Physical therapy and hemato-oncology
Of the children who are diagnosed with cancer each year, about 45% (approximately 270 children) have a form of hemato-oncology. This makes it the most common type of cancer in childhood. Within this group, acute lymphoblastic leukemia (ALL) is the most common diagnosis.
When a child has or has had a hemato-oncological condition, they may experience various side effects, such as muscle weakness and fatigue. As a (pediatric) physical therapist, you tailor treatment to training functional skills or improving physical fitness, for example.
Our e-learning includes a hemato-oncological case, and the learning portal offers several e-learning modules on (pediatric) physical therapy in hemato-oncology. The specific physical therapy approach depends on the type of cancer.
Side effects and late effects
During admission for a stem cell transplant, children are at increased risk of losing muscle strength, flexibility, physical fitness, and independence in mobility or daily functioning. This is due to the length of treatment, isolation, and overall malaise. Children who are already severely weakened or limited as a result of previous chemotherapy treatments are particularly at risk of further decline in functioning.
Each year, a limited number of children undergo a stem cell transplant. Physical activity before, during, and after a stem cell transplant is very important. Staying active can help a child recover more quickly from the transplant and feel less fatigued. This may also help the child cope better with possible complications after the transplant.
Once a child returns home, the body initially uses energy to rebuild the immune system. As a result, the child may feel tired. After about three months, immune function and physical fitness have often improved considerably. Some children, however, continue to experience fatigue and reduced fitness for a longer period. How a child can stay active during these different phases is described in the folder ‘Staying active around a stem cell transplant’.
Children may be referred to a community-based (pediatric) physical therapist if improvements in strength, flexibility, daily functioning, and or endurance are delayed. Would you like to know more about training physical fitness? You can read more here.
Exercise testingTo properly assess endurance and provide targeted sports and physical activity advice, a maximal exercise test can be performed by an exercise physiologist at the Princess Máxima Center, following the (pediatric) physical therapy assessment. One hundred days after the stem cell transplant, children attend an outpatient follow-up visit. During this post-screening, recovery after admission is evaluated based on physical examination and exercise testing.
Children who are treated with high doses of corticosteroids may develop osteonecrosis. Because blood supply to the joint, usually the hip or knee, has been temporarily disrupted, part of the joint surface dies.
Osteonecrosis, also known as bone necrosis, occurs in about 5–9% of all age groups. About 30% of cases occur in adolescents between 15 and 18 years of age. The development of osteonecrosis is often related to the use of dexamethasone. Osteonecrosis can cause significant pain and may lead to limitations in daily functioning.
Symptomatic osteonecrosis (ON) is defined as persistent pain in the extremities or hips that is not related to recent vincristine use, in combination with characteristic abnormalities on magnetic resonance imaging (MRI). It occurs mainly in patients with acute lymphoblastic leukemia or non-Hodgkin lymphoma who are treated with corticosteroids and asparaginase.
The severity of ON can be classified using the Ponte di Legno Toxicity Working Group criteria (PTWG criteria).
Children at increased risk of developing osteonecrosis are those older than ten years, especially adolescents aged 15–18 years. Other risk factors described in the literature, although less clearly established, include female sex, higher body mass index, higher cumulative doses of corticosteroids, and hyperlipidemia.
At the Princess Máxima Center, the physical therapist assesses limitations in daily activities and joint mobility. Advice is given on appropriate load and the gradual build-up of physical activity. As a primary care (pediatric) physical therapist, you can, depending on the child’s needs, focus on muscle-strengthening exercises to reduce load on the affected bone. In addition, you can help the child learn how to regulate physical load, which may reduce symptoms.
During and/or after cancer treatment in childhood, pulmonary complications may occur.
Respiratory problems, including breathing difficulties, can occur in children with cancer. We mainly see these problems arise over short periods in children in the acute phase of hematologic malignancies or solid tumors. At the Princess Máxima Center, the cause of breathing problems must be treated promptly. In some cases, a physical therapist is also involved. Most children present with dyspnea or develop symptoms of respiratory dysfunction.
Pulmonary complications may be caused primarily by the cancer itself or secondarily by oncologic treatment. There are many different causes. In addition to oncologic complications and tumors, iatrogenic causes or infections can also lead to respiratory problems.
Risk groupsSome children have an increased risk of developing pulmonary complications.
Children with a primary tumor or metastases in the lungs:
Solid tumors, including Wilms tumor, sarcomas, and neuroblastoma
Children with mediastinal involvement:
Hematologic malignancies, including lymphomas and acute lymphoblastic leukemia (ALL)
Children with respiratory infection(s):
Opportunistic infections, including Staphylococcus, Streptococcus, and influenza
Viruses, including CMV and Pneumocystis
Fungi, including Candida and Aspergillus
As a community-based physical therapist, you are unlikely to encounter acute pulmonary complications, given the phase in which these occur and the urgency with which they must be treated. However, it is important to know whether a child has experienced breathing problems in the past or continues to have symptoms in the long term.
Polyneuropathy may develop during or after pediatric oncology treatment. This can result in sensory, motor, and autonomic impairment, causing children to experience symptoms such as tingling sensations and loss of muscle strength in the hands and feet.
Polyneuropathy can occur as a result of treatment with vincristine, which affects the peripheral nerves. Polyneuropathy usually resolves within several months after treatment is stopped. About 25% of children continue to experience long-term symptoms, such as reduced reflex activity and impaired motor function. Vincristine is a chemotherapy drug prescribed for several types of cancer. Conditions for which vincristine is used include:
Retinoblastoma
Symptoms may occur in the motor, sensory, and autonomic domains. As a (pediatric) physical therapist, you may therefore encounter children with an abnormal gait pattern. This may present as a slower walking speed, shorter step length, or a wider base of support. Possible contributing factors include impaired balance, reduced strength of the ankle dorsiflexors, or reduced muscle length of the gastrocnemius muscle. Muscle shortening can also occur in the wrist and hand flexors. Weakness in the upper extremities is mainly seen during wrist and or finger abduction and extension.
You can read more about polyneuropathy in this folder and in the presentation available in our learning portal.
Fatigue is a complex and common symptom in children with cancer and in adults who had cancer during childhood. It can occur as a side effect during and after oncological treatment, but also as a late effect.
Fatigue is seen across different childhood cancer treatment trajectories. Examples include specific chemotherapy regimens, but children who have received radiation therapy also frequently experience fatigue. Fatigue is more common in adolescents.
Exercise interventions can help reduce experienced fatigue. At the Princess Máxima Center, we follow the principle of Maximal Movement. Moving as much as possible during and after treatment means being physically active within the child’s individual limits. These limits differ for each child, situation, and phase of treatment. Maximal movement can range from sitting upright in bed to intensive walking and or strength training.
You, as a pediatric physical therapist, can play an important role in this. You can read more about this on the website of the Dutch Childhood Cancer Association.
LiteraturePatel, P., et al. (2023). Guideline for the management of fatigue in children and adolescents with cancer or pediatric hematopoietic cell transplant recipients: 2023 update. EClinicalMedicine, 63, 102147.
https://doi.org/10.1016/j.eclinm.2023.102147