Clinical neurological findings of children with acute lymphoblastic leukaemia at diagnosis and during treatment

Rehabilitation including structured active play intervention for preschoolers with cancer during treatment: A RePlay qualitative study of parents' experiences

PURPOSE

Preschool children receiving cancer treatment experience decreased gross motor function and challenges in personal and social development. For preschoolers, parents are critical for their child's cancer treatment trajectory, including their participation in physical activity. This study aimed to explore the parents' experiences with a novel rehabilitation intervention, including structured active play for preschoolers with cancer during treatment.

METHOD

Through criterion sampling, 23 parents of 18 preschool children diagnosed with cancer were interviewed from August 2021 until April 2023. A hermeneutic-phenomenological-inspired inductive thematic analysis was performed.

RESULTS

Based on 19 interviews with parents, three themes emerged: 1) pushing in the right direction, 2) sharing the responsibility, and 3) creating joyful experiences. The parents experienced that participation in the intervention resulted in physical progress for their child, and the child generally could develop personally and socially. The parents shared a common goal with a healthcare professional, who led the way in their child's physical development and gave them the space to participate with their child. The child actively chose to participate in structured active play, resulting in an altered perception of the hospital experience for both parents and children.

CONCLUSION

The parents' experiences showed that with the support, knowledge, and expertise of an exercise professional, rehabilitation including structured active play can be a way to integrate movement and physical activity for preschoolers in their cancer treatment trajectory. The repetitive structure of the active play sessions was experienced as motivating for the children and simultaneously challenging their physical, social, and personal development.

TRIAL AND PROTOCOL REGISTRATION

ClinicalTrials.gov: NCT04672681. Registered December 17, 2020. https://clinicaltrials.gov/ct2/show/NCT04672681.

Identifying fine motor difficulties in children with acute lymphoblastic leukemia: a scoping review

PURPOSE

Survival rates for children diagnosed with acute lymphoblastic leukemia (ALL) have increased significantly over recent decades, and thus attention shifted toward understanding the adverse effects of cancer treatment. Chemotherapy has side effects that could affect muscle state and diminish motor performance. This scoping review was conducted to map the breadth of evidence for different tools used in fine motor skills assessment, the extent of upper extremity strength, and fine motor performance, highlighting the potential risk factors that may influence these skills.

METHODS

In March 2023, full-text studies that examined fine motor performance and/or upper extremity strength were identified via searches in PubMed, Science Direct, Scopus, Web of Science, and PEDro databases. The titles and abstracts of selected studies were screened according to the inclusion and exclusion criteria.

RESULTS

The search yielded initial 418 citations and 26 peer-reviewed articles were finally included in the review. Considerable heterogeneity was observed regarding the methods of evaluating fine motor skills. The results of this review indicate that children and adolescents with ALL experienced fine motor limitations and upper extremity weakness either during or after cessation of treatment.

CONCLUSION

This scoping review presents a broad overview of the literature addressing fine motor difficulties in the pediatric population with ALL. Results accentuate the need to incorporate strengthening and occupational therapy training to preserve muscle strength and minimize future fine motor problems along the course of chemotherapeutic treatment. Little evidence was reported regarding the risk factors that may impair muscle strength and motor performance.

Vincristine-Induced Peripheral Neuropathy in Children With Malignancy and the Effect of Missed Doses on Treatment Success

INTRODUCTION

Recognizing the symptoms of vincristine-induced peripheral neuropathy (VIPN) earlier is crucial to preventing the persistent neurological sequelae. The treatment of neuropathy is to discontinue the drug, and the effect of a missed dose of vincristine on treatment success is unclear. This study aims to evaluate VIPN in children with malignancy and the effect of skipping vincristine doses on the treatment success of patients at a single center, retrospectively.

METHODS

Medical records of the children with cancer who received vincristine in our institution between 2013 and 2020 were analyzed retrospectively.

RESULTS

Vincristine neuropathy was found in 42 (7%) of 598 pediatric patients who received at least one dose of vincristine during the study period. Neuropathy developed at a statistically significantly lower cumulative dose in patients younger than seven years of age (p=0.04). The mean neuropathy duration of the cases was 8.5 months, and the findings of 40 (95.2%) cases improved. The mean cumulative dose was higher in patients with diffuse nerve involvement. The missed dose of vincristine was lower in the cases in complete remission compared to the other cases and higher doses of vincristine were missed in the stable disease group than in the remission group (p=0.03).

CONCLUSION

VIPN can be encountered in less cumulative doses, mainly in the younger age group. Missed doses of vincristine may affect treatment success, and more comprehensive studies are needed to show this effect more clearly.

The rehabilitation including structured active play (RePlay) model: A conceptual model for organizing physical rehabilitation sessions based on structured active play for preschoolers with cancer

Anti-cancer treatments, as well as cancer itself, reduce children's cardiorespiratory fitness, muscle strength, and gross motor functions. Early rehabilitation programs, including physical activity for childhood cancer patients, can counteract these adverse effects. Previous studies of school-aged children (6-18 years old) indicate that physical activity, including aerobic and resistance training, is safe, feasible, and effective. The goal of structured physical activity rehabilitation for preschool children (1-5 years old) is to support gross motor development and opportunities to move freely in various ways. Specific rehabilitation for preschoolers diagnosed with cancer is needed to promote physical-, social-, and personal development. This paper introduces a conceptual model-The RePlay (Rehabilitation including structured active play) Model-for organizing physical rehabilitation sessions based on structured active play for preschoolers with cancer. The theory and empirically based model combine knowledge of early childhood development, play, physical activity and rehabilitation for children with cancer, and cancer treatment. With this model, we propose how to structure rehabilitation sessions, including goal-oriented, age-sensitive, fun movement activities that facilitate preschoolers to develop gross motor skills while enhancing their social and personal skills, through four core principles: (1) ritual practices, (2) reinforcement of movement through repetition, (3) development through appropriate challenge, and (4) adjusting activities to accommodate treatment-related side effects. This model holds promise for use with preschoolers diagnosed with cancer, as it is scalable and pragmatic and accounts for the children's fluctuating physical capacity and daily wellbeing during cancer treatment.

Acute Lymphoblastic Leukemia Masquerading as Guillain-Barré Syndrome

INTRODUCTION

Neurological manifestations of acute lymphoblastic leukemia (ALL) have been reported as cranial neuropathies or meningeal symptoms most common in children. However, ALL can rarely involve the nerve roots causing symmetrical polyradiculopathy which can present with rapid onset paralysis, mimicking Guillain-Barré Syndrome (GBS). The symmetrical polyradiculopathy can be the earliest manifestation of ALL occurring even before the hematological and systemic manifestations.

