Benefits of intrahospital exercise training after pediatric bone marrow transplantation

Impact of Exercise on Psychological Well-Being in Patients with Pediatric Cancer: An Experimental Study

Objective: This study was conducted to investigate the effects of exercise on psychological disorders in patients receiving childhood cancer treatment. Methods: The study group consisted of patients with cancer between the ages of 9 and 17 who were treated in the Hematology-Oncology units of Erciyes University. For the sample group, children with cancer were informed about the content of the study, and 40 children with cancer agreed to participate in the study voluntarily. The volunteers were divided into two groups, control and experimental, each consisting of 20 people. For the pre-test, participants completed a socio-demographic information form, as well as the Kovacs Depression scale, Beck Anxiety Inventory, and the pediatric cancer quality of life scale for children. Volunteers in the experimental group engaged in aerobic and strength exercises for an eight-week period. The study was completed with 8 volunteers in the control group and 14 volunteers in the experimental group due to various factors, such as voluntary withdrawal, disease progression, and mortality. After this period, the volunteers were asked to complete the same scales once more as a post-test. The SPSS 22.00 statistical analysis program was used. The independent samples t-test was employed to compare the pre-test and post-test findings of the control and experimental groups, while the paired samples t-test was used for within-group evaluations. Results: In the within-group comparisons, significant differences were observed in favor of the post-test scores in the experimental group for both the anxiety scale (p < 0.05, Mean: 8.14) and the quality-of-life child form (p < 0.05, Mean: 38.14). For intergroup comparisons, significant differences were found in favor of the experimental group in terms of post-test scores of depression (p < 0.05, mean: 10.57) and anxiety scales (p < 0.05, mean: 8.14). Conclusions: It is postulated that this outcome stems from the positive effects of sports activities in helping children undergoing cancer treatment distance themselves from their psychological adversities.

Extended Reality Gaming for Exercise and Mindfulness Throughout Pediatric Cancer Rehabilitation: Protocol for a Randomized Controlled Trial

BACKGROUND

Pediatric patients with cancer have limited options to self-manage their health while they are undergoing treatments in the hospital and after they are discharged to their homes. Extended reality (ER) using head-mounted displays has emerged as an immersive method of improving pain and mental health and promoting health-enhancing physical activity among a variety of clinical groups, but there is currently no established protocol for improving both physical and mental health in pediatric cancer rehabilitation.

OBJECTIVE

This phase I, pilot, feasibility randomized controlled trial aims to investigate the potential effects of a 14-week ER program on physical activity participation and indicators of health among pediatric patients with cancer who undergo bone marrow transplantation. An ancillary aim is to evaluate the feasibility of the program through participant engagement.

METHODS

This study includes a 2-arm parallel group design with a 1-group crossover (the control group will start the intervention after a waiting period). Overall, 16 pediatric patients with cancer undergoing rehabilitation (aged ≥8 years) at a children's hospital will be randomly allocated into one of two groups: (1) an immediate start group that undergoes an ER program in the hospital until discharge and then for 8 weeks at home (total duration of approximately 14 weeks), and (2) a waitlist control group that undergoes usual care in the hospital and for 8 weeks at home, before receiving the 8-week home ER program. The program will include active video gaming with rhythmic music exercises as well as mindfulness-based practices using a high-quality app. Home-based programming will include behavioral coaching calls. Physical activity will be measured daily through step counts using a tri-axial accelerometer. Health outcomes will be measured across time and include global health, measured by the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health Scale Short Form 7+2, and lung function, measured by a forced expiratory volume using a peak flow meter. Feasibility will be evaluated through participant engagement metrics, such as enrollment, dropout, adverse events, and attendance rates. Descriptive statistics will be obtained for all study variables. Outcomes will be modeled using mixed modeling procedures, and changes in means will be estimated with CIs.

RESULTS

The study was funded in February 2024. Recruitment procedures started on June 27, 2024. All data are anticipated to be collected by February 2026. Full trial results are anticipated to be analyzed and submitted for publication by March 2026. The study's anticipated end date is March 31, 2026.

CONCLUSIONS

This trial tests an accessible remote program for improving both physical and mental health among pediatric patients with cancer. The knowledge obtained from this study will inform the development of a larger trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06298357; https://clinicaltrials.gov/study/NCT06298357.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64879.

The Impact of Interactive Video Games Training on the Quality of Life of Children Treated for Leukemia

OBJECTIVES

The study aimed to assess the impact of interactive video games (IVGs) as a form of physical activity (PA) on the quality of life.

METHODS

The study used a quality-of-life questionnaire (KIDSCREEN-10) and the HBSC questionnaire. In order to determine individual IVGs training parameters, an initial assessment of cardiorespiratory fitness level was performed, using the Cardio Pulmonary Exercise Test-Godfrey's progressive protocol. Children in the intervention group participated in 12 interval training sessions using IVGs (Microsoft's Xbox 360 S console with Kinect,).

RESULTS

The study included 21 patients (7-13 years old; 12 boys and 9 girls) treated for acute lymphoblastic leukemia (n = 13) and acute myeloid leukemia (n = 8). Before the IVGs, all children had insufficient PA levels (90% of children in the intervention group and 90.91% of children in the control group did not engage in any PA during the last 7 days). After the intervention, 80% of the children in the IVGs group undertook PA lasting at least 60 min a day, three times a week. They exhibited better well-being, a subjective feeling of improved physical fitness (p < 0.0001), a greater subjective sense of strength and energy (p < 0.0001), and less feeling of sadness (p = 0.0016) than the children from the control group (p = 0.0205).

CONCLUSIONS

The results of our study confirmed that an attractive form of virtual game or sport is willingly undertaken by children undergoing cancer treatment, and has significant benefits in improving the quality-of-life parameters. There is a clear need to create specific recommendations and rehabilitation models for children with cancer.

Effectiveness of Therapeutic Exercise for Children Undergoing Treatment for Cancer: A Systematic Review

PURPOSE

To evaluate the effectiveness of therapeutic physical exercise (TPE) interventions on the physical functioning, psychosocial well-being, and quality of life (QoL) of children undergoing treatment for cancer.

METHOD

Systematic review: databases were searched in April 2023. Selection criteria: children (<18 years old) undergoing treatment for cancer or a malignant neoplasm, randomized controlled trial design, utilization of TPE, and including physical and psychosocial outcomes. Internal validity was measured with Physiotherapy Evidence Database scale.

RESULTS

Seven randomized controlled trials were included. Most studies showed that strength, fatigue, and QoL improved after the intervention. Cardiorespiratory capacity through 6-minute walk test and physical activity levels were better in the experimental groups. No changes were noted in other variables.

CONCLUSIONS

This review supports the importance of a TPE program during cancer treatment, with the aim of maintaining physical capacities and counteracting physical inactivity.

