its benefits for cancer children and their families.

Longitudinal Evaluation of Neuromuscular Dysfunction in Long-term Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study

BACKGROUND

Children treated for cancer are at risk for neuromuscular dysfunction, but data are limited regarding prevalence, longitudinal patterns, and long-term impact.

METHODS

Longitudinal surveys from 25,583 childhood cancer survivors ≥5 years from diagnosis and 5,044 siblings from the Childhood Cancer Survivor Study were used to estimate the prevalence and cumulative incidence of neuromuscular dysfunction. Multivariable models adjusted for age, sex, race, and ethnicity estimated prevalence ratios (PR) of neuromuscular dysfunction in survivors compared with siblings, and associations with treatments and late health/socioeconomic outcomes.

RESULTS

Prevalence of neuromuscular dysfunction was 14.7% in survivors 5 years postdiagnosis versus 1.5% in siblings [PR, 9.9; 95% confidence interval (CI), 7.9-12.4], and highest in survivors of central nervous system (CNS) tumors (PR, 27.6; 95% CI, 22.1-34.6) and sarcomas (PR, 11.5; 95% CI, 9.1-14.5). Cumulative incidence rose to 24.3% in survivors 20 years postdiagnosis (95% CI, 23.8-24.8). Spinal radiotherapy and increasing cranial radiotherapy dose were associated with increased prevalence of neuromuscular dysfunction. Platinum exposure (vs. none) was associated with neuromuscular dysfunction (PR, 1.8; 95% CI, 1.5-2.1), even after excluding survivors with CNS tumors, cranial/spinal radiotherapy, or amputation. Neuromuscular dysfunction was associated with concurrent or later obesity (PR, 1.1; 95% CI, 1.1-1.2), anxiety (PR, 2.5; 95% CI, 2.2-2.9), depression (PR, 2.1; 95% CI, 1.9-2.3), and lower likelihood of graduating college (PR, 0.92; 95% CI, 0.90-0.94) and employment (PR, 0.8; 95% CI, 0.8-0.9).

CONCLUSIONS

Neuromuscular dysfunction is prevalent in childhood cancer survivors, continues to increase posttherapy, and is associated with adverse health and socioeconomic outcomes.

IMPACT

Interventions are needed to prevent and treat neuromuscular dysfunction, especially in survivors with platinum and radiation exposure.

A review of movement disorders in chemotherapy-induced neurotoxicity

Chemotherapy agents used in the standard treatments for many types of cancer are neurotoxic and can lead to lasting sensory and motor symptoms that compromise day-to-day movement functions in cancer survivors. To date, the details of movement disorders associated with chemotherapy are known largely through self-reported symptoms and functional limitations. There are few quantitative studies of specific movement deficits, limiting our understanding of dysfunction, as well as effective assessments and interventions. The aim of this narrative review is to consolidate the current understanding of sensorimotor disabilities based on quantitative measures in cancer survivors who received chemotherapy. We performed literature searches on PubMed and found 32 relevant movement studies. We categorized these studies into three themes based on the movement deficits investigated: (1) balance and postural control; (2) gait function; (3) upper limb function. This literature suggests that cancer survivors have increased postural sway, more conservative gait patterns, and suboptimal hand function compared to healthy individuals. More studies are needed that use objective measures of sensorimotor function to better characterize movement disabilities and investigate the underlying causes, as required for developing targeted assessments and interventions. By updating our understanding of movement impairments in this population, we identify significant gaps in knowledge that will help guide the direction of future research.

The Italian consensus conference on the role of rehabilitation for children and adolescents with leukemia, central nervous system, and bone tumors, part 1: Review of the conference and presentation of consensus statements on rehabilitative evaluation of motor aspects

Because of increasing survival rates in pediatric oncology, attention is focusing on cancer and its treatment-related side effects. Rehabilitation may reduce their impact. However, the literature does not provide strong evidence regarding rehabilitation pathways. Therefore, the Italian Association of Pediatric Hematology and Oncology organized a consensus conference on the role of rehabilitation of motor impairments in children/adolescents affected by leukemia, central nervous system, and bone tumors to define recommendations for daily practice. The grading of recommendation assessment, developing and evaluation (GRADE) method was used in order to formulate questions, select outcomes, evaluate evidence, and create recommendations. This paper includes the results on the rehabilitation assessment.

