Intrahospital supervised exercise training: a complementary tool in the therapeutic armamentarium against childhood leukemia

Exercise and Childhood Cancer-A Historical Review

Simple Summary

Childhood cancer survivors are at risk of developing important adverse effects, but there is growing evidence that physical exercise could help in this regard. The present review summarizes the history of pediatric exercise oncology and the main milestones achieved along the way. Overall, physical exercise appears to be safe and beneficial even during the most aggressive phases of pediatric cancer treatment and can represent an effective coadjuvant therapy for attenuating cancer-related adverse effects.

Abstract

Childhood cancer survivors are at risk of developing important adverse effects, many of which persist for years after the end of treatment. The implementation of interventions aiming at attenuating tumor/treatment-associated adverse effects is therefore a major issue in pediatric oncology, and there is growing evidence that physical exercise could help in this regard. The present review aims to summarize the main milestones achieved in pediatric exercise oncology. For this purpose, we conducted a systematic review of relevant studies written in English in the electronic database PubMed (from inception to 14 August 2021). This review traces the field of pediatric exercise oncology throughout recent history based on three fundamental pillars: (i) exercise during childhood cancer treatment; (ii) exercise during/after hematopoietic stem cell transplantation; and (iii) exercise after childhood cancer treatment. Accumulating evidence––although still preliminary in many cases––supports the safety and potential benefits of regular exercise (with no major contraindications in general) in the childhood cancer continuum, even during the most aggressive phases of treatment. Exercise can indeed represent an effective coadjuvant therapy for attenuating cancer-related adverse effects.

EFFECTS OF PHYSICAL EXERCISE DURING HOSPITALIZATION IN CHILDREN AND ADOLESCENTS WITH CANCER: A SYSTEMATIC REVIEW

Objective:

To identify the effects of exercise programs during hospitalization on children and adolescents with cancer.

Data source:

This is a systematic review, carried out in PubMed/ Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Latin American and Caribbean Center on Health Sciences Information (BIREME), and Physiotherapy Evidence Database (PEDro). We selected studies that included children and adolescents diagnosed with cancer (solid or hematologic) and submitted to exercise protocols during hospitalization. Studies involving patients with other pathologies or with a medical contraindication for exercise were excluded. We used the following search strategy: Neoplasm OR Leukemia OR Cancer OR Tumor OR Medical Oncology AND Hospitalization OR Inpatient Care Units OR Intrahospital AND Exercise. The methodological quality of the studies was analyzed by the PEDro scale.

Data synthesis:

Among the 626 articles found, only 9 fulfilled the inclusion criteria, obtaining a regular methodological quality. The samples had 172 participants, aged 4 to 18 years. Only 6 studies presented both intervention group and control group. The intervention group received strength, aerobic, and muscle stretching exercises, and games, among others. The control group received the standard treatment. The studies varied regarding time, frequency, intensity, and type of exercise. Most studies showed an increase in muscle strength (4/5), followed by an improvement in physical fitness (2/3) and functional capacity (2/4). No adverse events were reported during the interventions. The methodological quality was considered regular.

Conclusions:

The findings suggest that. during hospitalization of children and adolescents with cancer, exercise improves muscle strength, physical fitness, and functionality.

Bone morbidity in pediatric acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL), currently the most common pediatric leukemia, has a high curability rate of up to 90%. Endocrine disorders are highly prevalent in children with ALL, and skeletal morbidity is a major issue induced by multiple factors associated with ALL. Leukemia itself is a predominant risk factor for decreased bone formation, and major bone destruction occurs secondary to chemotherapeutic agents. Glucocorticoids are cornerstone drugs used throughout the course of ALL treatment that exert significant effects on demineralization and osteoclastogenesis. After completion of treatment, ALL survivors are prone to multiple hormone deficiencies that eventually affect bone mineral accrual. Dual-energy X-ray absorptiometry, the most widely used method of measuring bone mineral density, is used to determine the presence of childhood osteoporosis and vertebral fracture. Supplementation with calcium and vitamin D, administration of pyrophosphate analogues, and promotion of mobility and exercise are effective options to prevent further bone resorption and fracture incidence. This review focuses on addressing bone morbidity after pediatric ALL treatment and provides an overview of bone pathology based on skeletal outcomes to increase awareness among pediatric hemato-oncologists and endocrinologists.

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

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

Exercise training in childhood cancer: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Physical capacity and quality of life (QoL) are typically impaired in children/adolescents with cancer. Our primary objective was to examine the effects of exercise training performed after diagnosis of any type of pediatric cancer on physical capacity-related endpoints, survival, disease relapse and adverse effects.