Gut microbiome in children undergoing hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) is used in children as a treatment for various cancers, e.g. acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), or other diseases, e.g. severe congenital immunodeficiency, metabolic disorders, hence the patient population is quite diverse. There is an increasing interest on the role of the microbiome in peri-transplant period. In this review, concepts of HSCT with the focus on the importance of microbiome composition, its changes during treatment and possible microbiota oriented interventions will be discussed. This paper analyzes data in pediatric population, but in view of interesting results and absence of analogous data for pediatric patients, it also looks at studies performed on adult population and pre-clinical trials on animals discussing possible translation to children.

The Italian Consensus Conference on the role of rehabilitation for children and adolescents with leukemia, central nervous system tumors, and bone cancer, part 2: general principles for the rehabilitation treatment of motor function impairments

In Italy, 1400 children and 800 adolescents are diagnosed with cancer every year. About 80% of them can be cured but are at high risk of experiencing severe side effects, many of which respond to rehabilitation treatment. Due to the paucity of literature on this topic, 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 tumors, and bone cancer to state recommendations to improve clinical practice. This paper includes the consensus on the rehabilitation of children and adolescents with these cancers.

Effects of Combined Interventions of Physical Activity and Diet in Childhood Cancer Survivors: A Systematic Review

Physical activity and diet have complementary benefits for attenuating adverse health effects that childhood cancer survivors experience after the end of treatment. This review aimed to explore the impact of combined physical activity and diet interventions on the health status of childhood cancer survivors. A thorough review of the literature was carried out using the Cochrane Library, PubMed, Scielo, LILACS and Web of Science databases for studies published until June 2024. Studies concerning survivors of childhood cancer of any type engaged exclusively in combined diet/physical activity interventions were included in this review. Three manuscripts met the inclusion criteria. The results indicated that combined physical activity plus diet interventions showed beneficial impacts for the intestinal microbiome, percentage of calories from sweet foods, daily consumption of sugary beverages, reduction in sedentary activity, and mood (1 out of 1 study for each of the presented outcomes). Although more rigorous studies are needed, these findings showed promising results regarding the impact of interventions involving both physical activity and diet on childhood cancer survivors.

Effectiveness of exergaming in reducing cancer-related fatigue among children with acute lymphoblastic leukemia: a randomized controlled trial

BACKGROUND

Little is known about the effectiveness of the newly emerging technology of exergaming in reducing Cancer Related Fatigue (CRF).

OBJECTIVES

The study's primary aim was to examine the effectiveness of exergaming in reducing CRF; the secondary aims were to improve functional capacity/endurance and promote physical activity (PA) among children with acute lymphoblastic leukemia (ALL).

METHODS

In this Randomized Controlled Trial (RCT), 45 children aged 6-14 years were randomly assigned into group-I, n = 22, and group II, n = 23. Group-I played exergaming of moderate intensity for 60 min, twice a week for three weeks. Group II was given an instructional session regarding the benefits of PA with advice to practice PA for 60 min twice a week. CRF, functional capacity/endurance, and PA were measured using the pediatric quality of life multidimensional fatigue scale (Ped-QLMFS), six-minute walk test (6-MWT), and Godin-Shepard Leisure Time Physical Activity Questionnaire (QSLTPAQ) respectively. All measurements were taken thrice; in the first, third, and fifth weeks of intervention.

RESULTS

Group-I demonstrated a significant reduction of CRF, and a significant increase of functional capacity/endurance compared to group-II over the five weeks study period. The effect of time × intervention interaction was significant. Based on Cohen's guidelines, CRF and functional capacity/endurance had large effect sizes (η² = 0.41, p = .00) and (η² = 0.27, p = .00) respectively.

CONCLUSION

The protocol of exergaming used in this RCT effectively reduces CRF and promotes functional capacity/endurance and PA in children with ALL undergoing chemotherapy. It may provide an alternative treatment modality to decrease the healthcare load.Key messagesCancer-related fatigue (CRF) is described as physical exhaustion, sleep disturbance, emotional distress, and cognitive dysfunction.Exergaming reduces CRF and promotes functional capacity/endurance and physical activity in children with acute lymphoblastic leukemia undergoing chemotherapy.Exergaming may provide an alternative treatment modality to decrease the healthcare load.

Exercise rehabilitation to treat sarcopenia in pediatric transplant populations

BACKGROUND

In adult transplant (Tx) populations, exercise rehabilitation strategies may improve sarcopenia components (muscle mass [MM], strength [MS], and physical performance [PP]). Limited data are available regarding exercise rehabilitation therapy in pediatric Tx populations.

METHODS

The purpose of this review is to critically evaluate the feasibility and impact of exercise programs (EP) that include resistance exercise (RE) on markers of sarcopenia in pediatric Tx populations. Literature searches in SCOPUS and WEB OF SCIENCE were conducted to identify studies applying EP with a RE component in pediatric populations in the Tx setting.

RESULTS

Twelve articles (2008-2022) met inclusion criteria. The exercise interventions varied in length (3 weeks-12 months), intensity (low to moderate), time pre/post Tx (0 days-5 years post Tx), age of participants (3-18 years), adherence (63%-94%), and methodologies to measure components of sarcopenia. No studies measured all three components of sarcopenia concurrently. Approximately, 60% of studies found positive effects on MS and PP. Only one pediatric study measured body composition, therefore, the effect of exercise programs with RE components on MM is unknown.

CONCLUSIONS

Exercise programs may be a beneficial treatment for sarcopenia in Tx populations, particularly in components of MS and PP. Studies measuring all three aspects of sarcopenia together in response to RE training in pediatrics remains an important gap. Studies that include body composition measurements in response to exercise are needed. Special considerations for the development of RE programs in pediatrics Tx populations are safety, supervision, engagement through family/peer involvement and incorporation of game/play-based elements.

Effects of Exercise and Physical Activity Levels on Childhood Cancer: An Umbrella Review

Patients and survivors of childhood cancer experience adverse effects related to the disease and its treatment. These adverse effects are associated with both physiological and psychological health. Exercise helps manage the side effects and improve the health outcomes. The objective of this umbrella review is to search the current literature in the context of exercise and physical activity as complementary interventions on pediatric cancer and to provide comprehensive information about the derived health outcomes. A literature search was conducted on the Cochrane, PubMed, and Embase databases for systematic reviews published up to January 2023. Moreover, a hand search of reference lists was performed. We included participants under 19 years of age at diagnosis of any type of childhood cancer, without restriction on the type or phase of treatment, who participated in exercise interventions. The results showed a beneficial impact on fatigue, muscle strength, aerobic capacity, activity and participation levels, psychosocial health, cardiovascular/cardiorespiratory fitness, physical function, bone mineral density, and brain volume and structure, with limited and not serious adverse effects. These findings documented that exercise interventions had a positive effect on many physiological and psychological health outcomes in pediatric cancer patients and survivors.