Motor function in survivors of pediatric acute lymphoblastic leukemia treated with chemotherapy-only

BACKGROUND

Up to 43% of survivors of pediatric acute lymphoblastic leukemia (ALL) may exhibit fine-motor problems. Information on manual dexterity in this cohort is still limited.

OBJECTIVES

We tested survivors of childhood ALL treated with chemotherapy-only for fine-motor function in terms of drawing and handwriting abilities using a Digitizing Tablet (DT) with three tasks for drawing and handwriting of varying complexity, for ataxia using the International Cooperative Ataxia Rating Scale (ICARS), and for tremor and hand-eye coordination using the Nine Hole Steadiness Tester (NHST).

RESULTS

We examined a cohort of non-irradiated survivors (n = 31) after a median time of 3.5 years after end of therapy. In all tasks of the DT the cohort demonstrated significant (p < 0.05) impairment of speed, automation, and variability in at least two tasks and significantly more pressure. Impaired speed (SPV) inversely correlated with lag time since end of therapy. Dexterity performance of six survivors (19%) lay below the 5th percentile. No survivor exhibited ataxia, tremor, or impaired hand-steadiness.

CONCLUSION

Despite the absence of gross ataxia, tremor, and impaired hand-eye coordination, we nevertheless detected significant fine-motor impairment in a relevant number of survivors of childhood ALL. Prospective studies are needed to reveal the pathophysiological underpinnings and genetic risk factors for development of such deficits due to ALL and its treatment.

Associating Physical Activity Levels with Motor Performance and Physical Function in Childhood Survivors of Acute Lymphoblastic Leukemia

Purpose: This cross-sectional, observational study investigated whether physical activity (PA) levels are associated with motor performance and physical function in children after treatment for acute lymphoblastic leukemia (ALL). Method: Participants aged 8-13 years who had completed treatment for ALL (3-36 months post-treatment) were tested at their oncology long-term follow-up appointment at the British Columbia Children's Hospital. PA level was measured using the Physical Activity Questionnaire for Older Children (PAQ-C). Motor performance was measured using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, Short Form (BOT-2 SF), and physical function was measured using the 6-minute walk test (6MWT). Results: Thirteen children completed testing. PAQ-C scores were not associated with BOT-2 SF or 6MWT performance. Eleven children (85%) performed below the norm for the 6MWT. Children with elevated body mass index had poorer 6MWT but similar PAQ-C scores. Conclusion: PA was not found to be associated with motor performance and physical function. Participants who were overweight or obese had poorer 6MWT performance, which may indicate the need for closer monitoring of post-treatment weight status and physical function in the oncology follow-up setting.

Oxidative Stress, Motor Abilities, and Behavioral Adjustment in Children Treated for Acute Lymphoblastic Leukemia

PURPOSE/OBJECTIVES

To examine associations among oxidative stress, fine and visual-motor abilities, and behavioral adjustment in children receiving chemotherapy for acute lymphoblastic leukemia (ALL)
.

DESIGN

A prospective, repeated-measures design
.

SETTING

Two pediatric oncology settings in the southwestern United States.

SAMPLE

89 children with ALL were followed from diagnosis to the end of chemotherapy.

METHODS

Serial cerebrospinal fluid samples were collected during scheduled lumbar punctures and analyzed for oxidative stress biomarkers. Children completed fine motor dexterity, visual processing speed, and visual-motor integration measures at three time points. Parents completed child behavior ratings at the same times.

MAIN RESEARCH VARIABLES

Oxidative stress, fine motor dexterity, visual processing, visual-motor integration, and behavioral adjustment
.

FINDINGS

Children with ALL had below-average fine motor dexterity, visual processing speed, and visual-motor integration following the induction phase of ALL therapy. By end of therapy, visual processing speed normalized, and fine motor dexterity and visual-motor integration remained below average. Oxidative stress measures correlated with fine motor dexterity and visual-motor integration. Decreased motor functioning was associated with increased hyperactivity and anxiety
.

CONCLUSIONS

Oxidative stress occurs following chemo-therapy for childhood ALL and is related to impaired fine motor skills and visual symptoms
.

IMPLICATIONS FOR NURSING

Early intervention should be considered to prevent fine motor and visual-spatial deficits, as well as behavioral problems.

