APCP Journal Volume 4 Number 2 (2013) 34-39 Physiotherapy Following Haematopoietic Stem Cell Transplant in Children Deborah Rowley MCSP*, Lauren Mellows Sheffield Children s Hospital *Corresponding author s email: Deborah.Rowley@sch.nhs.uk ABSTRACT Haematopoietic stem cell transplant (HSCT) is used in the treatment of children with haematological and nonhaematological malignancies, bone marrow failure conditions and some metabolic disorders with the aim of prolonging life (Bennett-Rees and Hopkins, 2008). Alongside the obvious benefits of this treatment there are well documented adverse effects which have the potential to impact on all aspects of the child s and family s life including exercise, activity and participation. With ongoing pressures to provide evidence-based practice in this tough economic climate, and anecdotal evidence that current physiotherapy input with this client group is often inconsistent, we conducted a literature search and review of current practice. The aim of this search was to review the potential benefits of inpatient and outpatient exercise programmes with this client group to help develop an evidence-based physiotherapy service at Sheffield Children s Hospital. The literature identified was not extensive and of varying quality. Many of the papers were specifically related to the adult population with few studies having been conducted in children. In the literature sourced, specific exercise programmes provided to people undergoing HSCT in both inpatient and outpatient settings were reported to lead to positive and significant changes. These included improvements in muscle strength, endurance, levels of fatigue, and quality of life, amongst others. The literature review identified the need for further research within this specific population. It also indicated that specific inpatient and outpatient physiotherapy programmes for children might lead to a reduction in loss of performance and therefore improved participation. It also highlighted the need for specific outcome measures to demonstrate that the child s and physiotherapist s goals are being met. Background With increasing numbers of childhood cancer survivors due to improving multiple treatment modalities (Bradwell, 2009) and increasing pressure to improve the quality of life for these survivors, it is important to understand the consequences of childhood cancer treatment, and also provide the best possible rehabilitation to this population group. The National Cancer Action Team (2013) discussed the need for rehabilitation to be all encompassing with the potential to help maximise resources ensuring that patients can be as independent as possible. Function (2003). The proposition of exercise as a modality within physiotherapy with the aim of maintaining and improving functioning during and after HSCT has been adopted at Sheffield Children s Hospital for a number of years. The basis behind this was, however, unclear and it was felt that a questionnaire, to canvas current practice in different centres, and a literature search could be used to benchmark, formalise and develop the service to inform clinicians and managers further of the benefits that this service may have the potential to offer. Method The long and short-term adverse effects on physical and psychological functioning of children with cancer and children requiring HSCT have been comprehensively documented in the literature, as well as the widely known effects of prolonged bed rest (Reeves, 2010). These include fatigue, muscle weakness, (Kovalszki et al, 2008) and loss of endurance leading to reduced activity with emotional and psychological distress (Phipps et al, 2002) spanning all elements of the World Health Organisations International Classification of To identify current clinical practice within this population, an email was sent to paediatric centres where HSCT was used as a treatment option. The initial email was sent to 20 physiotherapists regularly involved with the Paediatric Oncology Physiotherapy Group in 2010. A follow-up email was sent approximately 1 month later. The email consisted of an introduction describing what was being reviewed and 4 questions with the aim of determining current physiotherapy practice in the UK. 34
The questions asked were: 1. Does your centre treat children using HSCT? 2. If so, what is the current role of physiotherapy with this client group? 3. Do you have a specific procedure in terms of assessment and treatment? 4. Do you use specific outcome measures as a standard? The literature review was conducted using key search terms identified by the authors - haematopoietic stem transplantation, bone marrow transplantation, stem cell transplantation, physical therapy modalities, physical therapy speciality, physiotherapy, physical therapy, exercise, exercise movement techniques, exercise therapy, muscle performance, muscle function, paediatric physical therapy. Boolean logic was undertaken using the following search engines, CINAHL, MEDLINE, EMBASE and AHMED. Initial inclusion criteria included research articles addressing inpatient or outpatient physiotherapy exercise programmes for children undergoing HSCT. Due to the small number of articles collated this was then expanded to include adult literature. The search was limited to literature published within the last 10 years, from 2002 to August 2012 to ensure that data was up-to-date. The literature also had to be in the English language due to difficulties with interpreting articles. Articles that matched key themes identified to answer the clinical question were then reviewed by both authors to pick out data related to the key themes. These included: type of exercise; whether this was undertaken within inpatient or outpatient