Gut Microbiome Suffers from Hematopoietic Stem Cell Transplantation in Childhood and Its Characteristics Are Positively Associated with Intra-Hospital Physical Exercise

Gut microbiome impairment is a serious side effect of cancer treatment. The aim of this study was to identify the effects of hematopoietic stem cell transplantation (HSCT) treatment on gut microbiota composition in children with acute lymphoblastic leukemia (ALL). Fecal microbiotas were categorized using specific primers targeting the V1-V3 region of 16S rDNA in eligible pediatric ALL patients after HSCT (n = 16) and in healthy controls (Ctrl, n = 13). An intra-hospital exercise program was also organized for child patients during HSCT treatment. Significant differences in gut microbiota composition were observed between ALL HSCT and Ctrl with further negative effects. Plasma C-reactive protein correlated positively with the pathogenic bacteria Enterococcus spp. and negatively with beneficial bacteria Butyriccocus spp. or Akkermansia spp., respectively (rs = 0.511, p = 0.05; rs = -0.541, p = 0.04; rs = -0.738, p = 0.02). Bacterial alpha diversity correlated with the exercise training characteristics. Therefore, specific changes in the microbiota of children were associated with systemic inflammation or the ability to exercise physically during HSCT treatment.

Effects of an exercise program during pediatric stem cell transplantation: A randomized controlled trial

BACKGROUND

During pediatric hematopoietic stem cell transplant (HSCT), there is significant reduction in physical activity, leading to loss of strength and function, along with decline in quality of life (QoL). This study evaluates the effects of a supervised exercise program on functional ability, mobility, strength, and QoL during and following pediatric HSCT.

METHODS

Patients ages 4-21 years presenting for HSCT were randomized to either an intervention group, who underwent exercise routines three times weekly and once weekly on discharge for 6 weeks supervised by a physical therapist, or the control group, which was treated per standard of care. Forty subjects were recruited for the study, 20 in each arm. Physical therapy and QoL assessments were conducted at three time points: pre-HSCT (baseline), on the day of hospital discharge, and 6 weeks after discharge.

RESULTS

Exercise capacity and endurance using Six-Minute Walk test (p = .023) and strength using manual muscle testing (p = .005) were improved in the exercise group, compared to the control group. There was evidence that some QoL outcomes (measured using the Patient Reported Outcomes Measurement Information System) were improved 6 weeks post discharge, with observed decreases in anxiety (p = .0009) and fatigue (p = .037).

CONCLUSION

Supervised exercise program during pediatric HSCT has positive effects on endurance, functional mobility, and muscle strength, and may also result in improvements in some aspects of QoL. This trial was registered at www.

CLINICALTRIALS

gov as NCT04663503.

Physical and functional performance assessment in pediatric oncology: a systematic review

BACKGROUND

Research indicates reduced physical performance from diagnosis into survivorship of pediatric cancer patients. However, there is no systematic information or guideline available on the methods to assess physical performance and function in this population. The purpose was to systematically compile and describe assessments of physical performance and function in patients and survivors of pediatric cancer, including cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait and motor performance test batteries.

METHODS

We searched the databases PubMed, SPORTDiscus, and Cochrane Database and performed abstract and full-text selection of 2619 articles according to the Cochrane Handbook of Systematic Reviews. Information on patients characteristics, assessments, information on validity and reliability, and relevant references was extracted.

RESULTS

In summary, 63 different assessments were found in 149 studies including 11639 participants. Most studies evaluated cardiorespiratory fitness and muscle strength with the majority conducted off treatment. Some outcomes (e.g. speed) and diagnoses (e.g. neuroblastoma) were severely underrepresented. With the exception of gait, leukemia patients represented the largest group of individuals tested.

CONCLUSIONS

Insufficient data and patient heterogeneity complicate uniform recommendations for assessments. Our results support researchers and practitioners in selecting appropriate assessment to meet their specific research questions or individual daily practice needs.

IMPACT

This systematic review includes 149 studies and provides a comprehensive summary of 63 assessments to evaluate cardiorespiratory fitness, muscle strength, speed, balance, flexibility, functional mobility, gait or motor performance test batteries in patients and survivors of pediatric cancer. We present the most studied fields within the pediatric cancer population, which are cardiorespiratory fitness and muscle strength, off treatment phase, and leukemia patients. We propose research priorities by identification of subgroups in terms of cancer type, phase of treatment, and outcome of interest that are underrepresented in studies currently available.

Playing With a Purpose: The Impact of Therapeutic Recreation During Hospitalization

Background: Youth undergoing cancer treatment and hematopoietic stem cell transplant (HSCT) spend significant time in the hospital, which is disruptive to their physical, social, and emotional development. Therapeutic recreation (TR) can help individuals with an illness maintain or improve their health, quality of life, and physical functioning. TR is an understudied intervention, particularly with youth in the hospital setting. Methods: Forty-nine children (median age = 12 years, interquartile range [IQR] 11-15 years) hospitalized for cancer treatment or HSCT were assigned to participate in either the historical control or TR intervention. Participants wore a Fitbit charge HR for three days to measure movement. At the end of the study participation, they completed self-report measures of mood, social connectedness, and health-related quality of life. Results: Compared with historical controls, the TR intervention group had improved positive affect and decreased mood disturbance (p = 0.03); had better sleep quality (p = 0.003); and was more satisfied with the leisure activities offered in the hospital (p = 0.01). There were no differences in the number of steps taken per day, somatic distress, cooperation with cares, or interaction with medical personnel or caregivers. Both groups reported poor availability and support of peer companions. Discussion: TR is one avenue to increase leisure activities and positively impact mood. More thought needs to be given to how TR programs can be leveraged to increase physical activity and social connectedness.

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.

Self-reported physical activity and lack of association with health-related quality of life in a pediatric solid-organ transplant population

BACKGROUND

Physical activity (PA) has been shown to have benefits, including improving health-related quality of life (HRQOL). However, there are few and conflicting studies assessing PA and its relationship with HRQOL in a pediatric solid-organ transplant (SOT) population. The aim of this study was to assess whether overall HRQOL was associated with PA and to determine whether that association was independent of other baseline and contemporaneous clinical and demographic indicators.

METHODS

A retrospective cross-sectional review was performed on 55 pediatric transplant patients (13 heart, 27 kidney, and 15 liver transplant). PA was measured by PAQ-C/PAQ-A, and HRQOL was measured using PedsQL. Demographics, baseline, and contemporaneous data were collected.

RESULTS

There were no significant differences in baseline and contemporaneous characteristics between heart, kidney, and liver transplant recipients. SOT recipients were 15.0 (11.0-18.0) years old at completion of surveys. Median PAQ score was 2.3 (1.6-3.2), PedsQL total score was 77 (65-91), and PedsQL physical functioning score was 88 (72-97). The PedsQL total score was not significantly associated with PAQ score. The PAQ score was significantly associated with physical functioning subscore of the PedsQL (r = 0.37, p < 0.01). Higher physical functioning score was associated with time since transplant (r = 0.29, p = 0.031).

CONCLUSION

Our SOT cohort has a HRQOL similar to other chronic conditions and higher than previous reported HRQOL in pediatric SOT populations. Higher levels of PA and longer time since transplant are associated with higher physical functioning scores.