CASE REPORT

We report a case of a healthy 29-year-old man who presented with subacute bilateral lower extremity weakness and numbness preceded by a respiratory infection. He was initially treated as a suspected (GBS) but cerebrospinal fluid (CSF) findings suggested an alternative diagnosis. His prior TB exposure created a diagnostic confusion. Lumbar spine magnetic resonance imaging revealed nerve root enhancements at L4-L5 and L5-S1 that are seen in GBS and TB arachnoidids. Brain magnetic resonance imaging demonstrated bilateral distention of the optic nerve sheath complexes with CSF suggestive of intracranial hypertension. CSF revealed elevated protein, nucleated cells 2145 leukocytes/mm 3 , numerous atypical lymphoid cells. He was later diagnosed with ALL associated symmetrical polyradiculopathy presenting with GBS-like symptoms.

CONCLUSION

Symmetrical polyradiculopathy is a rare complication of ALL and can be confused with acute inflammatory demyelinating polyneuropathy. ALL associated polyradiculopathy in young individuals can be clinically indistinguishable from GBS. Our case highlights that when CSF findings are atypical for GBS, ALL should be considered on the differential diagnosis in patients presenting with GBS like symptoms.

Rehabilitation Including Structured Active Play for Preschoolers With Cancer (RePlay)-Study Protocol for a Randomized Controlled Trial

BACKGROUND

Children diagnosed with cancer experience muscle weakness and impaired physical function caused by treatment and related immobility. The situation forces them into a negative cycle of diminished participation in physical and leisure activities and isolation from peers; inhibiting the natural development of social and gross motor skills. This manuscript presents a protocol for a study that explores the effects of using structured active play to maintain preschoolers' age specific gross motor function and social and personal skills while undertaking intensive cancer treatment.

METHODS

The study is a two-arm, superiority randomized controlled trial with an intervention and a control group designed to evaluate the effects of a structured active play intervention on gross motor function. Gross motor subtests of the Peabody Developmental Motor Scales, Second Edition (PDMS-2) are used for measurement; with the primary end-point at 6 months post-treatment initiation. Eighty-four preschool children (aged 1-5 years), newly diagnosed with cancer at the Copenhagen University Hospital are randomly assigned to either an intervention or control group, using a 1:1 allocation. The intervention group receives a combined in-hospital and home-based program that includes structured active play activities, while the control group receives standard care, including physiotherapy. During hospital admission, the intervention group undertakes 45-min structured active play group sessions three times weekly, conducted by exercise professionals. Parents receive training and supervision to facilitate daily individual sessions outside of group sessions. Secondary study outcomes target the children's overall function level in everyday life, general physical performance, and health-related quality of life. As well, children's and parents' experiences within the intervention are explored and the children's social and personal development is observed.

DISCUSSION

Limited evidence exists regarding the effectiveness of rehabilitation interventions, particularly those including active play, for preschoolers diagnosed with cancer. This manuscript reporting on a study protocol will enhance clarity and transparency in reporting and offer insights for others with interest in this same topic. Once completed, findings from this study could extend knowledge about the conduct and measurement of effectiveness in rehabilitation initiatives. If study findings suggest that the intervention is effective, structured active play may become a standard part of rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04672681. Registered December 17, 2020. https://clinicaltrials.gov/ct2/show/NCT04672681.

Pharmacogenomics insights into precision pediatric oncology

PURPOSE OF REVIEW

Pharmacogenomic insights provide an opportunity to optimize medication dosing regimens and patient outcomes. However, the potential for interindividual genomic variability to guide medication dosing and toxicity monitoring is not yet standard of care. In this review, we present advances for the thiopurines, anthracyclines and vincristine and provide perspectives on the actionability of pharmacogenomic guidance in the future.

RECENT FINDINGS

The current guideline on thiopurines recommends that those with normal predicted thiopurine methyltransferase and NUDT15 expression receive standard-of-care dosing, while 'poor metabolizer' haplotypes receive a decreased 6-mercaptopurine starting dose to avoid bone marrow toxicity. Emerging evidence established significant polygenic contributions that predispose to anthracycline-induced cardiotoxicity and suggest this knowledge be used to identify those at higher risk of complications. In the case of vincristine, children who express CYP3A5 have a significantly reduced risk of peripheral neuropathy compared with those expressing an inactive form or the CYP3A4 isoform.

SUMMARY

The need for adequately powered pediatric clinical trials, coupled with the study of epigenetic mechanisms and their influence on phenotypic variation and the integration of precision survivorship into precision approaches are featured as important areas for focused investments in the future.

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.

Incidence of vincristine induced neurotoxicity in children with acute lymphoblastic leukemia and its correlation with nutritional deficiencies

Injection vincristine is an important component of therapy for acute lymphoblastic leukemia (ALL). An important adverse effect of vincristine is neurotoxicity. The incidence of this adverse effect is well studied. The present was undertaken to determine the incidence of vincristine-induced neurotoxicity in children with ALL after the induction of remission phase of chemotherapy and to ascertain its correlation with undernutrition, vitamin B12, folate and iron deficiency. Thirty children (1-18 years) with ALL were enrolled at the commencement of chemotherapy. The electrophysiological evaluation was done at baseline and repeated after four doses of vincristine (1.5 mg/m²/dose). Clinical evaluation was done regularly. Anthropometry and serum B12, folate and ferritin levels were assessed at baseline. Twelve children over a 4-week period of observation had peripheral neuropathy clinically. The autonomic system was most commonly involved followed by motor and sensory system respectively. On electrophysiological testing, half of the patients had evidence of neuropathy. Micronutrient deficiencies were present in a significant number of patients-63.3% had a B12 deficiency, 20% were deficient in folate and 43.3% in iron. The incidence of vincristine-induced neuropathy in patients with/without these micro-nutrient deficiencies was not statistically significantly different. Vincristine-induced neuropathy is common in Indian children with ALL. The present study did not find any correlation between the occurrences of vincristine-induced neuropathy and nutritional deficiencies. Larger studies are warranted to evaluate the contribution of micronutrient deficiencies to the development of peripheral neuropathy in childhood ALL.

Aspects of vincristine-induced neuropathy in hematologic malignancies: a systematic review

PURPOSE

Vincristine is widely used as anticancer therapy for a variety of hematological malignancies. The treatment is limited by progressive vincristine-induced neuropathy, possibly including both peripheral sensory and motor nerves, autonomic nervous functions, and the central nervous system. This dose-limiting side-effect can diminish quality of life and, furthermore, cause discontinuation of vincristine treatment. The present review elucidates the current knowledge regarding vincristine-induced neuropathy in hematologic malignancies, focusing on neuropathy assessment, clinical and molecular predictive markers, drug-drug interference, prevention, and treatment.

METHODS

This review is conducted by a systematic search strategy for the identification of relevant literature in the PubMed and Embase databases.

RESULTS

No clinical parameters displayed convincing potential as predictors of vincristine-induced neuropathy; however, preexisting neuropathy was consistently reported to be associated with an increased risk of neurotoxicity. In contrast, molecular markers, including polymorphisms in genes involved in the pharmacodynamics and pharmacokinetics of vincristine, displayed great potential as predictive markers of neuropathy incidence and severity. Furthermore, antifungal drugs, such as itraconazole and voriconazole, decrease the metabolism of vincristine and consequently lead to severe neuropathy when co-administered with vincristine, underscoring why fluconazole should be the antifungal drug of choice.

