Exercise as it relates to Disease/Exercise program intervention for children with leukaemia

A critical review of journal article "Effects of an Intrahospital Exercise program Intervention for children with leukaemia" Alejandro F. San Juan, Steven J. Fleck, Carolina Chamorro-vina, Jose Luis Mate-munoz, Susana Moral, Margarita Perz, Claudia Cardona, Maria Fernandez Del Valle, Mercedes Hernandez, ManuelRamirez, Luis Madero, and Alejandro Lucia. (2006) Journal of the American College of Sports Medicine, 2007;39(1):13-21.

What is the background to this research?
Acute lymphoblastic leukemia (ALL) accounts for 26% of all childhood cancers. With increased survival rates, there has been increasing recognition of adverse short-, mid-, or long-term effects associated with treatment and the cancer itself that impair the quality of life (QOL) and functional capacity of patients and survivors of childhood ALL. Some include:
 * Impaired neurophysiological functioning gross
 * Sarcopenia and muscle weakness
 * Osteopenia and Osteoporosis
 * Reduced ankle range of motion

Structured, supervised exercise training has been shown to increase the functional capacity of adult cancer patients and survivors with improvements in their QOL. However, minimal research has been performed with childhood cancers. Any findings for adult cancer patients cannot ensure a child, particularly prepubescent children, would respond in the same manner. This study chose to investigate the effects of a 16-week intra-hospital supervised condition program including both resistance and aerobic training. Also included was a 20-week detraining period on measures of aerobic fitness, muscular strength, functional mobility, ankle range of motion and QOL in children receiving treatment for ALL.

Where is the research from?
The study was conducted at the Children’s Hospital Nino Jesus of Madrid, Department of Onco-Haematology and Bone Marrow Transplantation, Madrid, Spain. Supported by a grant from the fondo de investigacions do Sanitarias (FIS) and from the European University of Madrid and correspondence with Steven J. Fleck, PHD at the Sport Science Department of Colorado College in Colorado Springs, United States of America. Author Steven J. Fleck PhD has taken part in many exercise intervention studies in relation to chronic diseases and published a book in 1987 named Designing Resistance Training Programs.

What kind of research was this?
The research conducted in the article is an observational study on the intervention of exercise on child patients with ALL and the effects posed by a conditioning program and detraining period during treatment.

What did the research involve?
All subjects were patients of the Children’s Hospital Nino Jesus of Madrid, Spain and the study was conducted within the hospital gymnasium designed for the children during treatment against ALL. In order to maintain the health of the subjects they received fortnightly oncologist appointments during the training period for physical evaluation and blood analysis.

Participants/Patients: A preliminary screening of patients was conducted in order to deem the eligibility of the participant for the needs of the study. The following conditions had to be met: Due to ethical and logistical reasons it was not possible to have a control group. This is a weakness within the experimental design. The study consisted of four boys, three girls with a mean age of 5.1 years old. With a small sample size, this makes it difficult to evaluate the results and observe valid effects of an exercise intervention.
 * Undergoing last phase of maintenance therapy against standard-medium risk ALL
 * Time elapsed after start of treatment ranging between 18-24 months
 * 4-7 years of age and within Tanner’s stage 1 of maturation status
 * Having no conditions that could contraindicate vigorous physical activity

Measurements at Pretraining, Posttraining and Detraining: All of the subjects had never participated in a weight training or conditioning program before the study. In order the minimise the influence of a learning effects, all subjects went through a familiarisation period which consisted of a 4-6-week period with two to three sessions per week. All exercise tests were performed under similar environmental conditions and at the same time of day. Heart rate was continuously monitored by a 12-lead ECG during tests. Subjects were asked to eat a normal diet 3hr before test protocols.

Training Intervention: All subjects followed the 16-week training program of three sessions a week. Each session was accompanied by a low intensity warm-up and cool-down of light aerobic exercise and stretching exercises involving major muscle groups. Sessions were split into strength training and aerobic training with both areas focused on involving major muscle groups.

What were the basic results?
Given the small sample size the study chose to use the nonparametric Friedman Test to compare the mean values. The study had an 85% adherence to training with all subjects missing no more than two training sessions in a row. High adherence to training could be due to the parents having the responsibility to enforce the adherence and not the subject themselves.

Both body mass and height increased significantly between pre-training and post-training. Training also improved Vo2 peak, dynamic muscle strength of the upper and lower extremities and functional mobility and doesn’t significantly decrease after 20 weeks of detraining. These findings contradict information discovered in adult cancer patients who had a significant decrease in the detraining phase. As children grow, they experience an increase aerobic fitness without training and explains why detraining effects are insignificant. Justified by the natural growth process seen in children.

Unfortunately, no significant differences were found during the study period for self-reported QOL of children or in the parents’ evaluations of their children’s QOL. This could be due to the fact that the subject’s parents were responsible for adherence. This means that the subjects motivation may not have stemmed from themselves. One study found information that providing physical activities (PA) with an engaging and enjoyable experience lead to child adhering to the PA. If the subjects found the prescribed training more engaging and fun could this have led to more self-motivation for the study and improve their QOL.

What conclusions can we take from this research?
The study suggests that intra-hospital exercise intervention programs for both adult and child cancer patients positively improve physical fitness. However, children do experience less loss during detraining (which could be justified by the natural growth process given further research). No effects on self-reported QOL were found through the duration of the study. Suggestions were made to further investigate ways in order to improve QOL of ALL children. In summary, young children with ALL receiving the last phase of cancer treatment can safely undergo an intra-hospital program and experience positive physical benefits.

Practical advice
A larger sample size is needed in order to validate the significance of the results. In order to improve QOL reported, exercises chosen for the study should be evaluated on the effectiveness to engage and motivate. This would allow the subjects to enjoy their time in the study. In order to build on the significance of intra-hospital exercise interventions for ALL patients, the study should to be conducted in all timeline areas of cancer treatment to understand its full impact. At the time of publication, not many studies have been conducted on this intervention group. With the base knowledge gathered by the study, it can be expanded upon in future studies.

Further information/resources
The following resources provide information regarding the signs, symptoms and treatment of children with leukaemia.
 * https://www.leukaemia.org.au/blood-cancer-information/
 * https://www.cancer.org/cancer/leukemia-in-children/about/what-is-childhood-leukemia.html