Cardiorespiratory fitness and physical performance after childhood hematopoietic stem cell transplantation: a systematic review and meta-analysis

The effects of childhood hematopoietic stem cell transplantation (HSCT) on key organs can impair cardiorespiratory fitness, muscle strength, and physical performance. We aimed to provide an overview of childhood HSCT survivors' status on these parameters compared with healthy controls and discuss current insights into clinical risk factors. We performed a systematic search in six scientific databases, including studies published before April 2019 and performed a meta-analysis on cardiorespiratory fitness. Muscle strength and physical performance status were presented narratively. We included ten studies embodying 517 childhood HSCT survivors (mean 17.8 years at follow-up). The meta-analysis (n = 4 studies) showed that childhood HSCT survivors have lower cardiorespiratory fitness compared with healthy controls (Standard mean difference (SMD) -1.32 [95% CI -1-58 to -1.07]; I² 2%, p < 0.00001). Collectively, the studies indicated that childhood HSCT survivors have lower muscle strength (n = 4 studies) and physical performance (n = 3 studies) compared with healthy controls. Childhood HSCT survivors have impaired cardiorespiratory fitness years after ended treatment. Muscle strength and physical performance seem to be impaired, although these measures are insufficiently investigated. Associations between HSCT-specific clinical risk factors and cardiorespiratory fitness, muscle strength, and physical performance are required.

Physical therapy interventions, other than general physical exercise interventions, in children and adolescents before, during and following treatment for cancer

BACKGROUND

Children and adolescents diagnosed with cancer are at high risk of experiencing severe side effects from cancer treatment, many of which are amenable to physical therapy. These side effects can negatively impact a child's quality of life and ability to participate in daily activities (e.g. play and attendance at school). Researchers have evaluated physical therapy interventions in children with cancer and childhood cancer survivors. However, factors such as small sample sizes, varying intervention protocols and differences in cancer types among trials make it difficult to draw conclusions about efficacy.

OBJECTIVES

The primary aim of this review was to evaluate the efficacy of physical therapy interventions - with a specific focus on symptom relief and compensation of therapy-related side effects - on the quality of life of children and adolescents diagnosed with cancer. Participants must be between the ages of 0 and 19 years at the time of the physical therapy intervention study. The intervention may occur prior to, during or following cancer treatment. The intervention must be compared to a control group of children receiving standard care, no physical therapy intervention or a comparison intervention. We have excluded general physical exercise studies where the primary aim was to improve physical fitness through aerobic, anaerobic, resistance exercise or combined physical exercise training regimens (i.e. combined aerobic and resistance exercise regimens). We have also intended to record the occurrence of any adverse effects resulting from physical therapy interventions. The secondary aims were to evaluate the efficacy of physical therapy on impairments of pain, peripheral neuropathy, balance, gait, functional abilities and mobility, motor function and performance, range of motion, strength and fatigue.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, ongoing trial registries, conference proceedings and the reference lists of relevant studies and reviews in March 2020. We also contacted oncology rehabilitation researchers working in paediatrics in March 2020 to identify additional studies.

SELECTION CRITERIA

The review included randomised controlled trials (RCTs), cross-over trials, and controlled clinical trials (CCTs) that compared the effects of physical therapy interventions to a control group, and involved children and adolescents diagnosed with cancer between the ages of 0 and 19 years at the time of the intervention. We excluded studies examining general physical exercise interventions where the primary aim was to improve physical fitness through aerobic exercise, resistance exercise or combined physical exercise training regimens (i.e. combined aerobic and resistance exercise regimens).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We found no RCTs, cross-over trials or CCTs comparing the effects of physical therapy interventions with a focus on symptom relief and compensation of therapy-related side effects for children and adolescents between the ages of 0 and 19 years.

AUTHORS' CONCLUSIONS

Results demonstrate that the evidence to date is inadequate to inform clinical practice. Recommendations for future research include the need for large-scale, high-quality designs that examine: (1) paediatric populations with same cancer types; (2) similar intervention protocols; (3) long-term outcomes; (4) physical therapy interventions (e.g. electrophysical modalities and sensory interventions); and (5) outcomes commonly impaired in children with cancer (e.g. peripheral neuropathy and gait deficits).

Effect of physical exercise on the functional capacity of children and adolescents submitted to transplantation of hematopoietic stem cells-A systematic review with meta-analysis

Previous studies have shown beneficial effects of physical exercise (PE) in adults submitted to hematopoietic stem cell transplantation (HSCT). Conduct a systematic review about the effects of PE on the functional capacity of children and adolescents submitted to HSCT. The studies were searched in the databases MEDLINE (via PubMed), Central Register of Controlled Trials (Cochrane CENTRAL), EMBASE, LILACS, and Evidence Database in Physical Therapy (PEDro) (CRD42018080093). Two independent reviewers performed the article selection, data extraction, and methodological quality assessment. Randomized and nonrandomized clinical trials comparing PE with usual treatment in children and adolescents aged 3-18 years were included. The risk of bias was assessed using the Cochrane Collaboration tool and ROBINS-I tool, and the overall quality of the evidence was determined by the GRADE system. We included three studies with 91 patients. PE improved the functional capacity assessed by the timed up and down stairs test (MD -1.23 [95% CI, 2.27 to -.20, I2 = 0%]), but there was no significant effect in the six-minute walk test (MD 44.63 [95% CI, -20.86 to 110.13, I2 = 83%]). The benefits regarding quality of life and peripheral muscle strength of these individuals were not clearly demonstrated, but positive responses were observed in relation to the analyzed data. None of the studies evaluated the fatigue. The limitations found were the high heterogeneity between studies, as well as the sample size and the low methodological rigor. PE might be favorable to improve the functional capacity of children and adolescents treated with HSCT. However, further studies are needed to clarify the best PE program.

Validation of an exercise booklet for children with acute lymphoblastic leukemia

Abstract Introduction: Leukemia is the most common childhood cancer, and acute lymphoblastic leukemia (ALL) accounts for 75 to 80% of all such cases in this population. Survival has increased among children and adolescents due to advances in diagnosis and treatment, with a growing emphasis on the need for rehabilitation to improve functionality and quality of life, mitigating the long-term effects of treatment. Objective: To describe the process of compiling and validating an exercise booklet for children and adolescents during and after treatment for acute lymphoblastic leukemia. Methods: Methodological study using the Delphi technique for validation. The panel of experts consisted of seven healthcare professionals and three mothers of children without ALL. The booklet was evaluated using a form containing 15 items scored on a 5-point Likert scale, and by qualitative assessment. The frequency of the expert ratings, percentage agreement and content validity index (CVI) were presented for each item and the instrument as a whole. Analyses were performed in R 3.5.1 software. Results: The booklet containing stretching, aerobics, strength and relaxation exercises was validated in the second round, reaching 100% consensus. When assessed only by the mothers, 93.33% consensus was achieved in a single round. Conclusion: The exercises booklet was validated for use in the population studied.

