The Role of
Physical Therapy
in Pediatric Oncology
Your Name and Credentials
Your Institution
Tracking Utilization
• To track utilization of this resource, please email the Pediatric
Oncology SIG chairs with the final version of your presentation. Any
feedback is also welcome!
• Susan Miale (susan.miale@stonybrook.edu)
• Kristin Brown (kbrown8@lifespan.org)
Instructions for Use
• This presentation is meant to be used as a TEMPLATE that can be
personalized for each practice setting and/or clinic site.
• This is a starting point for education to other medical professionals.
Expand and adapt to the target audience as appropriate to provide
the best possible information.
• Suggestions for personalization are HIGHLIGHTED IN RED and
have been provided for:
• areas of focus
• places to add to slides
• places to add other bullet points
Objectives
At the conclusion of this activity, the participant will be able to:
• Identify the side effects of cancer and cancer treatment that
necessitate physical therapy (PT) in the developing child
• Demonstrate knowledge of typical motor development
• Recognize the role of PT for children with oncological diseases
• Discuss how to effectively screen patients to determine the need for
PT services
• Recognize the benefits of collaboration with the medical team to
optimize rehabilitation outcomes
• ADD ADDITIONAL OBJECTIVES AS NECESSARY
Why should Physical Therapists be involved?
**See Notes section**
• Health status of adult survivors compared to siblings
General Health
OR 2.5
Functional
Impairment
OR 5.7
Mental
Health
OR 1.8
Activity Limitations
OR 2.7
Hudson et al. 2003
The Role of PT in Pediatric Oncology
• Disease and treatment occur during a critical point of development in
pediatric cancer
• Children have not yet acquired mature posture, gait, motor skills, cognitive
skills, social skills, etc.
• The process can alter the course of development
• Early screening and PT intervention is crucial to minimize long term
impairments / activity limitations for children with cancer
Provide Case Study (EXAMPLE)
• Based on your patient population (i.e. neuro, hem-onc, ortho, etc.)
• Focus on long-term outcomes
Side Effects of Cancer Treatment
Related to Physical Therapy
Cancer Treatment Side Effects Influencing PT
• Chemo-Induced Peripheral Neuropathy (CIPN)
• Steroid Myopathy
• CNS Effects
• Cardiac Effects / Decreased Endurance
• Fatigue
• Edema
• Avascular Necrosis (AVN)
• Orthopedic Procedures
Silver & Gilchrist 2011
Neuropathy in Pediatric Cancer Patients
• 83% of children treated with vincristine for non-CNS cancers have
ped-mTNS Score > 4
• Clinical Testing Deficits:
•
•
•
•
•
Light Touch 44%
Pin Sensation 46%
Vibration Sensation 37%
Strength 98%
Deep Tendon Reflexes 100%
• Higher scores on ped-mTNS associated with balance and manual
dexterity deficits
Gilchrist & Tanner 2013
Cardiotoxicity
• Patients treated by anthracyclines or mediastinal/neck radiation are
at risk for cardiotoxicity
(Shankar 2008)
• Early evidence shows that exercise may be beneficial prior to, during,
and post anthracycline treatment
(Jensen et al. 2013, Scott et al. 2013)
• Combination of strength training and aerobic training is beneficial in
patients with chronic heart failure
• Both are important to consider when treating patients at risk for
cardiotoxicity
Bartlo et al. 2007
Expand on Side Effects
• Put additional slides here to expand on side effects as they relate to
your primary patient population (i.e. SCT/BMT, ortho, neuro, etc.)
Common Impairments in
Children with Cancer
• Loss of ROM
• Pain
• Posture dysfunction
• Gait disturbances
• Muscle weakness
• Sensory impairments
• Balance impairments
• Motor skills impairments
• Poor endurance
• Expand or be concise depending on time of presentation
(**See NOTES section)
Activity and Participation Limitations
• Impairments can lead to restrictions in the following activities:
•
•
•
•
•
•
Activities of Daily Living (ADLs) – dressing, eating, etc.
School
Participation with peers and siblings
Sports
Age-Appropriate Play
Family and community outings
Role of PT Intervention
• Recently published systematic review of exercise interventions in
children with cancer
• Most studies involve supervised hospital-based exercise programs
and home-based activity programs
• Improvements demonstrated in:
•
•
•
•
Cardiopulmonary endurance
Strength
Fatigue
Physical function
Huang & Ness 2011
ADD CASE EXAMPLES
Screening for PT Services
Questions to Ask
Skills to Demonstrate
Screening Interview
• Has your child had any difficulty keeping up with his or her siblings or
peers?
• Has your child had any pain in the last 2 weeks?
• Can you child participate in all activities at school or at home that
they could participate in prior to diagnosis?
• Examples: playground, coloring/writing, physical education classes
Screening Physical Examination
**See NOTES section
• Range of Motion (ROM)
• Ankle dorsiflexion if being treated with vincristine
• Strength
• Floor to stand transfer (use of hands)
• Gait
• Ask if gait changes with fatigue
• Balance
• Single leg stance
• Motor Skills
• Jumping, hopping
Typical Motor Development
**See NOTES section
Typical Motor Skills (Campbell et al. 2012)
Age (yrs)
Gross Motor
Fine Motor
1
Walking,
Crawl up stairs
Picking up cheerio (pincer grasp);
Banging toys together
2
Squat to stand, early Running,
Jumping, Walks up/down stairs with rail,
Kicks ball, Throw/catch
Colors with whole-hand grasp;
Uses spoon
Undressing self
3
Heel-toe gait, Running,
Stairs with/without rail- step over step going
up, One leg balance 3 sec,
Riding a tricycle
Tripod grasp; imitating scribbles;
Puts on pants, socks, shoes;
buttons difficult
4
Hopping, Galloping, Catching using only
hands; step-over-step down stairs, Climb on
play structures
Drawing circle/square
Using scissors; button/un-button
large buttons; zippers
5
Skipping, jumping jacks, Riding a bike, Long
jump, Jump rope, Climb
Copies triangle; cuts shapes;
Draws person/letters
Typical Motor Skills
Age
Gross Motor
Fine Motor
6-10 years
Hopping side to side
Jump rope
Single leg stance 5-10 sec eyes
closed
Participates in youth sports
Write during school day without
hand fatigue
10-21 years
Mile run
20 single leg calf raises
Completes Presidential Fitness
testing
Involved in sports teams, weight
training, etc.