CONCLUSION

Reports from the 71 included studies clearly emphasize the lack of consistency in neuropathy assessment, grading systems, and reporting, making it difficult to interpret results between studies. Thus, truer clinical and molecular markers could emerge if the consistency of neuropathy detection and reporting increases by the use of conventional standardized neuropathy assessment tools and grading scales.

Modifying bone mineral density, physical function, and quality of life in children with acute lymphoblastic leukemia

BACKGROUND

The early effects of childhood acute lymphoblastic leukemia (ALL) include decreased physical function, bone mineral density (BMD/g/cm2 ), and health-related quality of life (HRQL). We assessed the capacity of a physical therapy and motivation-based intervention, beginning after diagnosis and continuing through the end of treatment, to positively modify these factors.

PROCEDURE

A 2.5-year randomized controlled trial of 73 patients aged 4-18.99 years within 10 days of ALL diagnosis assessed BMD at baseline (T0 ) and end of therapy (T3 ), strength, range of motion, endurance, motor skills, and HRQL at baseline (T0 ), 8 (T1 ), 15 (T2 ), and 135 (T3 ) weeks.

RESULTS

There were no significant changes between groups (intervention, n = 33; usual care, n = 40) in BMD (P = 0.059) at T3 or physical function and HRQL at T0 -T3 . While BMD declined in both the intervention (T0  = -0.21, T3  = -0.55) and usual care (T0  = -0.62, T3  = -0.78) groups, rates of decline did not differ between groups (P = 0.56). Univariate analysis (n = 73) showed associations of higher T3 bone density with body mass index T1 (P = 0.01), T2 (P = <0.0001), T3 (P = 0.01), T3 ankle flexibility/strength (P = 0.001), and T2 parent (P = 0.02)/T0 child (P = 0.03) perceptions of less bodily pain.

CONCLUSIONS

The intervention delivered during treatment was not successful in modifying BMD, physical function, or HRQL. Physical activity, at the level and intensity required to modify these factors, may not be feasible during early treatment owing to the child's responses to the disease and treatment. Future studies will consider intervention implementation during late maintenance therapy, extending into survivorship.

Autonomic Nervous System Pretransplant Malfunction Is a Powerful Predictor of Survival After Allogeneic Hematopoietic Cell Transplantation

BACKGROUND

Autonomic nervous system function indexed by heart rate variability (HRV) has shown prognostic value for mortality in various cardiovascular and noncardiovascular diseases including cancer. The purpose of this study was to evaluate an association between HRV and outcomes of allogeneic hematopoietic cell transplantation (allo-HCT).

METHODS

We prospectively measured HRV as a surrogate pretransplant marker of autonomic nervous system activity in consecutive allo-HCTs with hematological diseases.

RESULTS

We analyzed 112 allo-HCTs performed between July 2011 and July 2013 in our center. Univariate analysis showed that increased values of HRV components (low-frequency [LF] and high-frequency [HF] spectral component), SD of normal-to-normal RR interval (SDNN), and squares of the differences between adjacent normal-to-normal RR intervals (r-MSSD) were significantly associated with decreased probability of overall mortality (hazard ratio = 0.3 for LF, P < 0.001; hazard ratio = 0.3 for HF, P = 0.001; hazard ratio = 0.6 for SDNN, P = 0.004; and hazard ratio = 0.5 for r-MSSD, P = 0.014). Among these 4 indicators, the LF-added pretransplantation assessment of mortality, hematopoietic cell transplantation-comorbidity index, and disease risk index models showed the highest values of ΔAkaike information criterion (16.5, 22.2, and 11.4, respectively). When stratified into quartiles of LF groups, 2-year overall survival was 92.9, 84.5, 59.7, and 33.2%, respectively (P < 0.001). LF alone represented a better discriminating variable for the prediction of mortality when compared with pretransplantation assessment of mortality, hematopoietic cell transplantation-comorbidity index, and disease risk index. In addition, from bivariate analyses, decreased LF was an independent and significant factor for higher overall mortality in all models.

CONCLUSIONS

Indicators reflective of autonomic nervous system function might be a powerful predictor of survival after allo-HCT.

Vincristine-induced peripheral neuropathy in children with cancer: A systematic review

Vincristine-induced peripheral neuropathy (VIPN) is a dose-limiting side effect of vincristine (VCR) treatment in children, leading to diminished quality of life. Much remains unknown about the underlying mechanisms of VIPN. This review systematically summarizes the available literature concerning contributing factors of VIPN development in children. Studied factors include patient characteristics, VCR dose, administration method, pharmacokinetics, and genetic factors. Furthermore, this review reports on currently available tools to assess VIPN in children. In total, twenty-eight publications were included. Results indicate that Caucasian race, higher VCR dose, older age and low clearance negatively influence VIPN, although results regarding the latter two factors were rather conflicting. Moreover, genetic pathways influencing VIPN were identified. Furthermore, the studied tools to assess VIPN seriously impairs comparability across study results. Studying the factors and their interactions that seem to influence VIPN in children, should aid in personalized VCR treatment, thereby increasing VCR effectiveness while minimizing toxicity.

Decreased postural control in adult survivors of childhood cancer treated with chemotherapy

The objective of cancer treatment is to secure survival. However, as chemotherapeutic agents can affect the central and peripheral nervous systems, patients must undergo a process of central compensation. We explored the effectiveness of this compensation process by measuring postural behaviour in adult survivors of childhood cancer treated with chemotherapy (CTS). We recruited sixteen adults treated with chemotherapy in childhood for malignant solid (non-CNS) tumours and 25 healthy age-matched controls. Subjects performed posturography with eyes open and closed during quiet and perturbed standing. Repeated balance perturbations through calf vibrations were used to study postural adaptation. Subjects were stratified into two groups (treatment before or from 12 years of age) to determine age at treatment effects. Both quiet (p = 0.040) and perturbed standing (p ≤ 0.009) were significantly poorer in CTS compared to controls, particularly with eyes open and among those treated younger. Moreover, CTS had reduced levels of adaptation compared to controls, both with eyes closed and open. Hence, adults treated with chemotherapy for childhood cancer may suffer late effects of poorer postural control manifested as reduced contribution of vision and as reduced adaptation skills. These findings advocate development of chemotherapeutic agents that cause fewer long-term side effects when used for treating children.