Vincristine-associated neurological morbidity in the treatment of hepatoblastoma

Chemotherapy is an essential component of therapy for infants and children with hepatoblastoma. Vincristine has been a mainstay of chemotherapeutic regimens used by North American cooperative groups, based on indirect evidence of benefit and an assumption of minimal added toxicity. European cooperative group trials have reported comparable survival rates using regimens that omit vincristine. Further examination of the risk and benefit profile of vincristine relevant to hepatoblastoma clinical care paradigms is thus warranted. We evaluated the incidence of vincristine-related sensorimotor peripheral, autonomic, and cranial nerve neurological morbidities in 45 consecutive hepatoblastoma patients treated at our institution. Data suggest an increased risk of vincristine-associated neuropathic grade 2 and 3 events (neuropathic pain and gross motor impairment) in children ages 24 months old or younger, and particularly in children born prematurely. Formal prospective investigation of the relative risks and benefits of vincristine in hepatoblastoma treatment is warranted to assess the value of continued use of vincristine in this patient population.

Impairments that influence physical function among survivors of childhood cancer

Children treated for cancer are at increased risk of developing chronic health conditions, some of which may manifest during or soon after treatment while others emerge many years after therapy. These health problems may limit physical performance and functional capacity, interfering with participation in work, social, and recreational activities. In this review, we discuss treatment-induced impairments in the endocrine, musculoskeletal, neurological, and cardiopulmonary systems and their influence on mobility and physical function. We found that cranial radiation at a young age was associated with broad range of chronic conditions including obesity, short stature, low bone mineral density and neuromotor impairments. Anthracyclines and chest radiation are associated with both short and long-term cardiotoxicity. Although numerous chronic conditions are documented among individuals treated for childhood cancer, the impact of these conditions on mobility and function are not well characterized, with most studies limited to survivors of acute lymphoblastic leukemia and brain tumors. Moving forward, further research assessing the impact of chronic conditions on participation in work and social activities is required. Moreover, interventions to prevent or ameliorate the loss of physical function among children treated for cancer are likely to become an important area of survivorship research.

Vincristine and fine motor function of children with acute lymphoblastic leukemia

Background.

Children with acute lymphoblastic leukemia receive vincristine, a chemotherapy drug known to cause peripheral neuropathy. Yet, few studies have examined the association of vincristine to fine motor function.

Purpose.

This study will describe the fine motor skills and function of children with acute lymphoblastic leukemia on maintenance vincristine.

Method.

A prospective case series design assessed manual dexterity and parent-reported fine motor dysfunction of 15 children with acute lymphoblastic leukemia in relation to cumulative vincristine exposure.

Findings.

Almost half of the participants had below-average fine motor skills compared to age-related norms, and 57% of parents observed functional motor problems in their children. No significant associations were found between vincristine, manual dexterity, and functional motor skills.

Implications.

Early detection and intervention for fine motor difficulties is suggested. Research with a larger sample is necessary to further explore the association of vincristine and fine motor function in this clinical population.

Vincristine-induced neuropathy in childhood ALL (acute lymphoblastic leukemia) survivors: prevalence and electrophysiological characteristics

The prevalence and the burden of vincristine-induced neuropathy have been poorly documented in childhood acute lymphoblastic leukemia survivors. This cross-sectional study was carried out at a tertiary care center in northern India from October 2011 to June 2012. Eighty consecutive acute lymphoblastic leukemia survivors aged 5 to 18 years, within 3 years of completion of their chemotherapy, were enrolled. After clinical evaluation, detailed nerve conduction studies were performed and the reduced version of the Total Neuropathy Score was calculated. The mean age at the time of evaluation was 11.2 ± 3.2 years. 33.75% had neuropathy electrophysiologically. Symmetric motor axonal polyneuropathy was the most common pattern of involvement seen in 19 (23.8%) children. There was significant improvement with time, as revealed by lower prevalence of neuropathy with increasing interval following vincristine injection. 33.75% of the children had Reduced version of Total Neuropathy Score ≥ 1.