Complete all daily tasks without
hand fatigue
Recommended Activity Levels
• Age 1 – 3 years
• 30 minutes planned activity, 60 minutes unstructured activity / day
• Age 3 – 5 years
• 60 minutes planned activity, 60 minutes unstructured activity / day
• Age 6 – 17 years
• 60 minutes/day of moderate/vigorous physical activity
• Can add small increments to total 60 minutes
• Can include aerobic, strength, bone-building activities
• On a scale of 0-10, a 5-6 is moderate, a 7-8 is vigorous
http://kidshealth.org/parent/nutrition_fit/fitness/exercise.html#
http://www.cdc.gov/physicalactivity/everyone/guidelines/children.html
Referrals to Rehabilitation
Rehabilitation Service Referral?
• Consider the following when deciding on
rehabilitation service referral:
•
•
•
•
Age of child
Severity of deficits
Duration of deficits and time in treatment
Family readiness
• Mild deficits that last longer than 2 – 4 weeks are worth a referral as
they may delay acquisition of new motor skills in the future
• Example: Decreased running speed will cause a child to be discouraged in
participating in recreational activities with peers, possibly leading to
sedentary lifestyle, obesity and social isolation.
Referrals
• Physical Therapy
• Deficits in ROM, balance, strength, gross motor skills, endurance
• Occupational Therapy
• Deficits in fine motor skills, regression in ADLs (dressing, bathing, etc.),
feeding issues, cognitive issues
• Speech Language Pathology
• Articulation, language reception, cognitive, feeding issues
How and When to Refer
• **Provide specific information for your site.**
Team Approach
• Collaboration and communication is critical
• It is important for all team members to communicate the role of PT
to the child and family
• Ask questions about current exercise level
• Encourage exercise and PT
• Regular communication between PT and medical team regarding
safety of and response to exercise
• Lab values, precautions/contraindications, cardiac status,
adverse effects of exercise
• Opportunities for future research collaboration (site specific)
Summary
• Children and adolescents with cancer often have a high rehabilitation
potential.
• A team approach is necessary to optimize rehabilitation outcomes
and family compliance.
• Exercise can be worked into the daily routine of a child so as not to
overwhelm a family that is already stressed.
• ADD HERE!
References
• Bartlo P. Evidence-based application of aerobic and resistance training in
patients with congestive heart failure. J Cardiopulm Rehabil Prev.
2007;27(6):368-375.
• Campbell S, Palisano RJ, Orlin MN, eds. Physical Therapy for Children, 4th Edition.
St. Louis, MO: Elsevier Saunders, 2012.
• Centers for Disease Control and Prevention. Physical Activity for Everyone:
Guidelines: Children. 9 Nov 2011. Available at
http://www.ckc.gov/physicalactivity/everyone/guidelines/children/html.
Accessed January 1, 2014.
• Gilchrist LS, Tanner L. The pediatric-modified total neuropathy score: a reliable
and valid measure of chemotherapy-induced peripheral neuropathy in children
with non-CNS cancers. Support Care Cancer. 2013;21(3):847-856.
• Huang TT, Ness KK. Exercise interventions in children with cancer: a review. Int J
Pediatr. 2011;2011:461512.
• Hudson MM, Mertens A, Yasui Y, et al. Health status of adult long-term survivors
of childhood cancer. JAMA. 2003;290:1583-1592.
• Jensen BT, Lien CY, Hydock DS, Schneider CM, Hayward R. Exercise mitigates
cardiac doxorubicin accumulation and preserves function in the rat. J Cardiovasc
Pharmacol. 2013;62(3):263-269.
References
• Ness KK, Leisenring WM, Huang S, et al. Predictors of inactive lifestyle
among adult survivors of childhood cancer: a report from the childhood
cancer survivor study. Cancer. 2009;115(9):1984-1994.
• Scott JM, Lokoski S, Mackey JR, et al. The potential role of aerobic exercise
to modulate cardiotoxicity of molecularly targeted cancer therapeutics.
Oncologist. 2013;18(2):221-231.
• Shankar SM, Marina N, Hudson MM, et al. Monitoring for cardiovascular
disease in survivors of childhood cancer: report from Cardiovascular Disease
Task Force of the Children’s Oncology Group. Pediatrics. 2008
Feb;121(2):e387-396.
• Silver JK, Gilchrist LS. Cancer rehabilitation with a focus on evidence-based
outpatient physical and occupational therapy interventions. Am J Phys Med
Rehabil. 2011;90(Suppl 1):S5-15.
• The Nemours Foundation. Kids Health: Nutrition and Fitness Center.
Available at
http://kidshealth.org/parent/centers/fitness_nutrition_center.html.
Accessed January 1, 2014.
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Your Department
Your Contact Information
Thank you.