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

Ankle movement alterations during gait in children with acute lymphoblastic leukemia with suspected peripheral mononeuropathy. A cross-sectional study

BACKGROUND

Peripheral neuropathy due to chemotherapeutic drugs causes alterations in ankle movement during gait. This study aimed to describe the spatiotemporal parameters and ankle kinematics during gait in schoolchildren with acute lymphoblastic leukemia with clinically suspected peripheral neuropathy.

METHODS

In children with acute lymphoblastic leukemia in the maintenance phase, we calculated spatiotemporal and kinematic parameters of the ankle during gait using Kinovea® software. Furthermore, we identified alterations in the parameters obtained considering the values of the normality data from a stereophotogrammetry system as the reference values. Finally, we represented the kinematic parameters of the ankles calculated with Kinovea® compared to the normality values of the stereophotogrammetry.

FINDINGS

We evaluated 25 schoolchildren; 13 were male (52.0%) with a median age of 88.0months and a median of 60.0 weeks in the maintenance phase, and 54.8% were classified as standard risk. Spatiotemporal parameters: cadence (steps/min), bilateral step length (m), and average gait speed (m/s) in ALL children were significantly lower than reference values (p < 0.001). Except for right mid-stance and bilateral foot strike, initial swing showed that both ankles maintained plantar flexion values during gait, significantly lower in ALL patients (p < 0.05).

INTERPRETATION

We identified spatiotemporal and kinematics alterations in schoolchildren with acute lymphoblastic leukemia during all phases of the gait suggestive of alteration in ankle muscles during movement, probably due to peripheral neuropathy; nevertheless, our results should be taken with caution until the accuracy and reliability of Kinovea® software as a diagnostic test compared to the stereophotogrammetric system in children with ALL and healthy peers is proven.

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.

Cross-Training and Resistance Training in Adults with Type B Acute Lymphoblastic Leukemia during the Induction Phase: A Randomized Blind Pilot Study

Patients with acute lymphoblastic leukemia (ALL) undergoing induction decrease their physical capacity, lose muscle mass, and decrease their quality of life (QOL). The safety, feasibility, and benefits of exercise during chemotherapy have been proven, but the effects of cross-training activities have yet to be analyzed. To measure the effects of cross-training on body composition, physical performance, and QOL, a blind randomized clinical trial was carried out. A total of 33 patients were included and randomized into a cross-training exercise group (CEG), a resistance exercise group (REG), and a control group (CG). During induction, patients received an exercise routine three to five days a week for 30 to 50 min each. Body composition, QOL, and physical performance were measured at baseline, up to discharge, and at a follow-up of two months. Body composition improved in the REG and CEG. In the CG, muscle mass decreased and fat mass increased (p = 0.020 and 0.020, respectively). The REG and CEG had significant positive improvements in physical performance compared to the CG. QOL showed no differences in any group (p = 0.340). Cross-training and resistance exercise are essential to improve body composition and physical performance during induction. Considering the prognostic value of physical performance, we propose integrated training exercises as adjuvant therapy in adult patients with ALL.

Physical fitness throughout chemotherapy in children with acute lymphoblastic leukaemia and lymphoma

Acute lymphoblastic leukaemia/lymphoma (ALL/LBL) and its treatment interfere with normal physical functioning. However, it remains unclear how physical fitness (PF) is affected throughout treatment for ALL/LBL. Sixty-two patients (2.1 to 18.3 years) treated for ALL/LBL underwent four physical tests at nine timepoints from baseline up to 6 months post-treatment. We assessed muscle strength of the quadriceps and tibialis anterior, standing broad jump test (SBJ) for functional mobility and six-minute walk test (6MWT) for endurance. One-sample t-tests were used to compare our results to the norm at each timepoint. Norm-referenced Z-scores were predicted based on time, risk group and age at diagnosis, using linear mixed models. Quadriceps strength, SBJ and 6MWT scores were significantly lower than norm values at all timepoints from diagnosis up to 6 months after maintenance therapy. Significant decreases over time were encountered for quadriceps strength and SBJ, mainly occurring after induction therapy (F = 3.568, p < 0.001 and F = 2.699, p = 0.008, respectively). Age at diagnosis was a significant predictor for tibialis anterior strength (F = 5.266, p = 0.025), SBJ (F = 70.422, p < 0.001) and 6MWT (F = 15.890, p < 0.001) performances, with lower results in adolescents at all timepoints. Six months after treatment, quadriceps strength, 6MWT and SBJ scores remained below expected levels.