Effects of physical exercise for children and adolescents undergoing hematopoietic stem cell transplantation: a systematic review and meta-analysis

Hematopoietic stem cell transplantation (HSCT) is a treatment that requires long periods of hospitalization. The mobility restrictions result in physical, functional and psychological impairments. Physical exercise is a therapy that can restore physical and functional capacities; however, it is necessary to understand the effects of its practice in post-HSCT individuals. The purpose of this systematic review (SR) was to assess the impact of physical exercise in children and adolescents undergoing HSCT. The SR was conducted following the PRISMA guidelines through search in the electronic databases Embase, Lilacs, PEDro, PubMed and SCOPUS, without limitation of dates and languages. Randomized or non-randomized clinical trials with children and adolescents who underwent HSCT, aged between 3 to 19 years old, who participated in a regular physical activity program, were assessed. After removing duplicates and selecting studies according to the eligibility criteria, seven parallel studies incorporating hospitalized and discharged participants undertaking aerobic and strengthening exercises were included in this study. The main outcomes analyzed were exercise capacity, quality-of-life, body composition and freedom. Five studies comprised the meta-analysis regarding the effects of the distance walked in the 6-min walk test and quality-of-life. Physical exercise is considered to be safe, feasible and efficacious to prevent the decline of the quality-of-life in children and adolescents undergoing HCST, as well as a considerable improvement in physical capacity.

Combined resistance and aerobic exercise intervention improves fitness, insulin resistance and quality of life in survivors of childhood haemopoietic stem cell transplantation with total body irradiation

PURPOSE

To investigate the effects of a supervised combined resistance and aerobic training programme on cardiorespiratory fitness, body composition, insulin resistance and quality of life (QoL) in survivors of childhood haematopoietic stem cell transplantation (HSCT) with total body irradiation (TBI).

PARTICIPANTS

HSCT/TBI survivors (n = 20; 8 females). Mean (range) for age at study and time since HSCT/TBI was 16.7 (10.9-24.5) and 8.4 (2.3-16.0) years, respectively.

METHODS

After a 6-month run-in, participants undertook supervised 45- to 60-minute resistance and aerobic training twice weekly for 6 months, with a 6-month follow-up. The following assessments were made at 0, 6 (start of exercise programme), 12 (end of exercise programme) and 18 months: Body composition via dual energy X-ray absorptiometry, homeostatic model assessment of insulin resistance (HOMA-IR), cardiorespiratory fitness (treadmill-based peak rate of oxygen uptake (VO₂ peak) test), QoL questionnaires (36-Item Short Form Health Survey (SF-36) and Minneapolis-Manchester Quality of Life Instrument (MMQL).

RESULTS

Results expressed as mean (standard deviation) or geometric mean (range). There were significant improvements in VO₂ peak (35.7 (8.9) vs 41.7 (16.1) mL/min/kg, P = 0.05), fasted plasma insulin (16.56 (1.48-72.8) vs 12.62 (1.04-54.97) mIU/L, P = 0.03) and HOMA-IR (3.65 (0.30-17.26) vs 2.72 (0.22-12.89), P = 0.02) after the exercise intervention. There were also significant improvements in the SF-36 QoL general health domain (69.7 (14.3) vs 72.7 (16.0), P = 0.001) and the MMQL school domain (69.1 (25.2) vs (79.3 (21.6), P = 0.03) during the exercise intervention. No significant changes were observed in percentage body fat, fat mass or lean mass.

CONCLUSION

The supervised 6-month combined resistance and aerobic exercise programme significantly improved cardiorespiratory fitness, insulin resistance and QoL in childhood HSCT/TBI survivors, with no change in body composition, suggesting a metabolic training effect on muscle. These data support a role for targeted physical rehabilitation services in this group at high risk of diabetes and cardiovascular disease.

Peak Oxygen Uptake and Exercise Capacity of Children Undergoing Leukemia Treatment

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

Tailored Exercise during Hematopoietic Stem Cell Transplantation Hospitalization in Children with Cancer: A Prospective Cohort Study

We assessed the clinical effects of a supervised exercise (aerobic + resistance) intervention performed during inpatient hospitalization for pediatric hematopoietic stem cell transplantation (HSCT). Patients were placed in an exercise (n = 65 (47 and 18 with allogeneic (allo-) and autologous (auto-) HSCT, respectively)) or a control (n = 53 (39 and 14)) group. Exercise interventions were performed in isolated hospital patient rooms. Patients were followed-up from the beginning of the conditioning phase up to 6 years. We assessed survival, risk of graft-versus-host disease (GvHD) or graft failure (primary outcomes), and engraftment kinetics, supportive care, toxicity profile, and immune reconstitution for auto-HSCT and allo-HSCT. The exercise intervention was safe and did not affect the risk of mortality, acute/chronic GvHD, or graft failure (all p > 0.05). No between-group differences (p > 0.05) were found for the remainder of clinical endpoints, except for a reduced number of total and viral infections in the exercise group after allo-HSCT (unadjusted p = 0.005 for both total and viral infections, and adjusted p = 0.023 and 0.083, respectively). In conclusion, exercise performed during inpatient hospitalization for pediatric HSCT is safe and well tolerated during both auto and allo-HSCT and tends to decrease the risk of infection after allo-HSCT. These findings provide additional support to the notion that a multidisciplinary approach (i.e., including the work of exercise specialists) is suitable in the management of children undergoing HSCT. Further studies are needed to determine whether applying a different training stimulus (notably, higher exercise intensities) exerts positive effects on HSCT prognosis in these patients.

Improving Occupational Performance in Pediatric Hematopoietic Cell Transplant Recipients

IMPORTANCE

There is a critical gap in the literature regarding the efficacy of occupational therapy interventions for pediatric hematopoietic cell transplantation (HCT) patients.

OBJECTIVE

To demonstrate that occupational therapy 4-5×/wk during inpatient hospitalization positively affects strength, coordination, and independence in activities of daily living (ADLs) of pediatric patients during HCT.

DESIGN

Retrospective study.

SETTING

Inpatient bone marrow transplant unit at a children's hospital.

PARTICIPANTS

Thirty-two pediatric patients admitted for HCT.

OUTCOMES AND MEASURES

Patients were seen by an occupational therapist as part of an interdisciplinary program. Interventions included play and leisure engagement, upper extremity therapeutic exercises, fine motor activities, and ADL training. Strength, coordination, and daily living skills data were documented prospectively and analyzed retrospectively to compare differences between patients seen by occupational therapy at high versus low frequency.

RESULTS

For grip strength (dynamometer), fine motor dexterity (the 9-Hole Peg Test), and independence in ADLs (an ADL functional measure and the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test Daily Activities), the high-frequency group had a significantly smaller decrease in performance from time of admission at pretransplant (baseline) to peak decline after transplant. Grip strength and ADL scores for the high-frequency group returned to baseline at time of discharge more readily than for the low-frequency group.

CONCLUSIONS AND RELEVANCE

Participation in occupational therapy 4-5×/wk had positive effects on strength, coordination, and independence in ADLs for patients undergoing HCT.