Muscle strength, motor performance, cardiac and muscle biomarkers in detection of muscle side effects during and after acute lymphoblastic leukemia treatment in children

Muscle side effects have not been frequently assessed in childhood acute lymphoblastic leukemia (ALL) patients. Our objective was to determine the early and late muscle side effects during childhood ALL treatment. To this end, we examined the early muscle side effects in 15 newly diagnosed "therapy patients" (group I), and the late side effects in 18 ALL survivors "off therapy patients" (group II). Muscle side effects were assessed by measuring hand grip strength (HGS), the "timed up and go" (TUG) test, creatine phosphokinase, myoglobin, plasma electrolytes, cardiac troponin I before and after induction chemotherapy in group I. The same parameters and cranial radiotherapy dose were examined in group II at a single timepoint. Cumulative doses of chemotherapy were calculated, and echocardiograms were obtained for each group. As a result, we found that the HGS and TUG measures of group I at the end of induction were poorer than measures of the first admission, control subjects, and group II. Low HGS measures had been normalized over time, but the TUG measures remained poor. Overt rhabdomyolysis and pyomyositis were not detected in any of the patients. These results suggested that muscle side effect monitoring might be helpful in the follow-up of children with ALL.

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.

Assessment of gross motor skills and phenotype profile in children 9-11 years of age in survivors of acute lymphoblastic leukemia

BACKGROUND

The purpose of this study was to evaluate the usefulness of a new gross motor skill test battery in acute lymphoblastic leukemia (ALL) children who have been off therapy for at least 1 year and to assess its discriminatory power (discriminant analysis) from healthy children.

PROCEDURE

Twenty children (10 males and 10 females) 9-11 years of age (median age = 10.6 years) were assessed by the UQAC-UQAM test battery and then compared to recent provincial norms. This pilot study was also an opportunity to validate this test battery as a reliable tool for clinical or research purposes in the area of chronic or disabling diseases in children. Eleven motor skill variables grouped into five factors have been measured (speed, agility, balance, coordination, and reaction time).

RESULTS

Scores from 10 of the 11 motor skill tests showed significant differences when compared to the control group (P ≤ 0.05). Nearly 50% of patients obtained an average score below the 15th percentile. Furthermore, stepwise discriminant analysis allowed classifying successfully 88.4% of children in the correct group (ALL or Control). The normal development of GMS among children affected by ALL appears to have been compromised. The UQAC-UQAM test battery seems to be sensitive enough to quantify with precision the extent of the motor impairment in these children.

CONCLUSION

The UQAC-UQAM test battery appears to be a useful tool to evaluate the extent to which ALL survivors are affected. Early motor intervention should be considered for those patients even during the treatment periods.

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.

After the chemotherapy: potential mechanisms for chemotherapy-induced delayed skeletal muscle dysfunction in survivors of acute lymphoblastic leukaemia in childhood

There is evidence that survivors of childhood cancers, such as acute lymphoblastic leukemia (ALL), have increased rates of long-term skeletal muscle dysfunction. This places them at higher risk of physical restriction and functional impairment as well as potentially contributing to observed increases in cardiovascular disease and insulin resistance in later life. The mechanisms underlying these changes in skeletal muscle are unknown but chemotherapy drugs used in treatment for ALL are strongly implicated. Normal skeletal muscle growth, development, and function are dependent on correctly functioning muscle satellite cells, muscle motor neurons, and muscle mitochondria. Each of these key components is potentially susceptible to damage by chemotherapy in childhood, particularly prolonged courses including repeated administration of combination chemotherapy. If this chemotherapy-induced damage is not fully reversible, impairment of satellite cells, muscle motor innervation, and mitochondria could, either singly or together, lead to the emergence of delayed or persistent skeletal muscle dysfunction many years later. The known effects of individual drugs used in the treatment of ALL are outlined and the need for specific targeted studies to investigate the mechanisms underlying persistent muscle dysfunction in survivors of ALL and other childhood cancers is highlighted.

Neuromuscular impairments in adult survivors of childhood acute lymphoblastic leukemia: associations with physical performance and chemotherapy doses

BACKGROUND

Treatment regimens for childhood acute lymphoblastic leukemia (ALL) contain neurotoxic agents that may interfere with neuromuscular health. In this study, the authors examined associations between neuromuscular impairments and physical function and between neuromuscular impairments and doses of vincristine and intrathecal methotrexate used to treat leukemia among survivors of childhood ALL.

METHODS

ALL survivors >10 years from diagnosis participated in neuromuscular performance testing. Treatment data were abstracted from medical records. Regression models were used to evaluate associations between treatment factors, neuromuscular impairments, and physical performance.

RESULTS

Among 415 survivors (median age, 35 years; age range, 21-52 years), balance, mobility, and 6-minute walk (6MW) distances were 1.3 standard deviations below age-specific and sex-specific values in 15.4%, 3.6%, and 46.5% of participants, respectively. Impairments included absent Achilles tendon reflexes (39.5%), active dorsiflexion range of motion (ROM) <5 degrees (33.5%), and impaired knee extension strength (30.1%). In adjusted models (including cranial radiation), survivors who received cumulative intrathecal methotrexate doses ≥215 mg/m(2) were 3.4 times more likely (95% confidence interval, 1.2-9.8 times more likely) to have impaired ROM than survivors who received no intrathecal methotrexate, and survivors who received cumulative vincristine doses ≥39 mg/m(2) were 1.5 times more likely (95% CI, 1.0-2.5 times more likely) to have impaired ROM than survivors who received lower cumulative doses of vincristine. Higher intrathecal methotrexate doses were associated with reduced knee extension strength and 6MW distances.

CONCLUSIONS

Neuromuscular impairments were prevalent in childhood ALL survivors and interfered with physical performance. Higher cumulative doses of vincristine and/or intrathecal methotrexate were associated with long-term neuromuscular impairments, which have implications on future function as these survivors age.

The mystery of electroencephalography in acute lymphoblastic leukemia

The aim of the study was to evaluate changes in electroencephalogram (EEG) recordings during the course of acute lymphoblastic leukemia (ALL) in children. The study group consisted of 48 children with ALL who underwent a total of 72 EEGs at various stages of the disease. The medical files were reviewed for pertinent clinical data, and the EEGs were evaluated for changes in brain activity. Abnormal background activity was noted in 52.2% of the EEGs done at 1-10 days of therapy, in 43.5% of those done at 10-60 days, and only 4.3% of those done at later stages (p=0.037). These findings, together with earlier reports, suggest that early-stage ALL, even before treatment, may be associated with excessive slow EEG activity, which improves over time. The EEG changes, by themselves, are not an indication of central nervous system leukemia or a predictor of later seizures or other central nervous system involvement.

