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Noah Biorkman is a five year old from
Michigan who has made many news headlines in 2009. You may ask why.
This young boy was diagnosed with a neuroblastoma in 2007 when he
was just 3 years old. His prognosis looked good for a while until he
relapsed in September 2008. Now, his doctors are saying he may not
make it to Christmas day. His parents however, have decided to
celebrate the winter holiday a little early this year so their young
child gets to have one more Christmas. The young child loves
Christmas cards, so when his mother reached out to others asking for
people to send them, the nation has responded and continues to do
so. Each year more than 11,000 children and adolescents in the US
are diagnosed with some form of cancer (1). Cancer is more active in
children than in adults, with 80% of children with cancer having
metastasis. The current trend shows that while the incidence of
childhood cancer is increasing, mortality rates continue to
decrease (2). With technology continuing to improve, many parents and
children no longer have to live with the worry, fear, and sadness
that the Biorkman family has each day. It is estimated that 1 in 570
adults 20 to 34 years old is actually a survivor of childhood
cancer.
The most common childhood cancer in any and all developed countries
is acute lymphoblastic leukemia (ALL) (3). It is a malignant
proliferation of the white blood cells that begins in the bone
marrow and spills over into the circulation, resulting in the
involvement of many organs in the process (4). It results in anemia,
susceptibility to infection, and bruising. ALL occurs in 3-4 of
100,0000 children each year. Some of the generally accepted risk
factors for developing this cancer include white males ages 2-5 with
a high socioeconomic status, those that had an in utero x-ray
exposure, postnatal radiation, previous diagnosis of down syndrome,
bloom syndrome, or schwachman syndrome, neurofibromatosis type 1,
and ataxia-telangiectasis. Some suggestive factors for increased
risk include increased birth weight and maternal history of fetal
loss. There is limited evidence for those such as parental smoking
and postnatal infections, although they have been suggested.
Ultrasound and indoor radon are probably not associated with ALL (3).
The current treatment for children with ALL is an intense bout of
chemotherapy (4). Because the current treatment affects the central
nervous system (CNS), often time young children have difficulties
that arise with their balance (5). Also things such as decreased
muscle strength and range of motion (ROM) due to prolonged bed rest
can play a part in a balance deficit. Wright et al (5) conducted a
study to compare balance proficiency in children and youth who had
ALL in childhood with a group without disease. They also
investigated whether balance was associated with self-perceptions of
physical activity and health-related quality of life. The study
found that balance was in fact lower for the ALL group using the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) test
(5).
As physical therapists, we can strive to increase these balance
deficits found. Another study by Wright et al[4] determined that the
most obvious impairment was the limitation of active and passive
dorsiflexion. This is extremely important to consider, as it is a
vital part of ambulation. The most predictive factors here included
female gender and a younger age at diagnosis (4). Preventative steps
to maintain ROM and strength can be taken while the child is still
in the hospital. For example, bedside PT may be appropriate with
very gentle ROM techniques. Also, we can educate the family as to
what they can be doing with the child as well. Wright et al (4)
actually found that education and physical therapy intervention did
in fact improve children’s’ function. Strength, gait, and balance
training become very important when considering goals for the
children.
Osteoporosis is an issue for many children who are undergoing
treatment for ALL. According to White et al (6), some studies have
even found that these children already have decreased bone mineral
density (BMD) at the time of diagnosis before treatment has even
begun. It has been hypothesized by some that the disease process of
ALL itself is what causes the decrease in BMD. Another is that the
treatment of chemotherapy for ALL includes glucocorticoids and even
sometimes “methotrexate combined with steroids (6).” Physical
activity may help decrease, or slow down the loss of BMD in these
children with ALL (6). Physical therapists may be the only ones to
truly get these children up and moving. Parents may try to do
everything for the children as a way to protect them and keep them
from having any more increase in pain. This may mean they carry them
to the bathroom or up the stairs, and it can lead to a great
decrease in the actual weight bearing movements of the children. It
is important for physical therapists to stress the importance of
some physical activity in order to decrease the risk for early
osteoporosis.
Children withstand bumps and bruises often experiencing pain daily.
However, many patients with cancer, no matter the age have increased
levels of pain (7). This may come from the tumor itself or from side
effects of the treatment. So, how do we measure the level,
especially when the child has a life-threatening diagnosis?
O’Rourke (8) listed out many of the currently accepted and selected
measurement tools for pediatric pain management. The update listed
out the reliability, validity, and responsiveness as well. For pain
intensity, the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)
was found to be the best for children one to seven years old, the
Faces Pain Scale (FPS) for children four years and older, and the
neonatal facial coding system (NFCS) for preterm and full-term
infants. For pain location, intensity, and quality, the McGill Pain
Questionnaire was found to be the best, but it is intended for those
ages twelve and older. Therefore, health care providers can only
estimate and guess where in fact the pain is and its intensity in
younger children by the responsiveness of the child.
Gilchrist et al (7) suggests that the assessment of pain in the
person with cancer must be multifactoral. The perspective suggests
that mental functions, sensory functions and pain,
neuromusculoskeltal and movement-related functions and structures,
and functions of the cardiovascular, hematologic, immunologic and
respiratory systems must all be evaluated and appropriately
addressed (7). Many times, the tests to fully address all of the
aforementioned are performed by the physician, but the results can
help lead physical therapists to the most effective treatment
strategies and plan of care (7). Also, intense and all encompassing
screening by the PT can also lead to a referral back to the
physician if a “red flag” is seen that was missed by the physician
or has recently developed.
Last revised: February 5, 2012
by Alissa Elberts, DPT
References
1. Tecklin, J.S., Pediatric Physical Therapy. 2008, Baltimore, MD;
Philadelphia, PA: Lippincott Williams & Wilkins.
2. Long, T., Toscano, K., Handbook of Pediatric Physical Therapy. 2001,
Baltimore, MD; Philadelphia, PA: Lippincott Williams & Wilkins.
3. Bleyer, W.A., Barr, R.D., Cancer in Adolescents and Young Adults. 2007,
New York: Springer Berlin Heidelberg.
4. Wright, M.J., Hanna, S.E., Halton, J.M., Barr, R.D., Maintenance of Ankle
Range of Motion in Children Treated for Acute Lyphoblastic Leukemia.
Pediatric Physical Therapy, 2003. 15: p. 146-152.
5. Wright, M.J., Galea, V., Barr, R.D., Proficiency of Balance in Children
and Yourth Who Have Had Acute Lymphoblastic Leukemia. Physical Therapy 2005.
85: p. 782-790.
6. White, J., Flohr, J.A., Winter, S.S., Vener, J., Feinauer, L.R., Ransdell,
L.B., Potential benefits of physical activity for children with acute
lymphoblastic leukaemia. Pediatric Rehabilitation, 2005. 8(1): p. 53-58.
7. Gilchrist, L.S., Galantino, M., Wampler, M., Marchese, V.G., Morris, G.S.,
Ness, K.K., A Framework for Assessmetn in Oncology Rehabilitation. Physical
Therapy, 2009. 89(3): p. 286-306.
8. O'Rourke, D., The Measurement of Pain in Infants, Children, and
Adolsescents: From Policy to Practice. Physical Therapy, 2004. 84(6): p.
560-570.
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