CONCLUSION

The decreased quadriceps strength, functional mobility and endurance at all timepoints, with a large deterioration following induction therapy, suggest the need for early interventions, specifically in the adolescent population. The continued low results 6 months after therapy emphasise the importance of long-term rehabilitation.

WHAT IS KNOWN

•Acute lymphoblastic leukaemia is the most common type of cancer among children, with increasing survival rates due to therapeutic improvements. •Acute lymphoblastic leukaemia/lymphoma and its treatment can cause muscle weakness, neuromuscular toxicity and a decreased cardiopulmonary fitness. Together with physical inactivity, this can result in a decreased physical fitness.

WHAT IS NEW

•Quadriceps strength, functional mobility and endurance are decreased during treatment for acute lymphoblastic leukaemia/lymphoma. The lowest measurements are observed after induction therapy, suggesting the need for early interventions. •We observed continued lower results for quadriceps strength, functional mobility and endurance at the end of treatment, up to 6 months after therapy, supporting the need for long-term rehabilitation.

Efficacy of interdisciplinary rehabilitation in child cancer survivors: Impact on physical fitness, fatigue and body composition after 1-year follow-up

OBJECTIVE

Childhood cancer survivors experience reduced physical activity level, participation as well as health-related quality of life. This prospective, pre-/post-intervention and follow-up cohort study aims to determine the efficacy of an interdisciplinary rehabilitation on improving physical fitness, fatigue and body composition.

METHODS

A total of 24 childhood cancer survivors (mean age: 12.15 years ± 3.2; 14 females; 10 males) were recruited 6 months after medical treatment and received a 4-month interdisciplinary intervention. Cardiorespiratory fitness (PredVO_2peak and PredLoad_max ), body composition (dry lean weight) and quality of life (general fatigue) were assessed at baseline, post-intervention and 1-year follow-up. Linear mixed models were used to analyse data.

RESULTS

Linear mixed modelling revealed a significant main effect of time on predicted maximal load (F = 13.189, df = 36.179, p < 0.001), dry lean weight (F = 64.813, df = 37.019, p < 0.001) but also significant improvement of general fatigue score (-9.039 ± 4.300, 95% CI -17.741 to -0.336, p = 0.042), indicating a decline in general fatigue.

CONCLUSION

With emerging evidence that physical activity is safe and feasible, together with increasing numbers of childhood cancer survivors at risk for long-term chronic co-morbidities, this study advocates for better access to interdisciplinary rehabilitation programmes in order to improve their physical condition and their body composition and reduce fatigue.

Musculoskeletal impairments in children receiving intensive therapy for acute leukemia or undergoing hematopoietic stem cell transplant: A report from the Children's Oncology Group

BACKGROUND

Children receiving intensive chemotherapy for leukemia or undergoing hematopoietic stem cell transplant (HSCT) for solid tumors or leukemia are at risk for musculoskeletal (MSK) impairment from their underlying disease and from treatment. Data are limited on the incidence and nature of these disorders during intensive therapy. This study's objective was to provide a cross-sectional description of MSK impairments in this population.

PROCEDURE

Children with acute myeloid leukemia (AML), relapsed acute lymphoblastic leukemia (rALL), or undergoing HSCT were systematically assessed for MSK impairments as part of Children's Oncology Group study ACCL0934. Assessments occurred at study entry, at 2 months, and at 12 months and included evaluation for signs or symptoms of MSK impairment and the type, site, and diagnosis.