Somatosensory evoked potential for detection of subclinical neuropathy in Egyptian children with acute lymphoblastic leukaemia

To evaluate neurological changes developing during paediatric Acute Lymphoblastic Leukaemia (ALL) therapy clinically and through electrophysiological Study of Somatosensory Evoked Potentials (SSEPs) changes in different phases of therapy. Thirty five-ALL patients with age range from 3-14 years were included compared to 30 healthy controls. History, neurological examination, complete blood counts, cytological examination of bone marrow aspirate and cerebrospinal fluid with Measurement of Serum Methotrexate (MTX) were done. The SSEPs were performed and patients subjected to another SSEP with measurement of serum MTX level before and 10 days after intra-thecal injection (IMTX). Clinical neurological findings in patients after induction were depressed deep tendon reflexes (43.3%), hypotonia (28.6%), lost pain sensation (28.6%), muscle weakness (17.1%) and movement disorders (17.1%). Percentage of delayed SSEPs after induction were at levels of brachial plexus (28.6%), spinal cord (68.6%), cortical conduction (31.4%), ERB-N13 Inter Peak Latency (IPL) (74.3%) and N13-N20 IPL (17.1%) in the studied patients. Significant prolonged latency of N13 (p = 0.005), N20 (p = 0.04) and IPL of ERB-N 13 (p = 0.005), N13-N20 (p = 0.01), Inter-Side Difference (ISD) of N13 (p = 0.01), ERB-N13 (p = 0.02) and N13-N20 (p = 0.03) after induction compared to values at diagnosis. Significant positive correlation were found between serum MTX after IMTX with N13-N20 IPL (p = 0.01), N20 ISD (p = 0.03) with significant prolongation in N20 latency, N13-N20 IPL and ISD of N20 compared to values before injection. ALL patients have prolonged latency of SSEPs at cervical cord and cortical levels which increased after IMTX due to axonal injury throughout the cord. SSEPs could be an early diagnostic tool for subclinical neuropathy.

Vincristine-induced peripheral neuropathy in a neonate with congenital acute lymphoblastic leukemia

We report the case of a 46-day-old boy with a fulminant vincristine-induced peripheral neuropathy after treatment for congenital acute lymphoblastic leukemia. Flaccid paralysis developed at the end of the first phase of induction, requiring intubation and ventilation for 51 days. Treatment was initiated with levocarnitine, N-acetylcysteine, and pyridoxine and progressive reversal of the neuropathy occurred over the next 4 months. Potential differences in pathogenesis and presentation of vincristine neurotoxicity and Guillian-Barre syndrome in the neonate are discussed.

Peripheral neuropathy in survivors of childhood acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the most common form of cancer in children. Recent advances in treatment have led to dramatically improved survival rates. Standard ALL treatment includes multiple administrations of the chemotherapeutic drug vincristine, which is a known neurotoxic agent. Although peripheral neuropathy is a well-known toxicity among children receiving vincristine acutely, the long-term effects on the peripheral nervous system in these children are not clear. The objective of this study was to determine the prevalence of neuropathy and its impact on motor function and quality of life (QOL) among children who survived ALL. Thirty-seven survivors of childhood ALL aged 8-18 underwent evaluation for neuropathy through self-reported symptoms, standardized examinations, and nerve conduction studies (NCS). Functional impact of neuropathy was assessed using the Bruininks-Oseretsky test of Motor Proficiency (BOT-2). QOL was assessed using the PedsQL. Nerve conduction study abnormalities were seen in 29.7% of children who were longer than 2 years off therapy for ALL. Most children with an abnormal examination or NCS did not have subjective symptoms. Although overall motor function was below population norms on the BOT-2, presence of neuropathy did not significantly correlate with motor functional status or QOL.

Late-occurring neurologic sequelae in adult survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

PURPOSE

Children with acute lymphoblastic leukemia (ALL) are often cured, but the therapies they receive may be neurotoxic. Little is known about the incidence and severity of late-occurring neurologic sequelae in ALL survivors. Data were analyzed to determine the incidence of adverse long-term neurologic outcomes and treatment-related risk factors.

PATIENTS AND METHODS

We analyzed adverse neurologic outcomes that occurred after diagnosis in 4,151 adult survivors of childhood ALL who participated in the Childhood Cancer Survivor Study (CCSS), a retrospective cohort of 5-year survivors of childhood cancer diagnosed between 1970 and 1986. A randomly selected cohort of the survivors' siblings served as a comparison group. Self-reported auditory-vestibular-visual sensory deficits, focal neurologic dysfunction, seizures, and serious headaches were assessed.

RESULTS

The median age at outcome assessment was 20.2 years for survivors. The median follow-up time to death or last survey since ALL diagnosis was 14.1 years. Of the survivors, 64.5% received cranial radiation and 94% received intrathecal chemotherapy. Compared with the sibling cohort, survivors were at elevated risk for late-onset auditory-vestibular-visual sensory deficits (rate ratio [RR], 1.8; 95% CI, 1.5 to 2.2), coordination problems (RR, 4.1; 95% CI, 3.1 to 5.3), motor problems (RR, 5.0; 95% CI, 3.8 to 6.7), seizures (RR, 4.6; 95% CI, 3.4 to 6.2), and headaches (RR, 1.6; 95% CI, 1.4 to 1.7). In multivariable analysis, relapse was the most influential factor that increased risk of late neurologic complications.

CONCLUSION

Children treated with regimens that include cranial radiation for ALL and those who suffer a relapse are at increased risk for late-onset neurologic sequelae.

Polymorphisms in genes involved in vincristine pharmacokinetics or pharmacodynamics are not related to impaired motor performance in children with leukemia

INTRODUCTION

Impaired motor performance in children who completed treatment for acute lymphoblastic leukemia (ALL) may be related to polymorphisms of the metabolising gene CYP3A5 or vincristine toxicity related genes MDR-1 and MAPT.

METHODS

Motor performance was measured with the Movement Assessment Battery for Children (movement-ABC). DNA, from mononuclear blood cells was genotyped for CYP3A5, MDR-1 and MAPT polymorphisms.

RESULTS

Motor performance was not significantly affected by CYP3A5*3/*3 and CYP3A5*1*3 genotypes, MDR-1 polymorphisms or MAPT haplotype.

CONCLUSION

Our data did not show that CYP3A5, MDR-1 or MAPT polymorphisms are linked to impaired motor performance in children after treatment for ALL.

Decrease in peripheral muscle strength and ankle dorsiflexion as long-term side effects of treatment for childhood cancer

BACKGROUND

This study investigated muscle strength, passive ankle dorsiflexion, and their association with motor performance in children after treatment for acute lymphoblastic leukemia, Wilms tumor, B-non-Hodgkin lymphoma, and malignant mesenchymal tumors.

PROCEDURE

Muscle strength was assessed with a hand-held dynamometer and ankle dorsiflexion with a goniometer in 92 and 64 survivors, respectively. Motor performance was measured with the Movement Assessment Battery for Children (movement-ABC). Age at testing: 6.1-12.9 years. Mean time since completing treatment: 3.3 years. Results were compared to 155 healthy controls.

RESULTS

Muscle strength of the survivors was reduced in ankle dorsiflexors on both sides (P < 0.001), wrist dorsiflexors on the non-dominant side (P < 0.001), and pinch grip on the non-dominant (P = 0.001) and dominant side (P = 0.01). Passive ankle dorsiflexion of the survivors was significantly less on both sides (P < 0.01). Movement-ABC percentile score was affected by pinch grip strength on the non-dominant (P < 0.004), and dominant side (P = 0.024) but not by strength of other muscle groups or by passive ankle dorsiflexion.