setting; outcome measures used; changes recorded. This information was collated and used to create a structured pathway for physiotherapy input with this client group. Results There were 3 out of 20 replies received from the 2 rounds of email sent to physiotherapists in the Paediatric Oncology Physiotherapy Group. All 3 replies noted that: there was no routine or formal assessment provided to this client group; referral was made on an adhoc basis from the medical team involved; no specific outcome measures were being used when therapists were asked to review a child following HSCT; physiotherapy was based on the child s presenting condition and needs and the reason for the referral rather than an anticipatory approach. From the literature search 2 abstracts were identified in the paediatric population that met the inclusion and exclusion criteria. Tiffrassi et al (2010) presented their findings at the 36 th Annual Meeting of the European Group for Blood and Marrow Transplantation in Vienna. They described the implementation of regular supervised sports sessions with children undergoing HSCT whilst in-patients. They reported a positive impact on fatigue syndrome, but the results did not reach significance due to the small sample size, (the exact number was not detailed in the abstract). Chamorro et al (2011) synopsised their findings at the conference a year later. They presented a randomised control trial of 8 children undergoing HSCT. Four of the children were assigned to a moderate exercise group and 4 to a control group. The exercise included an hour of exercise 3 times per week for 10 weeks and involved the use of a gym, the Wii and specific home based exercises. They found that children within the exercise group had more mature natural killer cell phenotypes and an increase in natural killer cell cytotoxicity. There were very small numbers within this group and the significance of these results is not reported. If this was found to be significant it might indicate a reduced risk of infection and reduced risk of relapse within the exercise group. Neither of these abstracts were found as full articles. Due to the minimal amount of paediatric research available it was felt that the available adult literature would also need to be reviewed to give the authors a better understanding of the potential positive effects of exercise within this client group. Seven papers were identified for review and are presented in Appendix 1. Some older research is available as is reported in Wikemann and Huber s paper (2008). These were not considered in our review as they did not meet the inclusion criteria, although they all reported positive outcomes with no negative impacts of exercise with people undergoing HSCT. Discussion There has been very little research done during the last 10 years into exercise in patients receiving HSCT, particularly in the paediatric population. Further searches without a time limit may have produced more positive results and might be useful to conduct in the future. There is little higher level research available and only with small sample sizes in the adult population, demonstrating the need for RCT s with larger samples in both population groups. 35
As a result of the lack of research in the paediatric population, data was extracted from adult based research. The available research does indicate positive outcomes from exercise during both the inpatient and outpatient period in people undergoing HSCT with no negative effects found. With some of the papers indicating this positive change to be significant, it could be thought that exercise in this population has beneficial effects in terms of fatigue management, muscle strength, endurance, and cardiac and respiratory improvements, with improvements in activity levels and health related quality of life spanning all aspects of the World Health Organisations Classification of Function, (2003). As the research was conducted in an adult population, extrapolation to the paediatric setting should be done cautiously and highlights the need for further research in children following HSCT. The research should be considered with care as every paper reviewed reported different types of exercise undertaken, different lengths of exercise sessions and no consistency in whether the sessions were supervised or not. It is therefore impossible to make formulated suggestions on what type of exercise the population should be encouraged to undertake and whether this is biased to cardio-respiratory exercises or strength training. Further RCT s distinguishing between strength and cardio-respiratory training may be useful in targeting exercise sessions further. The authors believe that a combination of approaches and specific patient-led goals formulated following assessment should be considered as a practical approach to exercise sessions. Further exploration of the literature suggests that physical function and fitness in long term survivors of childhood cancer has been well explored (Van Brussel et al, 2006; Berg et al, 2009; Ness et al, 2005) including physical limitations and participation limitations within this population. Although the literature may not specifically target children who have undergone HSCT it can be assumed that children undergoing HSCT due to a diagnosis of cancer may present with these late effects in the future. This provides a further reason to promote activity during treatment with this more specific client group and to monitor outcomes as an outpatient as a preventative measure against future problems. Robertson and Johnson (2002) reviewed the need for physical exercise in children following a diagnosis of childhood cancer with the aim of improving quality of life and long-term outcome. They