Signal-to-noise velocity peaks difference: a new method for evaluating the handwriting movement fluency in children with dysgraphia

This study evaluated handwriting movement dysfluency related to dysgraphia. A new variable, the Signal-to-Noise velocity peaks difference (SNvpd), was proposed to describe abnormal velocity fluctuations in cursive handwriting. This variable was compared to two variables most frequently used variables for assessing handwriting fluency. This comparison was carried out for three different groups, children with dysgraphia, proficient children, and adults, all of whom wrote the same single word. The adults were taken as the reference. Results revealed that, of the three variables studied, the SNvpd proved most efficient in discriminating children with dysgraphia, and that furthermore, it had the significant advantage of facilitating the localization of dysfluency peaks within a word. Our results also showed that the movement dysfluency of children with dysgraphia was specific to certain letters. In light of these results, we discuss the methodological and theoretical relevance of this new variable to the analysis of handwriting movement with the aim of characterizing dysgraphia.

Motor functioning during and following treatment with chemotherapy for pediatric acute lymphoblastic leukemia

This systematic review evaluated empirical studies examining motor skills in children during and following treatment for acute lymphoblastic leukemia. Most studies indicated that children on-treatment display poorer gross and fine motor abilities than healthy peers, but generally have intact visual-motor integration skills. Studies have reported gross motor difficulties in 5-54% of survivors. There is some limited evidence for long-term fine motor deficits. The evidence for visual-motor integration difficulties in the survivor population is less consistent. Larger studies with a longitudinal design are needed to further specify the onset and timing of motor difficulties and ascertain risk factors.

Gross and fine motor skills in children treated for acute lymphoblastic leukaemia

OBJECTIVE

Chemotherapy treatment for acute lymphoblastic leukaemia (ALL) may disrupt motor development, with suggestions that gross and fine motor deficits are different depending on time since treatment.

METHODS

Thirty-seven participants aged between 2.5 to 5 years at the time of diagnosis were assessed using the Movement Assessment Battery for Children, 2nd Edition (MABC-2) and the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition, Short Form (BOT-2 SF), and divided into groups (i.e., months-off-treatment): (1) 0-12, (2) 13-24, and (3) 25-60 for comparison.

RESULTS

MABC-2 and BOT-2 SF mean total scores fell within the average range. Twenty-six percent of the sample performed in the impaired range on the MABC-2. Group 2 had significantly lower Manual Dexterity scores than the normative population and lower BOT-2 SF scores than Group 1.

CONCLUSION

Most children treated for ALL display appropriate motor skills, yet around a quarter experience general motor difficulties. Time-off-treatment did not affect the prevalence of motor impairments on any measure.

Chemotherapy-induced peripheral neuropathy in pediatric cancer patients

Chemotherapy forms the backbone of treatment for many types of pediatric cancers, but a main side effect of treatment is chemotherapy-induced peripheral neuropathy (CIPN). Damage to the peripheral nervous system by chemotherapeutic agents can occur at the axon, cell body, or myelin level, and the mechanism of damage differs based on the specific chemotherapeutic agent used. This review provides background on the current knowledge of pathophysiology, assessment, and intervention for CIPN, focusing specifically on issues relevant in pediatric cancers patients. Although specific, standardized measures of CIPN are available for adults, such measures are limited for use in the pediatric populations. Likewise, clinical trials for prevention and treatment of this neuropathy and related symptoms are rare in pediatrics, but some information can be gained from the basic and adult literature.

Loss of fine motor function correlates with ataxia and decline of cognition in cerebellar tumor survivors

BACKGROUND

Motor and cognitive function losses resemble handicaps in pediatric posterior fossa tumor survivors. Several factors determine type and extent of impairment. We quantified loss of fine motor function and its association with ataxia and intelligence in patients with and without adjuvant treatment.

PROCEDURE

Fine motor function, extent of ataxia and cognitive function were assessed in 25 medulloblastoma (MB) and 16 cerebellar pilocytic astrocytoma (PA) patients at least 1 year after completion of therapy. Kinematic parameters (speed, automation, variability, and pressure) of different movement complexity levels were investigated employing a digitizing graphic tablet. Degree of ataxia was quantified using the International Cooperative Ataxia Rating Scale and cognition was determined using the Wechsler Intelligence Scale.