WHAT THIS ARTICLE ADDS

This article provides evidence that occupational therapists are an important part of the interdisciplinary team treating pediatric bone marrow transplant patients. It also demonstrates that occupational therapy interventions delivered at a high frequency can have a positive impact on upper extremity strength and independence in ADLs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Late complications and quality of life assessment for survivors receiving allogeneic hematopoietic stem cell transplantation

PURPOSE

The survival rates of patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) have improved. However, HSCT can induce significant long-term complications. Therefore, we investigated the late complications and risk factors for quality of life (QOL) post-HSCT.

METHODS

We retrospectively analyzed 67 adult survivors over 2 years after HSCT between 2015 and 2018 at Ulsan University Hospital, Ulsan, Korea. The survey data including FACT-BMT, Hospital Anxiety and Depression Scale, and NCCN Distress Thermometer were collected as patient-reported outcomes using a tablet PC during a routine practice of survivorship clinic.

RESULTS

The median age was 46 years. The most common symptom was fatigue (80.6%). Younger age (< 60 years), acute lymphoblastic leukemia (ALL), chronic graft-versus-host disease (GVHD), and immunosuppressant use were significantly associated with worse QOL and depression. Additionally, younger survivors (< 60 years) showed significantly more fatigue and anxiety compared with elderly survivors (≥ 60 years). Female sex was significantly associated with lower physical well-being and higher distress than male sex.

CONCLUSION

Younger patients (< 60 years), female, ALL, chronic GVHD, and continuous immunosuppressant use were significant risk factors for worse QOL and depression. Hence, creating a more active survivorship care plan after HSCT, specifically for these patients, is required.

Evaluation Tools for Physical Activity Programs for Childhood Cancer: A Scoping Review

Research on the benefits of physical activity (PA) in childhood cancer has been translated into a handful of community-based programs. However, to foster further translation, an understanding of how to evaluate participant outcomes would be beneficial to provide feedback to participants and stimulate future research. Such a review would provide a summary of acceptable tools for work in this area. The purpose of this scoping review was to identify the evaluation tools that have been used in PA/exercise studies or programs for childhood cancer. This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies included in the review used physical and psychosocial evaluation tools within PA and exercise programs or research for childhood cancer. In addition, studies with measures of health behavior such as PA levels and activities of daily living were included. Tools that assessed physical fitness and physical performance were excluded. Information on the types of evaluation tools used, mean age of participants, and type of cancer was extracted. Psychometric properties of each evaluation tool are reported. The most commonly assessed patient outcomes were motor performance, fatigue, well-being, functional mobility, and quality of life. Less commonly reported patient outcomes were hope, self-efficacy, and self-perception. None of the evaluation tools reported in the PA/exercise and pediatric oncology literature assess physical literacy. This review was the first step in a knowledge translation process, identifying evaluation tools that have been used in PA/exercise programs in childhood cancer survivors, that will guide the development and evaluation of current and future community-based programs.

The VIE study: feasibility of a physical activity intervention in a multidisciplinary program in children with cancer

BACKGROUND

Cancer is one of the leading causes of death in the world. The physiological and psychological benefits of physical activity have been shown in children with cancer. However, almost one in two cancer patients do not follow the physical activity guidelines. The aim of this study will be to assess the feasibility of a physical activity program intervention in pediatric oncology and to assess the barriers and facilitators to the success or failure of this physical activity program.

METHODS

The VIE (valorization, implication, and education) intervention is a multidisciplinary program including physical activity, nutritional, and psychological interventions in pediatric oncology. This study involves one intervention group that will be followed over 2 years (evaluations and physical activity interventions) and one control group that will participate in only one evaluation. Children from the intervention group have been diagnosed and will be undergoing treatment at the Charles-Bruneau oncology center from the Sainte-Justine University Health Center (Montreal, Canada). The feasibility of this program will be measured through a comparison between sessions performed and sessions scheduled, while the security will be measured according to the number of reported incidents.

DISCUSSION

This study will examine the effects of exercise in pediatric oncology from diagnosis to the expected end of treatment (i.e., 2 years of follow-up). Currently, there are only a few longitudinal studies on physical activity and pediatric cancer. Physiological and psychological tests will allow a better knowledge of the evolution of the physical fitness and mental health of the patients during the period of care. It is necessary to document and provide complementary knowledge in the pediatric oncology field in order to engage the discourse with pediatric oncology health professionals to help patients during and after treatment. This is an important study in the exercise and oncology field to help patients and their family during and after cancer treatments.

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

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

Dietary and Exercise Interventions for Pediatric Oncology Patients: The Way Forward

This review focuses on diet and exercise interventions that have been conducted in pediatric cancer and pediatric stem cell transplant patients. It examines the different reasons for conducting lifestyle interventions with attention to the different outcome measurements and feasibility of these measures with an argument toward a need for standardization to move the field forward.

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.

Psychophysical effects of an exercise therapy during pediatric stem cell transplantation: a randomized controlled trial

This study evaluates the physical and psychosocial effects of an inpatient exercise program for children and adolescents undergoing hematopoietic stem cell transplantation (HSCT). Participants (n = 70) were randomized to an exercise intervention (IG: resistance, endurance, and flexibility training) or a non-exercise control group (CG: mental and relaxation training). Pre- (prior hospital admission; T0) and post- (day of discharge; T1) measurements included maximal isometric knee extension strength (KES; strain gauge force transducer), hand grip strength (HGS; JAMAR dynamometer), distance walked in 6 min (6MWD; 6-minute walk test), quality of life (QoL; KINDL-R) and medical parameters. Fifty-seven patients (IG: n = 28; 11.0 (5-17) years; CG: n = 29; 12.0 (6-18) years) completed the study. During hospitalization the IG and CG attended on average 3.1 (2-4) or 2.9 (0.3-4) training sessions weekly. KES, 6MWD, and HGS significantly decreased (p < 0.05) in the CG, while there were no changes in the IG. Pre- to post-changes in 6MWD and HGS differed significantly between groups (p < 0.05). QoL declined in both groups (p < 0.05). Our results indicate that a moderate exercise program is feasible and might counteract a treatment-associated decline of physical performance.

Transplant Energize Me Patient Outcome (TEMPO): A Quality Improvement Project that Maintains Functional Mobility in Pediatric Patients Admitted for Allogeneic Hematopoietic Cell Transplantation

Allogeneic hematopoietic cell transplantation (HCT) remains the definite cure for many pediatric hematologic diseases but causes profound deconditioning, which impairs daily physical functioning and may lead to further health complications. The Transplant Energize Me Patient Outcome (TEMPO) project is a standard-of-care, quality improvement (QI) project whose primary objective is to maintain physical functional mobility and strength throughout admission for pediatric allogeneic HCT patients. Specifically, TEMPO incorporates individualized and developmentally appropriate exercises and activities that are administered by a multidisciplinary team, who objectively measure and record a patient's physical stamina at predetermined frequencies. Discipline-specific metrics at admission, at weekly intervals, at discharge, and at 100 days after graft infusion (D100) are recorded in templated flowsheets in the electronic medical record. As a secondary objective, resource utilization as measured by length of stay, duration of parenteral feeds and narcotics, readmission by D100, and infections was compared between TEMPO and historical control (pre-TEMPO) allogeneic HCT patients. TEMPO participation maintained physical endurance and functional strength throughout hospitalization, an effect that was significantly sustained or improved at D100. Resource utilization did not significantly differ between patient cohorts. Taken together, the TEMPO QI Project maintains physical functional mobility, strength, and endurance, thereby decreasing physical deconditioning in pediatric allogeneic HCT patients, an effect that is objectively sustained at D100.