RESULTS

Six hundred three patients were included. MSK signs or symptoms were present in 48 (8.0%) children at study entry, 64 (13.5%) children at 2 months, and 40 (11.6%) children at 12 months. Arthralgia and/or gait abnormalities were the most common impairments; the knee was the most common site. Arthritis and tendonitis were both rare. Vincristine neuropathy, MSK impacts from central nervous system pathology, and bone or joint pain from underlying cancer were the most common diagnoses. Multivariate analysis demonstrated that having rALL (odds ratio [OR] 2.00, 95% CI 1.07-3.76, p = .03) or obesity (OR 2.10, 95% CI 1.12-3.95, p = .02) were risk factors for MSK impairment at study entry.

CONCLUSIONS

MSK impairments are common in this intensively treated patient population, especially in those with rALL and those who are obese.

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.

Severe fatigue after treatment for childhood cancer

BACKGROUND

Treatment strategies for childhood cancer are improving, resulting in higher survival rates. However, the consequences of childhood cancer do not end with the successful completion of cancer treatment. Most patients will develop late effects after cessation of treatment. Severe fatigue is seen as a common and debilitating late effect in cancer survivors. Although most research on fatigue has been performed in patients after adult-onset cancer, our review focuses on fatigue after childhood cancer.

OBJECTIVES

To estimate the prevalence of severe fatigue after treatment for childhood cancer. Secondary objectives are to describe the course of severe fatigue following cancer treatment and to examine risk factors for fatigue, or factors associated with it.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019; issue 8 March 2019), MEDLINE/PubMed (from 1945 to 8 March 2019), Embase/Ovid (from 1947 to 8 March 2019), reference lists of included articles and several conference proceedings from 2011 to 2018.

SELECTION CRITERIA

Observational studies, randomised controlled trials and controlled clinical trials reporting on fatigue in participants after treatment for childhood cancer. Case series and case reports were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risks of bias. If the publication did not present the prevalence of severe fatigue, we contacted study authors for additional information.

MAIN RESULTS

We included 30 studies (18,682 participants in total). Eighteen studies contributed to the main objective and 22 studies contributed to the secondary objectives. We found substantial differences between studies in cancer diagnosis, cancer treatment, age of participants, questionnaires used to assess fatigue, and sample size. All included studies scored at least one 'Risk of bias' item as unclear or high risk. We identified both clinical and statistical heterogeneity and therefore could not pool results, so we present them descriptively. Eighteen studies (describing 14,573 survivors) reported the prevalence of severe fatigue, which ranged from 0% to 61.7%. In a subgroup of three studies including children aged up to 18 years at fatigue assessment (268 survivors), prevalence rates ranged from 6.7% to 12.5%. In comparison, in a subgroup of 12 studies including participants aged 16 and over (13,952 survivors), prevalence rates ranged from 4.4% to 61.7%. The prevalence of severe fatigue in a subgroup of survivors of haematological cancer was presented in seven studies and ranged from 1.8% to 35.9% (1907 survivors). Prevalence of severe fatigue in brain cancer survivors was presented in two studies (252 survivors) and was 14.6% and 21.1% respectively. One study presented a prevalence for bone cancer survivors of 0.0% (17 survivors). Four studies provided prevalence rates of severe fatigue in control groups of siblings or population-based controls, which ranged from 3.1% to 10.3%. In these four studies, survivors were more often fatigued than controls, but this difference was statistically significant in only two studies. Studies assessing risk and associated factors for fatigue were heterogeneous, and definitions of the factors under study were often inconsistent, with results therefore presented descriptively. They found that depression might be associated with fatigue. In contrast, age at diagnosis and education level did not seem to be associated with fatigue. We were unable to calculate any overall risk estimate for any of the reported risks and associated factors, because we could not conduct meta-analysis. One study provided information about the course of fatigue over time, and found that over the course of 2.7 years, 32 of the 102 participants (31.4%) reported persistent severe fatigue.

AUTHORS' CONCLUSIONS

It is unclear how many childhood cancer survivors suffer from severe fatigue. This review encountered several difficulties. We found statistical and clinical heterogeneity and great variation in the reporting of possible risk and associated factors. The evidence in this review is therefore weak, and the exact prevalence of severe fatigue after treatment for childhood cancer remains to be determined. This is also the case for the course of severe fatigue following treatment and the strength of the relationship between fatigue and associated and risk factors. Despite these limitations, our review does provide a comprehensive overview of the existing literature about severe fatigue after treatment for childhood cancer.