RESULTS

Kinematic parameters of low and high complexity tasks as well as ataxia of MB patients were strongly impaired. Fine motor impairment was weaker in PA patients, but still evident in the complex task of writing. Ataxia was significantly more pronounced in medulloblastoma patients. Young age and short recovery time correlated significantly with impaired kinematic parameters. Ataxia was strongly associated with inferior fine motor function. Cognition, especially performance IQ, was associated with dysfunctional kinematic parameters.

CONCLUSION

The digitizing tablet detected extent of fine motor function loss at varying levels of complexity of pediatric cerebellar tumor survivors. This tool promises to be a potentially effective method for measuring fine motor function in clinical trials and may be helpful in studying mechanisms of neurotoxicity in posterior fossa tumor patients as well as success of rehabilitation.

The complexity of symptoms and problems experienced in children with cancer: a review of the literature

To adequately help children with cancer, care providers need to understand the complexity of symptoms and problems associated with the illness that children are experiencing, which can enable them to better tailor patient care individually to each child. In this integrative literature review, we identified the types of symptoms and problems that children with cancer can experience during treatment and rehabilitation; the terms/expressions they use to describe their symptoms and problems; how children's symptoms and problems vary during the course of their illness; and how they vary and co-vary with age, gender or race. Of the 1175 titles identified, 110 articles met the inclusion criteria and were included in the review. Seventy-eight were research-based. A total of 219 distinct symptoms or problems were identified in the literature either as the main problem or a symptom of the main problem. There is significant evidence that children and adolescents experience numerous and complex symptoms, and problems during and after treatment for cancer. Children use many different expressions to talk about their symptom experiences. However, few articles looked at how children's symptoms and problems varied during the course of their illness or the variations in symptom severity and degree of bother, or examined the relationship between children's symptom experience and age, gender, or race. Most instruments that were used to measure symptoms were interviewer-administered questionnaires, often adaptations from adult versions, and in younger children, symptoms were often obtained from adult informants. The insights gained from this review can be helpful to researchers and clinicians who wish to better understand how symptoms and problems are experienced from the children's own perspective. However, more research is needed: to better understand differences in symptom experiences among different age groups; to identify differences among children from distinct cultural, ethnic, or socio-economic backgrounds; to clarify how symptoms and problems interfere with daily life; and to refine assessment methods that allow even younger children to communicate their symptom experiences in an age-adjusted manner.

Chemobrain: a translational challenge for neurotoxicology

Neurotoxicity is a frequent accompaniment of cancer chemotherapy, and held by many oncologists to be the major dose-limiting side effect. It appears in many forms, but attracted attention during the past decade primarily because of complaints by patients of impaired cognitive function they have labeled as "chemobrain". Neuropsychological testing confirmed the validity of these complaints and has generated a substantial literature examining different aspects of cognitive impairment in various clinical populations undergoing a variety of treatments. Cognitive impairment is far from the only manifestation of neurotoxicity induced by chemotherapy, however. It alters sensory function and motor function as well. A critical need for patients is a suite of methods that will enable clinicians to trace the onset and progression of neurotoxicity so as to guide and balance decisions about the course of chemotherapy. This commentary describes some of the potential methods and encourages neurotoxicologists to enlist their unique skills in the service of these needs.

Visuomotor control in survivors of childhood acute lymphoblastic leukemia treated with chemotherapy only

Treatment for childhood acute lymphoblastic leukemia (ALL), which includes CNS prophylaxis, is associated with central and peripheral neurotoxicity. The purpose of the present study was to analyze the effects of chemotherapy on various levels of visuomotor control in survivors of childhood ALL treated without cranial irradiation, and to identify risk factors for possible deficits. Visuomotor function was compared between children after treatment for ALL (n = 34), children after treatment for Wilms tumor, which consists of non-CNS directed chemotherapy (n = 38), and healthy controls (n = 151). Three tasks were administered: a simple visual reaction time task and two tasks measuring visuomotor control with one requiring a higher level of cognitive control than the other. Visuomotor deficits were detected only in the ALL group, with poorer performance restricted to the condition requiring the highest level of control. Significant risk factors for poorer performance were female gender and a short time since end of treatment, and a trend was found for a young age at diagnosis. A high cumulative methotrexate dose was an adverse predictive factor in girls. The results indicate that chemotherapy-induced central neurotoxicity in childhood ALL treatment is associated with higher order visuomotor control deficits. Girls appear to be particularly vulnerable.