Skeletal Muscle Dysfunction and Exercise Intolerance in Children Treated with Haematopoietic Stem Cell Transplant-A Pilot Feasibility Study

Haematopoietic stem cell transplant (HSCT) is an intensive therapy for some pediatric hematological illnesses. Survivors are at risk for adverse effects including exercise intolerance. Peripheral tissue dysfunction may contribute to exercise intolerance; therefore, we examined the feasibility of a magnetic resonance spectroscopy (MRS) protocol to evaluate skeletal muscle metabolism in children post-HSCT. We measured demographic characteristics, aerobic exercise capacity (YMCA protocol), and skeletal muscle function in response to exercise (MRS; Siemens 3T MRI) in five children post-allogeneic HSCT and five age/body mass index-matched healthy controls (HCs). The mean age (± standard deviation) of the HSCT group and HC group were 11 ± 1.2 and 12.8 ± 2.4 years, respectively. Children post-HSCT had a lower peak aerobic exercise capacity compared to HCs (27.8 ± 3.4 vs. 40.3 ± 8.1 mL kg⁻¹ min⁻¹, respectively; p = 0.015). Exercise MRS testing protocols were successfully completed by all HSCT and HC participants; however, MRS-derived skeletal muscle metabolism variables were not different between the two groups. In conclusion, the use of exercise protocols in conjunction with MRS to assess peripheral skeletal muscle metabolism was achievable in children post-HSCT. In the future, larger studies should determine if skeletal muscle function is associated with exercise capacity in children post-HSCT.

Physical activity for children with chronic disease; a narrative review and practical applications

BACKGROUND

Physical activity (PA) is associated with a diverse range of health benefits. International guidelines suggest that children should be participating in a minimum of 60 min of moderate to vigorous intensity PA per day to achieve these benefits. However, current guidelines are intended for healthy children, and thus may not be applicable to children with a chronic disease. Specifically, the dose of PA and disease specific exercise considerations are not included in these guidelines, leaving such children with few, if any, evidence-based informed suggestions pertaining to PA. Thus, the purpose of this narrative review was to consider current literature in the area of exercise as medicine and provide practical applications for exercise in five prevalent pediatric chronic diseases: respiratory, congenital heart, metabolic, systemic inflammatory/autoimmune, and cancer.

METHODS

For each disease, we present the pathophysiology of exercise intolerance, summarize the pediatric exercise intervention research, and provide PA suggestions.

RESULTS

Overall, exercise intolerance is prevalent in pediatric chronic disease. PA is important and safe for most children with a chronic disease, however exercise prescription should involve the entire health care team to create an individualized program.

CONCLUSIONS

Future research, including a systematic review to create evidence-based guidelines, is needed to better understand the safety and efficacy of exercise among children with chronic disease.

Evaluation of cardiopulmonary exercise testing, heart function, and quality of life in children after allogenic hematopoietic stem cell transplantation

BACKGROUND

Physical fitness is an important determinant of quality of life (QOL) after hematopoietic stem cell transplantation. Cardiac function can influence exercise performance. The aim of this study was to assess these factors and their interrelationship.

PROCEDURE

Children underwent cardiopulmonary exercise testing (CPET) at least 1 year after hematopoietic stem cell transplantation (HSCT) and were compared with healthy controls. Systolic and diastolic heart function and left ventricle (LV) wall dimensions were measured. Health-related QOL (HR-QOL) was evaluated using PedsQL questionnaires.

RESULTS

Forty-three patients performed CPET (26 boys, 13.6 ± 3.4 years, weight 45.5 ± 13.3 kg, length 152.9 ± 17.5 cm, body surface area 1.35 ± 0.28). HSCT patients had lower maximal oxygen consumption (VO2peak/kg, 34.7 ± 8.4 vs 46.3 ± 7.1 mL/kg/min, P < 0.001), shorter exercise duration (9.1 ± 2.5 vs 12.9 ± 2.6 min, P < 0.001), and lower maximal load (%Ppeak 70.8 ± 19.7 vs 102.4% ± 15.9%, P < 0.001). Echocardiography demonstrated decreased interventricular septal wall thickness (interventricular septum in diastole [IVSd] Z-value -0.64 ± 0.69, P < 0.001), and more systolic (11% of patients) and diastolic dysfunction (high E/E' Z-value 1.06 ± 1.13, P < 0.001). LV dilatation correlates with VO2max/kg (r = -0.364, P = 0.017). HR-QOL showed lower overall and emotional functioning scores (respectively, P = 0.016 and P = 0.001). Patients after anthracycline therapy have the lowest maximal exercise performance, but have no difference in QOL. Diminished exercise performance is not encountered as a QOL limitation. Total body irradiation influences the domain of psychosocial functioning.

CONCLUSIONS

LV (systolic and diastolic) and right ventricle dysfunctions justify the need for thorough cardiac follow-up in children after HSCT. Lower physical fitness levels and lower HR-QOL emphasize the importance of CPET and fitness programs.

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.

Exercise training improves vascular function and secondary health measures in survivors of pediatric oncology related cerebral insult

Adolescent and young adult (AYA) survivors of pediatric oncology related cerebral insult are vulnerable to numerous treatment-induced deficits that significantly enhance cardiovascular disease risk. Regular exercise improves endothelial function, fitness, body composition and musculoskeletal function which may reduce predisposition for cardiovascular disease. Here we assessed the feasibility and effectiveness of a 24-week exercise intervention on cardiovascular, physical and metabolic outcomes in this population. Thirteen survivors (6 male, 7 female; median age 19 y (range 16-23 y) were recruited to participate in a 48-week study consisting of a 24-week control period (regular care) followed by a 24-week exercise intervention. Outcome measures were collected at entry (week 0) and following regular care (24-week) and exercise (48-week). Assessed variables included endothelial function (flow mediated dilation, FMD), blood pressure, heart rate (HR), aerobic capacity, anthropometry, body composition, muscular strength (3 repetition maximum testing), muscular endurance (repetitions/min) and physical activity levels (accelerometry). Compared to baseline, delta diameter (p = 0.008) and FMD (p = 0.029) of the brachial artery increased following exercise. Bicep-curl strength also increased following exercise compared to baseline (p = 0.019), while submaximal (6 min mark) measures of ventilation (p = 0.012), rating of perceived exertion (p = 0.012), HR (p = 0.001), absolute (p = 0.000) and relative (p = 0.000) aerobic capacity decreased. Breaks in sedentary time increased (p = 0.043) following exercise compared to regular care. Although the sample was small and heterogeneous, this study demonstrates that exercise is achievable and has positive effects on vascular function, submaximal fitness, local strength and physical activity in a population of AYA survivors of pediatric oncology related cerebral insult.