Bone morbidity in pediatric acute lymphoblastic leukemia

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

Trends in age- and sex-adjusted body mass index and the prevalence of malnutrition in children with cancer over 42 months after diagnosis: a single-center cohort study

The adequate nutritional status of pediatric cancer patients is particularly important to enable them to cope with the demands of the disease and its treatment and to maintain normal growth. Malnutrition and obesity have both been associated with reduced survival and increased drug toxicity. We investigated trends in the age- and sex-adjusted body mass index (ISO-BMI) and the prevalence of malnutrition in a Finnish cohort of 139 consecutive children receiving chemotherapy for cancer, with a follow-up period of 42 months after diagnosis. In total, 28% (39/139) of the patients experienced malnutrition (ISO-BMI < 17 or > 10% weight loss), and 12% (16/139) had a nasogastric tube or underwent gastrostomy. Patients with acute or chronic myeloid leukemia (5/10), central nervous system (CNS) tumors (5/13), or solid tumors (13/31) most frequently suffered from malnutrition. There was a significant increase in the ISO-BMI of patients with acute lymphoblastic leukemia (ALL) (+ 2.1 kg/m²) and lymphomas (+ 2.4 kg/m²) during the first 6 months, and the ISO-BMI of patients with ALL remained higher at 42 months compared to baseline (+ 1.9 kg/m²).Conclusion: The cumulative incidence of malnutrition in Finnish pediatric cancer patients is comparable to that reported in other populations. The nutritional status of patients with acute myeloid leukemia, CNS tumors, or solid tumors should be monitored with extra care to facilitate early intervention in the case of impending malnutrition.What is known:• Both malnutrition and obesity are associated with reduced survival and increased drug toxicity in pediatric cancer patients.What is new:• Overall, 28 % of Finnish children receiving chemotherapy for cancer suffer from malnutrition during the first 42 months following the initial cancer diagnosis. • ISO-BMI curves from initial diagnosis to 42 months after diagnosis are provided for patients with different types of cancer.

Effects of a home-exercise programme in childhood survivors of acute lymphoblastic leukaemia on physical fitness and physical functioning: results of a randomised clinical trial

PURPOSE

The aim of this study was to evaluate the effects of a home-exercise programme on physical fitness indicators and physical functioning after completion of chemotherapy in children and adolescents diagnosed with acute lymphoblastic leukaemia (ALL).

METHODS

Twenty-four survivors of ALL were assigned to usual care (control group, n = 12, 11.0 ± 3.7 years) or to a home-exercise programme (intervention group, n = 12, 11.8 ± 4.3 years). Peak oxygen uptake (VO₂peak ml/kg/min), minute ventilation (VE L/min), output of carbon dioxide (VCO₂ L/min), respiratory exchange ratio (RER), peak heart rate (beats/min), maximal load (W), VO₂ at anaerobic threshold (VO₂ at AT, ml/kg/min), pulse oxygen (PO₂ ml/beat), heart rate at anaerobic threshold (beats/min), handgrip test (pounds), flexibility (cm), Timed Up & Go test TUG (s), and Timed Up and Down Stairs test (TUDS s) were measured at baseline and over 16 weeks of intervention.

RESULTS

Adjusted mixed linear models revealed a significant group-time interaction + 6.7 (95% CI = 0.6-12.8 ml/kg/min; η² partial = 0.046, P = 0.035) for VO₂peak. Similarly, changes in mean values were observed after the home-exercise programme compared with baseline for VE (L/min) - 8.8 (3.0) (P = 0.035), VCO₂ - 0.2 (0.08), (P = 0.041), maximal load (W) - 35.5 (12.8) (P = 0.024), TUDS (s) 0.8 (2.6) (P = 0.010), and TUG (s) 0.6 (0.1) (P = 0.001); however, the group-time interaction was not significant.