METHODS

(a) Search and selection criteria: Systematic review in Pubmed and Web of Science (until August 2018) of randomized controlled trials (RCTs) of exercise interventions in children with cancer during treatment or within one year after its end. (b) Data collection: Two authors independently identified studies meeting inclusion criteria, extracted data, and assessed risk of bias using standardized forms. When needed, we contacted authors to request clarifications or additional data. (c) Statistical Analysis: The pooled standardized mean differences (SMD) were calculated for those endpoints for which a minimum of three RCTs used the same assessment method. We also calculated the pooled odds ratio (OR) of dying or having a tumor relapse.

RESULTS

Eight RCTs (n = 283 patients) were included in the systematic review. Of these, five studies (n = 173) could be meta-analyzed. Exercise training during pediatric cancer treatment significantly improves patients' functional mobility, as assessed with the timed up and down stairs test (SMD: -0.73, p < 0.001) and does not affect mortality (OR: 0.85, p = 0.76) or relapse risk (OR: 0.96, p = 0.94).

CONCLUSIONS

Exercise training in children with cancer improves functional mobility. More RCTs analyzing the effects of supervised exercise interventions are needed, as well as the development of a core-set of outcomes in pediatric oncology exercise research.

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.

Safety and Feasibility of Rehabilitation Interventions in Children Undergoing Hematopoietic Stem Cell Transplant With Thrombocytopenia

OBJECTIVE

To analyze the relation between platelet counts, intensities of physical therapy (PT) and occupational therapy (OT) services received, and frequencies of bleeding complications in children undergoing hematopoietic stem cell transplant (HSCT) during a period of severe thrombocytopenia.

DESIGN

Retrospective review study.

SETTING

Tertiary care hospital.

PARTICIPANTS

Children (N=63; age, <18y) hospitalized for HSCT in 2010 and 2011 who received PT and OT services while markedly thrombocytopenic (platelet count, ≤50K/mcL).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Intensities of PT and OT interventions, patients' platelet counts on specific therapy days, and any bleeding events (minor or major) that occurred during or shortly after rehabilitation interventions.

RESULTS

Sixty-two patients (accounting for 63 HSCTs) met the criteria for analysis. Fifty-six of these patients (57 HSCTs) underwent PT and/or OT while markedly thrombocytopenic. There was no correlation between platelet counts and intensities of rehabilitation interventions. There were no major bleeding events. There was no association between minor bleeding events and intensities of PT or OT interventions and no association between minor bleeding events and platelet counts. Only 5 minor bleeding events occurred during or after moderate or intensive therapy out of 346 PT and OT sessions (1.5%).

CONCLUSIONS

The results of our study suggest that bleeding complications during or after mobilization and supervised exercise during PT and OT in children with severe thrombocytopenia undergoing HSCT are minor and relatively rare. These are encouraging results for both patients and rehabilitation specialists treating this population who is at high risk of developing immobility-related complications.

The effect of individualized exercise interventions during treatment in pediatric patients with a malignant bone tumor

BACKGROUND

While research on exercise interventions during anticancer treatment is well-established in adults, only very few studies exist in children. However, pediatric patients experience great limitations to being physically active, and appropriate interventions are desired.

PROCEDURE

The present study aimed at investigating the effects of individualized exercise interventions during inpatient stays on pediatric patients with a malignant bone tumor. The parameter of interest was physical activity (PA). Patients' PA during home stays was assessed 6 weeks as well as 3, 6, 12, and 18 months post-surgery. Patients were distinguished into an intervention group and a control group. All patients received endoprosthetic replacement of the affected bone in the same institution.

RESULTS

A constant increase in all PA parameters was observed during follow-up. Exercise interventions were possible and appeared worthwhile. The intervention group showed better PA results at all measurements; however, no significant differences between groups were found. Furthermore, differences decreased especially after the cessation of the intervention. General problems in reaching appropriate power and compliance were observed.

CONCLUSIONS

Individualized exercise interventions in pediatric bone tumor patients are possible and appear to be beneficial. Such interventions should be implemented in adjuvant care; however, future research is needed to understand more about the effects of different interventions.

Exercise during hematopoietic stem cell transplant hospitalization in children

PURPOSE

The purpose of this controlled trial was to assess the effect of an approximately 3-wk intrahospital exercise intervention performed during inpatient hospitalization for pediatric allogeneic hematopoietic stem cell transplant (HSCT) on (i) immune cell recovery and (ii) body composition.

METHODS

Immune (i.e., blood counts of leukocytes, monocytes, lymphocytes, and lymphocyte subpopulations) and anthropometric variables (i.e., body mass, body mass index, and estimated fat-free mass) were measured before and after (+15 and 30 d) HSCT. Seven children (5 boys and 2 girls; age (mean +/- SD) = 8 +/- 4 yr) with high-risk cancer performed an individualized training program (aerobic + resistance exercises) in their isolated hospital rooms. We also assessed a control group (n = 13; 9 boys and 4 girls; age = 7 +/- 3 yr) with similar medical conditions and following the same transplant protocol.