CONCLUSION

Peripheral muscle strength and ankle dorsiflexion are reduced in the long-term in children treated for cancer with chemotherapy. However, neither decreased muscle strength nor reduced ankle dorsiflexion could completely explain reduced scores on the movement-ABC.

Are survivors of acute lymphoblastic leukemia (ALL) at increased risk of cardiovascular disease?

Through a variety of different mechanisms, it appears that survivors of childhood acute lymphoblastic leukemia have an increased prevalence of several cardiovascular risk factors and thus are at increased risk for developing cardiovascular disease. The aim of this paper is to describe the current understanding of particular risk factors, including obesity, physical inactivity, dyslipidemia, insulin resistance, and metabolic syndrome, that may contribute to cardiovascular disease in survivors of childhood ALL. The potential roles of different cancer therapies in the development of these risk factors are discussed. In addition, two other late effects that may affect cardiovascular health are discussed: late-onset anthracycline-induced left ventricular dysfunction and methotrexate-mediated elevations of homocysteine during therapy with the potential for endothelial dysfunction. Lastly, areas needing further investigation to elucidate these risks are highlighted.

No adverse effect of vincristine on handwriting in children after completion of therapy

BACKGROUND

Long-term writing difficulties in children after treatment with vincristine for acute lymphoblastic leukemia, Wilms tumor, B non-Hodgkin lymphoma, and malignant mesenchymal tumors, were investigated.

PROCEDURE

Handwriting of 33 survivors and 33 controls matched for age, sex, and grade, was assessed with the BHK-scale. The examiner was blinded for whether a child was a case or a control.

RESULTS

No significant difference in writing speed was found. Mean difference in number of letters produced during 5 min was 6.4 (+/-67.1, range -103 to +169). No significant difference was found in quality of writing scores; mean difference in points was 1.5 (+/-7.7, range -19 to +22). Cumulative vincristine dose, age at diagnosis or time since completion of treatment did not affect writing speed or quality.

CONCLUSION

Chemotherapy, including vincristine, does not lead to long-term problems in speed or quality of writing in children treated for cancer.

Decrease in motor performance in children with cancer is independent of the cumulative dose of vincristine

BACKGROUND

Impaired performance on motor tasks in children treated for acute lymphoblastic leukemia (ALL) after completion of treatment is often attributed to vincristine (VCR). Whether motor problems persist in other children who receive different cumulative doses of VCR is to the authors' knowledge not known. The objective of the current study was to determine the extent of motor problems in children with ALL, Wilms tumor (WT), B-cell non-Hodgkin lymphoma (B-NHL), and malignant mesenchymal tumors (MMT) and whether these motor problems were related to VCR dose.

METHODS

In 128 children ages 4-12 years who completed treatment after at least 1 year, motor performance was measured using the Movement Assessment Battery for Children (m-ABC).

RESULTS

The m-ABC scores of the total study group were significantly lower than those of the normal population (P < 0.001). There were no differences in scores noted between children with ALL, WT, B-NHL, or MMT. There also were no differences noted between those children with ALL who had received pulses of VCR and steroids during maintenance therapy and those who had not. All groups demonstrated large variability in scores. Scores were not found to be significantly different between those children who had received low (< 20 mg/m(2)), intermediate (20-40 mg/m(2)), or high (> 40 mg/m(2)) cumulative doses of VCR. Cumulative doses of corticosteroids and methotrexate did not affect scores, nor did age at diagnosis and time since the completion of therapy.

CONCLUSIONS

Although motor performance was impaired in all patient groups, no correlation was found between motor performance and the cumulative dose of VCR or other drugs, age, and follow-up time. Future studies have to address several issues, including whether polymorphisms in drug metabolizing genes or drug target genes explain the significant variability noted in the long-term motor outcome of children with cancer.

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.

Effects of physical therapy intervention for children with acute lymphoblastic leukemia

BACKGROUND

The purpose of this study was to examine the effects of physical therapy intervention in children with acute lymphoblastic leukemia (ALL).

PROCEDURE

Twenty-eight children aged 4-15 years were randomly assigned to an intervention or control group. The intervention group received five sessions of physical therapy and was instructed to perform an individualized home exercise program consisting of ankle dorsiflexion stretching, lower extremity strengthening, and aerobic exercise.

RESULTS

After 4 months children who received physical therapy intervention had significantly improved ankle dorsiflexion active range of motion and knee extension strength (P < 0.01). Differences were not found between the two groups for any of the other dependent variables.

CONCLUSIONS

Physical therapy intervention for children with ALL receiving maintenance chemotherapy improved two body functions important for normal gait. Physical therapy programs initiated earlier in treatment and with greater emphasis on endurance activities may also improve stamina and quality of life (QOL).

Measurement of balance in survivors of acute lymphoblastic leukemia in childhood

Survivors of acute lymphoblastic leukemia (ALL) in childhood have been identified with balance problems. The goals of this study were to objectively quantify these observations by measuring the displacement and velocity of the body centre of pressure, a measure of 'sway'. The subjects included 79 ALL survivors who were at least 1 year post-treatment for ALL and 83 age-matched controls. Testing was carried out using various static balance tests designed to challenge central nervous system maintenance of balance and postural control. Patients were different from controls, across all age groups, in the more difficult task in which they were required to balance over a narrow base of support. However this did not reach statistical significance. When they were asked to perform this task with their eyes closed 32% of the patients tested, as opposed to 2% of controls, were unable to complete the task (significant at P<0.01, chi(2)). The youngest group of patients (children aged 5-7 years) presented consistently with lower (or similar) displacement and lower velocity measures. This phenomenon has been observed in healthy children, however, in patients, these trends were magnified and beyond the normal age range in healthy children. The velocity values were significantly different from the other patient groups (normalized values for velocity; P<0.01). These observations then manifested as higher sway values when patients were challenged with a difficult task with their eyes closed. We propose that survivors of childhood ALL have delayed motor development compared to age-matched controls giving rise to impairment in balance and postural control. It is possible that these impairments are a consequence of intensive multi-agent chemotherapy and cranial irradiation.

Strength and functional mobility in children with acute lymphoblastic leukemia

BACKGROUND

The purposes of this pilot study were as follows: (1) to evaluate tools for measuring neuropathy in children with acute lymphoblastic leukemia (ALL), (2) to examine strength and functional mobility in children with ALL, and (3) to determine if there is a relationship between strength and function.

PROCEDURE

Strength of knee extension and ankle dorsiflexion as measured with a dynamometer and functional mobility with the Timed Up and Go (TUG) were examined in eight children with ALL, ages 4-15 years, before and during delayed intensification (DI) therapy and in age- and gender-matched controls.