discussed previous evidence, which reported the physical, neurological and psychological benefits of exercise in both adults and children, and whether exercise prescription as part of the rehabilitation of children with cancer could be achieved within the educational setting. They noted that school staff felt that they had not been given sufficient information on what exercise children who had had a cancer diagnosis could participate in and that clear specific liaison would be beneficial. It should be considered as to whether, firstly, this client group are, or are not, integrated into physical education sessions within school and, secondly, whether clear specific exercise programmes and advice would aid participation of this client group within physical education sessions in school. In addition, Department of Health guidelines on physical activity for children report that, All children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours a day. (DoH, 2011) Within these guidelines it is reported that physical capabilities should also be considered. Children undergoing HSCT often have very limited access to activity as a result of being isolated in a cubicle leading to reduced participation in physical activity. Promoting some physical activity whilst an inpatient along with the physical benefits noted for this specific group promotes and provides opportunities for physical activity as outlined in the DoH guideline. Other information that could be taken into consideration is the potential physical effects of prolonged bed rest on the child undergoing HSCT. When the child is an inpatient in isolation they often spend prolonged periods in bed and there is therefore the potential for general deconditioning. By discussing this potential with the patient and their carers and offering advice on activity and exercise sessions, some of this might be avoided. There is no indication in the literature reviewed as to whether the populations studied had specific goals around activity and participation with the outcome measures used within the study. This may limit the perceived benefits of using exercise as a modality within this client group. If the adult or child has a specific goal that is not met even though their muscle strength, for example, has improved; this rather limits the usefulness of the exercise regime to the client and therefore is less likely to be complied with. Further research into client based goal setting with exercise regimes would be a useful progression of the literature to make it more client focused and clinically relevant within the population. There are limitations with this study. Strict inclusion and exclusion criteria were set due to the staff time available to complete the project, which may have led to some useful articles being excluded. The limited number of research articles with limited sample sizes also means that strong conclusions cannot be drawn 36
on this alone. There may be other useful information that has been mentioned in this discussion, which may indicate the positive effects of physical exercise. The literature review was undertaken to provide an evidence base to formalise and develop the current clinical practice at Sheffield Children s Hospital with patients undergoing HSCT. It was felt that the information gathered was strong enough to structure the physiotherapy input with this client group. Initial assessment of children attending Sheffield Children s Hospital for HSCT now includes: a Quality of Life Questionnaire; muscle strength using the Oxford Scale; active range of movement of the lower limb; and a 6-minute walk test. Following discussion with the patient and their carers, goals are set for their inpatient stay and a 20-30 minute supervised exercise session is completed 5 days a week, depending on wellness. The session is usually supervised by a therapy assistant who informs the physiotherapist if there are concerns or need for re-assessment or progression. The sessions include: use of static peddles; the Wii; ball games; specific strengthening; and stretching. The child is reviewed on discharge from hospital, and at 6 and 12 weeks following discharge where the same outcome measures are repeated. If there are concerns when the child has been discharged further advice and/or treatment sessions are conducted to meet these needs. Children are now invited to attend an annual activity day to reinforce this advice and healthy lifestyle promotion. At this event children can participate in a range of community-based activities, which they may like to pursue in the future. Conclusions There is minimal literature looking specifically at the effects of inpatient and outpatient exercise programmes in children undergoing HSCT. The available literature in adults fused with literature exploring exercise in children, and more specifically in children with cancer, does however indicate only positive impacts of exercise. At Sheffield Children s Hospital, we have therefore introduced a structured pathway for physiotherapy input for children attending for HSCT with the aim of analysing the results in the future. References Baumann FT et al (2010) A controlled randomized study examining the effects of exercise therapy on patients undergoing haematopoietic stem cell transplantation. Bone Marrow Transplantation 45, (2), 355-362. Bennett-Rees N and Hopkins S (2008). Background to the Haematopoietic Stem Cell Transplant HSCT) Procedure. In Cancer in Children and Young People, edited by Faith Gibson and Louise Soanes. John Wiley & Sons, LTD. Berg C, Neufeld P, Harvey J, Downes A, and Hayashi R (2009). Late effects of childhood cancer, participation and quality of life of adolescents. 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