RESULTS

In both groups, the dendritic cell count decreased from pre-HSCT to +15 d post-HSCT and thereafter (up to +30 d) remained stabile; however, the posttransplant decrease was more abrupt in the control group than that in the intervention group (-87% vs -63%, respectively, from pre-HSCT to +15 d). The rest of the immune cell parameters measured showed a similar response from pre-HSCT to post-HSCT in both groups. We found a significant effect of the interaction group x time for all anthropometric variables (weight, body mass index, body fat, and fat-free mass), indicating an increase over the hospitalization period only in the intervention group, for example, body mass increased from 32.9 +/- 18.7 kg pre-HSCT to 35.4 +/- 18.6 kg at +30 d in the intervention group versus a decrease from 30.2 +/- 16.6 to 29.3 +/- 6.3 kg in the control group.

CONCLUSION

Our findings support the feasibility of exercise training interventions during hospitalization, including immunocompromised children.

Physical fitness in childhood and adolescence: a powerful marker of health

This review aims to summarize the latest developments with regard to physical fitness and several health outcomes in young people. The literature reviewed suggests that (1) cardiorespiratory fitness levels are associated with total and abdominal adiposity; (2) both cardiorespiratory and muscular fitness are shown to be associated with established and emerging cardiovascular disease risk factors; (3) improvements in muscular fitness and speed/agility, rather than cardiorespiratory fitness, seem to have a positive effect on skeletal health; (4) both cardiorespiratory and muscular fitness enhancements are recommended in pediatric cancer patients/survivors in order to attenuate fatigue and improve their quality of life; and (5) improvements in cardiorespiratory fitness have positive effects on depression, anxiety, mood status and self-esteem, and seem also to be associated with a higher academic performance. In conclusion, health promotion policies and physical activity programs should be designed to improve cardiorespiratory fitness, but also two other physical fitness components such us muscular fitness and speed/agility. Schools may play an important role by identifying children with low physical fitness and by promoting positive health behaviors such as encouraging children to be active, with special emphasis on the intensity of the activity.

Effects of an Intrahospital Exercise Program Intervention for Children with Leukemia

PURPOSE

The purpose was to investigate the effect of a 16-wk intrahospital supervised conditioning program including both resistance and aerobic training and a 20-wk detraining period on measures of aerobic fitness, muscular strength, functional mobility, ankle range of motion, and quality of life (QOL) in children receiving treatment for acute lymphoblastic leukemia (ALL).

METHODS

Seven children (four boys, three girls; age: 5.1 +/- 1.2 yr, body mass: 24.0 +/- 5.8 kg, height: 114.6 +/- 7.7 cm) in the maintenance phase of treatment against ALL performed three sessions per week for 16 wk of resistance (one set of 8-15 repetitions of 11 exercises) and aerobic training (30 min at > 70% HRmax) followed by 20 wk of detraining where no structured exercise program was performed. Before training, after training, and after detraining, a treadmill test determining .VO2peak and ventilator threshold (VT), muscular strength (6RM), functional mobility (timed up and down stairs test, time up and go 3-m and 10-m tests), passive and dynamic ankle range of motion, and self-reported quality of living were determined.

RESULTS

After training, significant increases in .VO2peak, VT, upper- and lower-body muscular strength, and all measures of functional mobility were shown (P < 0.05). Muscular strength was well maintained (significantly greater than before training and no significant decrease from after training) during detraining, whereas .VO2peak, VT, and functional mobility (not significantly different from before training but no significant decrease from after training) were only partially retained.

CONCLUSION

Young children in the maintenance phase of treatment against ALL can safely perform both aerobic and resistance training. Training results in significant increases in measures of aerobic fitness, strength, and functional mobility. During detraining, strength and functional mobility are well maintained, whereas .VO2peak and VT are partially maintained.

Physical activity during treatment in children with leukemia: a pilot study

The purpose of this pilot study was to measure physical activity (PA) levels in children undergoing treatment for acute lymphoblastic leukemia (ALL) and to compare the results with those from age-matched healthy children. We used the MTI Actigraph accelerometer to determine PA (during a 1 week period) in children (n = 7; age = 4–7 y) undergoing maintenance treatment for ALL and in age-matched controls (n = 7). The number of children accumulating at least 60 min of moderate-to-vigorous physical activity (MVPA) for 5 or more days of the week was 3 for the control group, whereas no children with ALL met this criterion. Significantly lower levels of total weekly time of MVPA were seen in children being treated for ALL (328 ± 107 min) than in controls (506 ± 175 min) (p < 0.05). When weekday data was analyzed, the ALL patients also had significantly lower mean daily times of MVPA (49 ± 23 min vs. 79 ± 25 min). It is thus important that young ALL sufferers are encouraged to participate in appropriate sports, games, and physical activities both in the family and school environments that will prime them with positive attitudes to PA during the critical early years of life.