RESULTS

The mean knee extension strength, ankle dorsiflexion strength, and TUG measures for children with ALL before DI were significantly less than the means for the controls. The mean dorsiflexion strength measures for the children with ALL after 4 weeks of DI therapy were significantly lower than at time zero. Correlation of -0.794 (P = 0.05) was found between knee extension strength and TUG score for children with ALL.

CONCLUSIONS

The dynamometer and TUG are reliable tools to measure strength and function in children with ALL early in their treatment. In this study, ankle dorsiflexion strength worsened during DI therapy. There was a correlation between strength and function in children with ALL.

Motor nervous system impairment persists in long-term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

The objective of the current study was to determine whether therapy for childhood acute lymphoblastic leukemia (ALL) results in long-lasting neurologic signs or electrophysiologic injuries within the motor tracts.

METHODS

Twenty-seven children who were treated for ALL were studied clinically 5 years after the cessation of therapy by means of motor-evoked potentials (MEPs) elicited by magnetic stimulation transcranially and peripherally. An equal number of healthy children matched with regard to age, gender, and height served as the control group.

RESULTS

The MEP latencies to the hands and legs elicited by stimulation at the cortex were prolonged significantly in the children treated for ALL compared with the control group, with the differences being 2.2 milliseconds [ms] (P < 0.001) from the cortex to the thenar on the right side and 2.0 ms (P < 0.001) on the left, and 1.4 ms (P = 0.004) from the cortex to the leg on the right side and 1.3 ms (P = 0.004) on the left. Correspondingly, the MEP latency from the fifth lumbar vertebrae (LV) level to the leg also was prolonged, by 1.0 ms (P = 0.005) on the right side and 0.8 ms (P = 0.005) on the left side. The calculated latency between the cortex and the LV level was not found to be significantly longer in those patients treated for ALL compared with the healthy controls. Neurologic signs, in the form of depressed deep tendon reflexes, were observed in 8% of the patients, whereas approximately 33% of the patients were found to have fine or gross motor difficulties and dysdiadochokinesia.

CONCLUSIONS

Neurologic signs still persisted 5 years after therapy for ALL. Approximately 33% of the patients had fine or gross motor difficulties and dysdiadochokinesia, and demyelinative injuries to the peripheral nerve tracts were found proximally but not within the central nervous system.

Analysis of handwriting of children during treatment for acute lymphoblastic leukemia

BACKGROUND

Children treated for acute lymphoblastic leukemia (ALL) often complain about handwriting problems.

PROCEDURE

Using a computerized writing task, we have prospectively studied the processes necessary for the production of handwriting movements in 11 children (5-12 years old) during treatment for ALL. Children were tested at time points closely related to the vincristine administration.

RESULTS AND CONCLUSIONS

Children treated for ALL drew slower, with longer pause durations and increased drawing pressure. Children were able to overcome the problems, except for a consistently increased drawing pressure. This increased drawing pressure may be an attempt of the children to obtain sufficient kinesthetic information and thus can be seen as an adequate adaptation mechanism in case of peripheral neuropathy due to the neurotoxic effects of vincristine. However, neurotoxic effects of other cytostatic drugs cannot be excluded.

Motor nervous pathway function is impaired after treatment of childhood acute lymphoblastic leukemia: a study with motor evoked potentials

BACKGROUND

The objective was to evaluate whether motor nervous pathways are affected when patients are treated for childhood acute lymphoblastic leukemia (ALL).

PROCEDURE

Thirty-two children with ALL were studied at the end of treatment by means of motor evoked potentials (MEPs) elicited by magnetic stimulation (MS) transcranially and peripherally and underwent a detailed neurological examination. Thirty-two healthy children matched with them for age, sex, and height served as a control group.

RESULTS

The latencies of the MEPs were significantly prolonged along the entire motor nervous pathway in the patients with ALL compared with the healthy controls, indicating demyelination in the thick motor fibres. The MEP amplitudes of the distal extremities elicited by stimulation at the brachial plexus and LV spinal level were significantly lowered in the patients treated for ALL, also indicating anatomical or functional loss of descending motor fibres and/or muscle fibres. The MEP amplitudes elicited by cortical MS showed wider variation and no clear abnormalities were found. Neurological signs and symptoms were common after treatment: 41% of the patients had depressed deep tendon reflexes, 31% had fine motor difficulties and 63% gross motor difficulties, and 34% had dysdiadochokinesia. The conduction delay within the peripheral nerve was related to the post-therapeutic interval after administration of vincristine and the lesions within the CNS to the number of injections of intrathecal methotrexate.

CONCLUSIONS

The present results show adverse effects of the ALL treatment on the entire motor nervous pathways. In our experience, the measurement of MEPs by MS provides an objective, painless, and practical tool for assessing the treatment-related neurotoxicity in both the CNS and the peripheral nerves. These disturbances in the motor nervous pathways at the end of treatment raise the question of the long-term effects of ALL treatment on the motor nerve tracts, and have led us to employ MEPs to study these effects in long-term survivors of ALL.

Pain variations during cancer treatment in children: a descriptive survey

Structural interviews were conducted with 66 children and their families to investigate how the experience of pain varied during cancer treatment. At diagnosis, 49% experienced cancer-related pain. Intense pain was more common at the beginning of treatment when it was often believed that pain treatment could be better. Procedure- and treatment-related pain were the major problems initially. Procedural pain gradually decreased, but treatment-related pain was constant and dominating. For some procedures pain was rated highest initially, lower during the second period, and higher again during the final part of treatment. Pain intensity measurement was seldom performed, and parents increasingly considered themselves better judges of their child's pain than professionals. Increased knowledge about pain and pain treatment in children with cancer, where most pain is iatrogenic, will help us to meet the needs and demands of children and parents, and to reduce pain to a minimum.

Motor performance of children during treatment for acute lymphoblastic leukemia

BACKGROUND

Daily life motor skills of children with acute lymphoblastic leukemia (ALL) were studied during treatment using the Movement Assessment Battery for Children (Movement ABC). In addition, the possible relation with vincristine treatment was investigated.

PROCEDURE

Seventeen children treated for ALL, aged 4-12 years, were compared to an age- and sex-matched control group.

RESULTS

The leukemia group performed more poorly than the control group on both fine and gross motor skills. In looking at the number of children with ALL who scored in the clinical range of the different subtests, problems in balance skills were found to be most pronounced at the end of induction therapy. Remarkably, half a year after reinduction therapy, problems with balance had decreased, whereas the number of children with fine motor problems had increased.

CONCLUSIONS

A relation between the gross motor problems and vincristine neurotoxicity seems plausible based on a descriptive analysis of the data, but this was not supported statistically.

Limitation of ankle range of motion in survivors of acute lymphoblastic leukemia: a cross-sectional study

BACKGROUND

The purpose of this study was to evaluate and determine the factors related to active and passive dorsiflexion range of motion (DF-ROM) in survivors of acute lymphoblastic leukemia (ALL), which is the most obvious impairment of musculoskeletal function in such children.

