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

Reducing Falls in Hospitalized Children and Adolescents with Cancer and Blood Disorders: A Quality Improvement Journey

Background

Falls in hospitalized pediatric patients represent a serious patient safety concern. Children and adolescents with cancer and blood disorders have inherent risk factors that increase the likelihood of injury from falls. The Hematology/Oncology (HO) and Stem Cell Transplant (SCT) inpatient units at Boston Children's Hospital embarked on a multiyear quality improvement journey to reduce inpatient falls in this population.

Methods

A targeted Falls Reduction Task Force implemented key initiatives between 2020 and 2023. These include enhancing communication strategies to heighten awareness of the highest fall-risk patients, conducting a formal apparent cause analysis on every fall with injury, and initiating a physical therapy-led program to reduce deconditioning. Outcome measures were total falls, rate of preventable falls with injury per 1000 patient days, and days between preventable falls with injury. Our quality improvement team used statistical process control charts to track changes over time.

Results

The combined rate of preventable falls with injury per 1000 patient days decreased from 0.63 in fiscal year (FY) 2020 to 0.25 in 2023. The SCT and HO units achieved a maximum of 442 days and 410 days, respectively, between preventable falls with injury in 2021-2023, compared with 124 and 117 days in 2020. The two units observed a 51% reduction in total falls over 4 years.

Conclusions

A multifaceted fall reduction quality initiative effectively reduced preventable falls with injury on pediatric HO and SCT inpatient units, thereby reducing avoidable harm in a vulnerable patient population.

"Prehabilitation" for Pediatric Patients With Cancer Before Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is associated with significant physical debility. Studies have suggested that physical activity can improve endurance and strength. However, studies have not yet investigated "prehabilitation," exercise before HSCT, to improve functional outcomes. We describe the impact of exercise therapy on physical debility in children undergoing HSCT to inform the implementation of prehabilitation. This review was conducted through a search of the electronic database PubMed. Articles included were those with original research, including randomized control trials, prospective studies, case controls, and retrospective studies. Eleven of the 191 resulting studies met our review criteria. None focused on prehabilitation, but instead on interventions during HSCT. Ten studies showed improvement or maintenance of strength, endurance, stretching, or aerobic fitness. This review shows that exercise therapy can positively affect outcomes in patients undergoing HSCT. Further investigations are needed to determine whether prehabilitation has better results than concurrent exercise.

Growth in the face of overwhelming pressure: A narrative review of sibling donor experiences in pediatric hematopoietic stem cell transplant

Sibling donation in pediatric hematopoietic stem cell transplant (HSCT) can be emotionally distressing for children, but may simultaneously evoke positive emotions, and has the potential to facilitate personal growth. We conducted a narrative review of sibling donor experiences, which included an analysis of psychosocial distress and post-traumatic growth (PTG). We searched the following databases: MEDLINE, CINAHL, PsycInfo, and SCOPUS. Search concepts used to develop key terms included HSCT, siblings, children, and psychosocial outcomes. Specific inclusion criteria included a) research articles published in English in peer-reviewed journals until September 2020, and b) reported trauma symptoms and PTG characteristics of sibling donation experiences. Four themes were identified: fear and anxiety related to HLA testing, overwhelming pressure to donate, guilt and blame when the ill child died, as well as emotional and physical isolation following donation. Sibling responses also included evidence of PTG, articulated as a deepened appreciation for life, closer relationships with the ill child and other family members, increased personal strength, and spiritual growth. These results highlight a critical need for future research approaches that further empower sibling donor voices, such as those found in participatory, arts-based methodologies.

Psychological Effects of a Structured Exercise Intervention During Umbilical Cord Blood Transplantation in Children and Adolescents

BACKGROUND

Children and adolescents undergoing umbilical cord blood transplantation (UCBT) are faced with severe fatigue and a decline in quality of life (QoL) during the inpatient period.

OBJECTIVE

To investigate the effect of a structured exercise intervention on fatigue, QoL and clinical outcomes among children and adolescents during UCBT.

METHODS

In this randomized controlled trial, participants (n = 48) were randomized to a control group (CG: usual care) or an intervention group (IG: a structured exercise intervention). Fatigue and QoL were assessed at hospital admission, 14 days after UCBT, and at discharge using linear mixed model analysis. In addition, engraftment kinetics, supportive treatment, transplant-related complications, and hospital length of stay were derived from medical records.

