Physical therapy and neuro-oncology
Of the children who are diagnosed with cancer each year, about 25% (approximately 150 children) have a form of neuro-oncology. As a (pediatric) physical therapist, you contribute to physical functioning in children with a brain tumor. This may include gait function, balance, or other consequences of neurological impairments.
Our e-learning includes information on physical therapy treatment in a neuro-oncological case. The learning portal offers a broader range of information about neuro-oncology.
(Pediatric) physical therapy care depends on the type of cancer. An overview of the different types of neuro-oncology can be found here.
Side effects
If, as a (pediatric) physical therapist, you receive a referral for a child who has or has had a brain tumor, your physical therapy treatment may focus on various neurological impairments. Which impairments are involved depends on the type and location of the tumor.
Common indications for (pediatric) physical therapy within the Neuro-oncology department at the Princess Máxima Center include:
Questions from parents and or the child related to movement.
Reduced motor abilities as a result of neurological damage caused by the tumor, tumor resection, radiation therapy, and or chemotherapy, such as paresis, spasticity, or ataxia.
Immobility due to pain and fear, or limited mobility due to postoperative paresis or spasticity, with possible consequences such as pressure injuries or contractures.
Optimizing functioning in preparation for discharge home, transfer to a rehabilitation center, or transfer to another hospital.
Assessing the need for assistive devices for discharge, in collaboration with an occupational therapist and transfer nurse, such as a wheelchair, walker, shower chair, or adjustable bed.
Abnormal gait pattern consistent with chemotherapy-induced neuropathy and or neurological damage, for example when:
walking speed is reduced, and or
walking distance is reduced, and or
participation in sports and play activities in daily life is limited.
Monitoring motor development when development is at risk.
Optimizing and maintaining physical fitness during and after oncological treatment.
In our learning portal, you can find more information about (pediatric) physical therapy treatment for conditions such as ataxia and spasticity.
AtaxiaAtaxia is a coordination disorder caused by damage to the cerebellum. Within pediatric oncology, cerebellar damage most commonly occurs as a result of a tumor in the posterior fossa, but it may also develop due to disease or injury to the brain caused by encephalitis, stroke, or traumatic brain injury. Ataxia can also be a side effect of certain medications or a degenerative condition. Ataxia involves impaired coordination of movements, making it difficult to perform smooth, goal-directed actions. Balance is therefore also affected. Pediatric physical therapy focuses on improving movement coordination and gait.
The Scale for the Assessment and Rating of Ataxia (SARA) is an assessment tool used to determine the severity of ataxia. In this video, a physical therapist from the Princess Máxima Center demonstrates how to perform this assessment.
SpasticitySpasticity is a movement disorder characterized by increased muscle tone, also known as hypertonia. It often presents as excessive flexion in the arm and extension in the leg. Spasticity may occur as a result of a tumor located in the corticospinal tract. It limits movement at both the activity and participation levels because muscles remain in a shortened position. Pediatric physical therapy focuses on maintaining function and physical condition.
ParesisParesis is partial paralysis of part of the body. It may occur in children with cerebral tumors located in the motor cortex, or in tumors located in the brainstem or lower regions. Children experience reduced muscle strength, which limits activities and alters gait patterns.
Acquired brain injury (ABI) can have a major impact on a child’s life. Some children experience memory and concentration problems, making school more challenging. Others have delayed growth, epilepsy, slower movement, or chronic fatigue. Some children develop behavioral problems. As a pediatric physical therapist, you support children with difficulties in walking, physical fitness, and other movement-related limitations. It is therefore important to be familiar with the symptoms associated with ABI.
For support from a rehabilitation center, a national treatment program has been developed for children and adolescents with ABI who are referred to specialist medical rehabilitation. This program outlines the range of treatments available in specialist rehabilitation and covers the entire rehabilitation process.
In the learning portal, you will find the module ‘Not running, but planning’, which helps you support children with ABI-related symptoms in finding a balance. This module also provides insight into how an occupational therapist approaches ABI-related challenges.
Cerebellar Mutism Syndrome (CMS) is a complication that occurs in about 25% of children after surgery for a tumor in the posterior fossa. Symptoms include speech problems, ataxia, and or emotional lability.
In addition to speech difficulties, children with CMS may experience problems with:
making precise movements with the arms and legs
eating and drinking
increased irritability
The syndrome is usually temporary. However, some children continue to have difficulties with speech and movement.
While a speech therapist can support speech and eating or drinking problems, you as a pediatric physical therapist may receive a referral for a child who needs treatment for, for example, ataxia. Practicing balance and motor learning may be part of your treatment plan.
A brain tumor can disrupt hormone regulation. As a result, a child may have a slower metabolism, gain weight, sleep poorly, experience vision problems, and have low mood. This leads to reduced energy and fatigue, which in turn can result in less physical activity. Because of fatigue, a child may also feel less motivated to be physically active.
Staying active is important, as it helps prevent symptoms from worsening. Physical activity can even reduce fatigue. Exercise also helps increase metabolism. Within (pediatric) physical therapy, the focus is on reduced physical activity and decreased energy expenditure or metabolism that may occur after hypothalamic damage.
A child may engage in moderate-intensity physical activity, such as cycling to school while talking with a friend, as well as vigorous-intensity activity, such as running during physical education class. The Dutch Physical Activity Guidelines for children can be used as a reference. More information can be found in the folder ‘Physical activity with disrupted hormone regulation’.
LiteraturePolyneuropathy 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.
A toe-walking deformity can limit a child’s ability to walk, participate in sports, and play. In addition, toe walking can be painful.
Toe walking may develop in children with a brain tumor, referred to as neurological toe walking, or in children with a bone tumor, referred to as non-neurological toe walking.
Neurological toe walking* Hypertonia as a result of a brain tumor
* Muscle weakness caused by a central brain tumor or a tumor in or around the peripheral nervous system, such as chemotherapy-induced peripheral neuropathy (CIPN) or hourglass-shaped neuroblastoma
Non-neurological toe walkingProlonged bed rest or inactivity
Development of a toe-walking position after cast immobilization for bone tumors
If preventive measures during the hospital admission period have not been sufficient to avoid toe walking, several treatment options are available. These include active movement and weight bearing, passive movement and manual stretching, the use of insoles or heel lifts, splints or ankle–foot orthoses, serial casting to correct the toe-walking position, or surgical intervention.
A goniometer is used to evaluate the effectiveness of the intervention.
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