PROCEDURE

The subjects included 54 survivors of ALL treated on Dana-Farber Cancer Institute protocols and 54 comparable healthy children. Bilateral active and passive DF-ROM were measured with the knee extended.

RESULTS

The survivors of ALL had significantly less active and passive DF-ROM (6.4 vs. 16.8, 10.5 vs. 18.8 degrees, respectively, P < 0.001) than the comparison children. Weight for age at the time of assessment and change in height during treatment showed significant negative correlations with DF-ROM. Length of time-off treatment was not associated with DF-ROM.

CONCLUSIONS

Multiple regression analyses identified the variables of age at diagnosis and gender as significant predictors of both DF-ROM measures following treatment. Children diagnosed at a younger age and females were at greater risk for restricted DF-ROM. Close monitoring and preventative therapy programs for this complication are warranted for children, especially young girls receiving treatment for ALL.

Long-term gross motor performance following treatment for acute lymphoblastic leukemia

BACKGROUND

The primary purpose of this descriptive study was to determine the long-term effects of cancer treatment in childhood on musculoskeletal function and gross motor skills.

PROCEDURE

Musculoskeletal and gross motor function were assessed in a cohort of 36 survivors of acute lymphoblastic leukemia (ALL) seen in a pediatric tertiary care referral centre, compared to 36 age and gender matched comparison subjects. Basic gross motor skills were assessed using dimensions D: standing, and E: walking, running, and jumping of the Gross Motor Function Measure (GMFM). Strength, balance, and running speed and agility were assessed using the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). Hand grip strength and ankle dorsiflexion range of motion were also measured. Findings in the children with ALL were compared by dependent (paired) t-tests to those in age and gender matched children.

RESULTS

The GMFM scores for standing were 98.7% and for walking, running, and jumping were 99% of normal. The mean standard scores for the BOTMP were significantly lower than those of the comparison group: strength 11.5 vs. 19.4, balance 9.4 vs. 15.5, and running speed and agility 9.9 vs. 16.6. The ALL subjects had less hand grip strength 156.3 vs. 190.2, and less ankle dorsiflexion 7.5 vs. 16.1 degrees than the comparison group. The survivors of childhood leukemia were able to perform most basic gross motor functions. However, musculoskeletal impairment was evident and levels of motor proficiency were significantly poorer than those of age and gender matched children.

CONCLUSIONS

Programs to promote physical activity and limit disability may improve gross motor function and increase overall quality-of-life in survivors of leukemia in childhood.

Nerve lesions after therapy for childhood acute lymphoblastic leukemia

BACKGROUND

The objective of the current study was to use somatosensory evoked potentials (SEP) to detect signs of nerve lesions in the peripheral nerve and in the central nervous system (CNS) after 3 years of treatment for childhood acute lymphoblastic leukemia (ALL).

METHODS

The somatosensory potentials evoked by stimulation of the median nerve and posterior tibial nerve were recorded in 31 children with ALL after 3 years of therapy. All patients were examined clinically. The 14 standard risk patients had been treated with chemotherapy according to the Nordic regimen, and the 17 intermediate risk or high risk patients had been treated with chemotherapy and cranial irradiation according to the ALL BFM-83 protocol.

RESULTS

A decrease in amplitudes was observed at the brachial plexus and spinal cord (C7) in the median SEP, and at the knee, spinal cord (Th12), and cortex in the tibial SEP, indicating axonal injury within the entire CNS in the patients with ALL compared with healthy age-, gender-, and height-matched controls. Prolongation of the SEP latencies was found within the spinal cord, indicating demyelination. These SEP changes had persisted for 2 years since the last injection/infusion of vincristine or methotrexate, which are the principal neurotoxic drugs used in chemotherapy for ALL. Clinical signs of nerve injury such as depressed deep tendon reflexes and gross or fine motor difficulties were found in approximately 33% of the patients and dysdiadochokinesia in 50%.

CONCLUSIONS

Treatment of ALL in children principally with vincristine and methotrexate causes long-standing axonal injury throughout the nervous system and demyelination within the spinal cord. These changes are associated with clinical neurologic findings.

"Refuses to walk" as an ED presentation of acute childhood leukemia

New onset of childhood acute leukemia may present to the emergency department in a variety of ways. This report describes the case of a 3-year-old boy who refused to walk and had minimal physical findings, normal X-rays, and nearly normal lab screening results. His white blood cell count differential led to the diagnosis of acute leukemia. The presentation and evaluation of acute leukemia in children is reviewed. Emergency physicians must be prepared to rule out malignancy in the child who refuses to walk when other more common causes, such as infection and trauma, seem unlikely.

Chemotherapy for acute lymphoblastic leukemia may cause subtle changes of the spinal cord detectable by somatosensory evoked potentials

Intrathecal chemotherapy has been determined to cause transient or permanent paraparesis due to myelopathy in patients with leukemia or other malignancies. To systematically evaluate the effect of methotrexate on spinal cord function, somatosensory evoked potentials (SEP) were measured in children with acute lymphoblastic leukemia (ALL). A prospective evaluation was performed in 38 consecutive children aged 1.4-15.3 years with newly diagnosed ALL during treatment. Intrathecal methotrexate therapy was included in the therapy schedule of all patients as central nervous system (CNS) therapy in addition to intravenous chemotherapy in 19 standard risk patients and intravenous chemotherapy with cranial irradiation in 19 intermediate or high-risk patients. The measured conduction times were compared with those of 38 control children matched for age, height, and sex. A significant increase in the conduction time of the tibial nerve SEP was found between the Th12 level and the cortex in children with ALL after receiving intrathecal methotrexate therapy during the induction and CNS therapy phases when compared with their controls. The difference of the mean latencies was 1.45 ms (95% CI 0.39-2.51; P < 0.01). There was no significant delay in the median nerve SEP from the brain stem to the cortex, indicating that the conduction delay was in the area of the spinal cord exposed to intrathecal methotrexate. Moreover, the cortical amplitudes of the median nerve SEPs were significantly reduced when measured immediately after intravenous and intrathecal methotrexate and compared to the amplitudes measured after induction therapy in standard risk patients (P = 0.001). Intrathecal methotrexate with systemic chemotherapy causes a deterioration in the somatosensory pathways within the CNS, suggesting also spinal cord dysfunction in children with ALL in addition to the cerebral dysfunction described earlier.

Fine motor and handwriting problems after treatment for childhood acute lymphoblastic leukemia

Motor skills were investigated in 18 children 2 years after treatment for acute lymphoblastic leukemia (ALL). Gross and fine motor functioning were examined with the Movement Assessment Battery for Children. Handwriting as a specific fine motor skill was studied with a computerized writing task. We conclude that 2 years after cessation of treatment motor problems in ALL survivors were still present. Dysfunctions were mainly pronounced in handwriting and fine motor skills.