RESULTS

4 patients completed the study, the IG participated in an average of 2.12 (1.36-2.8) sessions with a duration of 24 (16-34) min weekly, and the total rate of adherence to the training program was 70.59%. For fatigue and QoL, there was a significant effect of time in the control group, with the total score of fatigue decreased from T1 to T2 (73.9vs 60.9, P = .001) and T1 to T3 (73.9vs 65.6, P = .049), and the QoL scores decreased from T1 to T2 (73.9vs 66.1, P = .043). The hospital length of stay was less in the intervention group (P = .034).

CONCLUSION

Our randomized study indicated that structured exercise interventions might exert a protective effect by attenuating the decline in fatigue and QoL, and shortening duration of hospitalization.

Rehabilitation in children and adolescents undergoing stem cell transplantation: A pilot study focused on motor performance

OBJECTIVES

The aim of this pilot trial is evaluating the preliminary effectiveness of two in-hospital interventions in the maintenance of motor performance in children/adolescents undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives investigated the interventions' feasibility, impact on fatigue and to what degree the subjects' maintained their ankle dorsiflexion range of movement (ROM), functional mobility, muscle strength and flexibility.

METHODS

This trial included 5- to 18-year-old participants, affected by oncological and non-oncological diseases during hospitalisation for autologous/allogenic HSCT. The subjects were assigned to an exercise group (EG), or a counselling group based on a cluster model based on inpatient timeframe. The EG subjects performed strengthening, stretching and aerobic exercises for 30 min/5 days a week. Both groups followed rehabilitation counselling indications (RCI), 7 days a week.

RESULTS

Forty-nine participants were enrolled (median age = 12.9 years) (EG n = 36). In both groups the participants maintained their baseline motor performance and ankle ROM, and the children/adolescents and parents reduced their levels of fatigue. However, the interventions were not effective in maintaining strength.

CONCLUSION

In maintaining the subjects' motor performance, the RCI results are significant because they pave the way for the application in clinical practice contexts where there are poor rehabilitation resources. Clinical Trials registration NCT03842735.

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.

The effects of administered interventions on quality of life of children with cancer in Turkey: A systematic review and meta-analysis

OBJECTIVE

The present systematic review and meta-analysis aimed to analyse the effects of administered interventions on the quality of life of children with cancer in Turkey.

METHODS

The quantitative studies conducted with paediatric oncology patients, analysing the quality of life of Turkish children, and published papers from 2009 to 2019 were searched. Joanna Briggs Institution MAStARI Experimental and Quasi-Experimental Research Control List and Quality Index were used for methodological assessment. Five studies comprising a total of 264 samples were included. Four studies were nonrandomised controlled trials, and one was a quasi-experimental study.

RESULTS

Tests for heterogeneity showed that the studies, which included interventions increasing the quality of life of children with cancer, were heterogeneous. The common effect size of all studies on quality of life was determined as having a strong positive effect.

CONCLUSIONS

This meta-analysis and systematic review contribute to the knowledge of Turkish health care professionals regarding these interventions by producing results with high levels of evidence on the improvement of the quality of life among children with cancer. The present study also significantly raises awareness and encourages health care professionals to implement interventions for the improvement of quality of life among children with cancer.

The Effects and Mechanisms of Exercise on the Treatment of Depression

Background: It is necessary to seek alternative therapies for depression, because side effects of medications lead to poor adherence and some patients do not achieve a clinical treatment effect. Recently the role of exercise as a low-cost and easy-to-use treatment for depression has gained attention with a number of studies showing that exercise is effective at reducing depressive symptoms and improving body functions such as cardiorespiratory system and cognitive function. Because of the heterogeneity of exercise therapy programs, there is no standardized and unified program. Few studies have summarized the specific properties of exercise programs (type, intensity, duration, and frequency) and clinical prescriptions for exercise are not mentioned in most articles. Aims: This study aimed to investigate the feasibility and efficacy of exercise therapy for patients with depression, in order to appraise the evidence and outline accepted guidelines to direct individualized treatment plans for patients with depression based on their individual situations. Methods: A systematic review of English language literature including papers published from 2010 to present in PubMed was performed. Given the feasibility of prescribing exercise therapy for patients with depression, nearly 3 years of clinical studies on the treatments of depressive symptoms with exercise were first reviewed, comparing the exercise programs utilized. Conclusions: Exercise has therapeutic effects on depression in all age groups (mostly 18-65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression. Moderate intensity exercise is enough to reduce depressive symptoms, but higher-dose exercise is better for overall functioning. Exercise therapy has become more widely used because of its benefits to the cardiovascular system, emotional state, and systemic functions. Recommendations: Aerobic exercise/mind-body exercise (3-5 sessions per week with moderate intensity lasting for 4-16 weeks) is recommended. Individualized protocols in the form of group exercise with supervision are effective at increasing adherence to treatment.

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.