CONCLUSION

The home-exercise programme resulted in changes in measures of VO₂peak, VE, VCO₂, and functional capacity during daily life activities (TUDS and TUG test). This is an interesting and important study that surely adds to the current body of knowledge/literature on the safety of exercise interventions, especially in children with haematological cancer.

Kids Are Moving: A Physical Activity Program for Children With Cancer

Children undergoing cancer treatment are less active than healthy peers. Inactivity persists into survivorship, negatively influencing health and quality of life. Fatigue is one of the most prevalent symptoms during treatment yet children with increased physical activity (PA) have less fatigue. This pilot study evaluated the impact of coaching on PA and fatigue in children undergoing cancer treatment delivered by pediatric oncology nurse practitioners (NPs) during routine clinic visits. NPs used motivational interviewing during clinic visits to coach children and their families on strategies to increase PA at home. Self-report measures of PA and fatigue were completed at treatment months 2, 4, and 6. PA was also measured using actigraphy. Among 30 children ages 6 to 18 years, 7 had acute lymphoblastic leukemia (ALL), 11 had lymphoma, and 12 had solid tumors. Patterns of fatigue were different by disease group with trends to fatigue decreasing during treatment in the patients with ALL ( p = .09) and lymphoma ( p = .13) but increasing in those with solid tumors ( p = .06). Self-report PA was unchanged. Actigraph measurements remained stable for the group. NPs reported time challenges in implementing coaching during the clinic visit and in providing coaching continuity. The intensive, repeating chemotherapy cycles in solid tumor treatment may contribute to increasing fatigue. Treatment intensity decreases during ALL and lymphoma treatment, which may allow for improvement in fatigue. Inactivity persisted during treatment but did not progress. Future research is needed to evaluate more “dose-intensive” PA interventions in larger samples of specific disease groups.

Physical Fitness of School-Age Children after Cancer Treatment

The aim of the study was to assess physical fitness of school-age children after cancer treatment. The study was comprised of one hundred and fifty six children-children after cancer treatment (n = 71, mean age 11.22 ± 3.11 years) vs. healthy children previously untreated for cancer (n = 85, mean age 10.71 ± 1.22 years). Physical fitness was assessed indirectly based on a ball throw (assessment of strength, coordination, and upper limb speed), long jump (assessment of jumping ability, speed, and coordination), and a 60 m run (assessment of speed). The analysis was performed based on the Student's t-test for independent samples and the analysis of variance and the post-hoc least significant difference test (LSD test). Children from the study group threw the ball closer and had shorter long jump performance compared to the control group, i.e., 12.93 [m] vs. 19.79 [m], respectively (p < 0.001) and 2.46 [m] vs. 2.70 [m], respectively (p = 0.02). However, their mean running time was longer, i.e., 13.33 [s] vs. 11.73 [s], respectively (p = 0.01). Division according to sex showed additionally significantly shorter ball throw distance in the study group in both girls (p = 0.001) and boys (p < 0.001), significantly shorter jump length in the group of girls (p = 0.01), and significantly longer running time in the group of boys (p = 0.04). Children treated for cancer are characterized by decreased physical fitness, and motor ability is sex-dependent. Both groups showed decreased strength, coordination, and upper limb speed. Additionally, worse jumping ability was found in girls whereas decreased speed was observed in boys.

The role of adiponectin, LEPTIN, and ghrelin in the progress and prognosis of childhood acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Dysregulation of adipokine pathways is implicated in the carcinogenesis and ALL. The aim of this study is to present the most recent data available regarding the role of leptin, adiponectin and ghrelin in the pathogenesis and prognosis of ALL. The PubMed database was searched using 'Leptin', 'Adiponectin', 'Ghrelin', 'Cancer', 'Children' and 'Acute Lymphoblastic Leukemia' as keywords. The majority of the studies indicated that leptin levels are increased and adiponectin levels are decreased in ALL children at diagnosis, as well as in ALL survivors. Ghrelin levels were found to be lower at diagnosis and progressively increased during treatment. Further research is warranted, as the heterogeneity of the current studies, various treatment protocols and differences in sample sizes make it difficult to deduce solid conclusions regarding the role of adipokines in ALL.