Physical training interventions for children and teenagers affected by acute lymphoblastic leukemia and related treatment impairments

A decreased physical fitness has been reported in patients and survivors of acute lymphoblastic leukemia (ALL). This is influenced by the negative effects of the disease and by the treatments of childhood cancer.

In the past, children were advised to recover in bed, and to take as much relax as possible. Nowadays, it is considered that too much immobility may result in a further decrease of physical fitness and functioning. Exercise training for ALL children has frequently been reported to improve physical fitness and the well-being of the children, since it prevents the negative effects of a sedentary life-style, such as obesity and a poor skeletal health. In recent years, different studies and protocols on this subject has become available for children and young adults with cancer, both during and after treatment.

The efficacy of recent physical exercise training interventions, that act on several ALL impairments in children such as skeletal, musculoskeletal, neuromuscular, cardiopulmonary and cardiovascular systems, fatigue, body balance disorders and metabolism alterations have been examined.

These side effects might be prevented or significantly reduced by introducing a physical exercise program during or shortly after cancer treatment. Several interventions are discussed and presented for each impairment, reducing their level caused by the disease and thus suggesting the importance of physical training activity in ameliorating the children quality of life.

Impact of the initial fitness level on the effects of a structured exercise therapy during pediatric stem cell transplantation

BACKGROUND

Before and after hematopoietic stem cell transplantation (HSCT), most patients suffer from psychophysical limitations due to the treatment. Exercise interventions demonstrate beneficial effects on, for example, strength, endurance, or health-related quality of life during and after HSCT, but with a great variation among patients concerning the response to exercise. This study examines the influence of the initial fitness on the effects of an exercise therapy in pediatric HSCT.

PROCEDURE

Fifty-three children and adolescents (10.9 ± 3.5 years) scheduled for HSCT were randomized into an exercise intervention group (IG) or a control group (CG). During hospitalization, the IG performed endurance, strength, and flexibility training three times per week. The CG included a nonexercise program. A 6-min walk test was completed before and after the inpatient period. Baseline results (6-min walking distance [6MWD]) were used to split both groups into the following: IG_UNFIT , n = 14; IG_FIT , n = 12; CG_UNFIT , n = 16; CG_FIT , n = 11. Differences in outcome changes between groups were analyzed with H-test.

RESULT

Intergroup comparison revealed significant differences between IG_UNFIT and CG_UNFIT (P < 0.05). The IG_UNFIT increased their 6MWD by +8% (vs. IG_FIT , +1%); both CGs presented a decline in 6MWD (CG_UNFIT , -14%; CG_FIT , -16%). At discharge, the IG_FIT achieved 85.5 ± 10.3% of healthy reference values.

CONCLUSIONS

The current results indicate that exercise during pediatric HSCT is feasible and contributes to prevention of treatment-related loss of physical function. As seen in healthy persons, patients' benefits might depend on their initial fitness level. As a diminished physical capability may result in higher training effects, impaired especially patients should engage in exercise.

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.

A home-based physical activity intervention using activity trackers in survivors of childhood cancer: A pilot study

BACKGROUND

Over 70% of childhood cancer survivors develop late complications from therapy, many of which can be mitigated by physical activity. Survivors engage in exercise at similar or lower rates than their sedentary healthy peers. We piloted a novel home-based exercise intervention with a motivational activity tracker. We evaluated (i) feasibility, (ii) impact on activity levels and physical fitness, and (iii) barriers, preferences, and beliefs regarding physical activity.

METHODS

Childhood cancer survivors currently 15 years or older and not meeting the Centers for Disease Control and Prevention physical activity guidelines were enrolled and instructed to wear the Fitbit One, a 4.8 cm × 1.8 cm motivational activity tracker, daily for 6 months. Baseline and follow-up evaluations included self-report surveys, an Actigraph accelerometer for 7 days, and a VO₂ maximum test by cardiac stress test.

RESULTS

Nineteen participants were enrolled (13.4% participation rate) with a mean age of 24.3 ± 5.8 years (range 15-35). Four participants withdrew with a 79% retention rate. Participants wore the Fitbit an average of 19.0 ± 4.7 days per month during months 1-3 and 15.0 ± 7.9 days per month during months 4-6. Total weekly moderate to vigorous physical activity increased from 265.6 ± 117.0 to 301.4 ± 135.4 min and VO₂ maximum increased from 25.7 ± 7.7 to 27.2 ± 7.4 ml/kg/min. These changes were not statistically significant (P = 0.47 and 0.30, respectively). Survey responses indicated no change in barriers, preferences, and beliefs regarding physical activity.

CONCLUSIONS

This pilot study of a motivational activity tracker demonstrated feasibility as measured by participant retention, receptivity, and belief of utility. Future studies with a large sample size are needed to demonstrate the efficacy and sustainability of this intervention.

Influence of a Moderate-Intensity Exercise Program on Early NK Cell Immune Recovery in Pediatric Patients After Reduced-Intensity Hematopoietic Stem Cell Transplantation

Introduction: After allogeneic hematopoietic stem cell transplantation (HSCT), NK cell reconstitution, which is crucial for positive outcomes, is dominated by the CD56^bright subset with low NK cell cytotoxicity (NKCC) activity. Moderate exercise has been described as a potent NK cell stimulus in adults with cancer. Purpose: To determine the effects of a moderate-intensity exercise program on NK cell recovery early after HSCT and the feasibility of this intervention. Methods: Six children undergoing allogeneic HSCT were randomized to an exercise program (EP) or control (CT) group. The EP group performed a 10-week training combining in-hospital and home-based EP. Results: We observed a significant increase in the posttraining/pretraining ratio of the CD56^dim subset (EP = 1.27 ± 0.07; CT = 0.99 ± 0.08; P < .005) of the EP group. The ratio of NKCC was 8 times greater in the EP group. Conclusion: Data suggest that a moderate-intensity EP program performed early after HSCT is feasible and might redistribute the CD56^dim/CD56^brigh NK cell subset, improving NKCC. The results are still preliminary and must be interpreted with caution.

Rehabilitative intervention during and after pediatric hematopoietic stem cell transplantation: An analysis of the existing literature

Hematopoietic stem cell transplantation is a therapeutic strategy for several oncohematological diseases. It increases survival rates but leads to a high incidence of related effects. The objective of this paper was to examine the existing literature on physical exercise interventions among pediatric HSCT recipients to explore the most often utilized rehabilitative assessment and treatment tools. Studies published from 2002 to April 1, 2015 were selected: 10 studies were included. A previous literary review has shown that rehabilitation programs have a positive impact on quality of life. Our analysis identified some significant outcome variables and shared intervention areas.