PT Classroom - Childhood Cancer and Physical Therapy  ׀ by Alissa Elberts, DPT

Alissa Elberts, DPT, graduated with her Doctor of Physical Therapy degree from Marquette University in May of 2010. She also received her BS degree in exercise science from Marquette University in 2008. Alissa works as a physical therapist with Wheaton Franciscan Healthcare in Racine where she works in the inpatient acute setting and is also a clinical instructor for physical therapy students.


Childhood Cancer and Physical Therapy

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


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.

Terms & Conditions

Please review our terms and conditions carefully before utilization of the Site. The information on this Site is for informational purposes only and should in no way replace a conventional visit to an actual live physical therapist or other healthcare professional. It is recommended that you seek professional and medical advise from your physical therapist or physician prior to any form of self treatment.