# Exercise as it relates to Disease/The effects of cancer at the end of the acute treatment phase has on motor performance

The following article is a critique and analysis of the paper: Motor performance in children and adolescents with cancer at the end of the acute treatment phase. Miriam Götte, Sabine V. Kesting, Corinna C. Winter, Dieter Rosenbaum & Joachim Boos

## What is the background to this research?

Childhood cancer is the leading cause of disease-related death among 1 to 19 year old’s in the United States, with survival rates varying across various cancer types.Childhood Cancer and Treatment Effects on Motor Performance Many studies have found that childhood cancer has a significant impairment to the motor performance at the end of acute paediatric cancer treatment regarding motor mobility test. This is because the treatments they are receiving can damage healthy cells and keep them from developing normally. The chemotherapy is responsible for survival can produce long-term health-related outcomes that can occur months or even years after completing their cancer treatment. It’s said the long-term health-related outcomes can contribute to 60-90% of chronic health conditions developed from childhood cancer and its treatment. Motor abilities have been proven to be essential for daily life activities of children and adolescents and should therefore be trained individually during and after their treatment. As children's main motor skills are coordination, flexibility, speed, and strength, deficits often occur in cancer patients. They can potentially lead to impaired general mobility and problems coping with daily tasks.

## Where is the research from?

The authors in this article work in various departments at the University Hospital of Munster, Germany. Three authors worked in the Department of Paediatric Hematology and Oncology, from which this study was conducted. The other three authors worked in the Movement Analysis Lab, Institute for Experimental Musculoskeletal Medicine, at the same hospital in Germany. This study was funded by the Cora-Lobscheid Foundation and was communicated by David Nadal.

## What kind of research was this?

This was a single-center study that was conducted between November 2011 and September 2013. These types of studies are usually set up in a particular hospital, clinic, or general practice. They are generally small-scaled studies and are cheaper, which are easier to obtain funding for. They also provide the flexibility of approach if it's necessary for clinicians and scientists to develop new treatments. For these studies to happen, physicians should apply the findings of these trials after carefully evaluating their methodology, particularly after comparing the context of the trial with their own situation.

## What did the research involve?

The study involved oncological treatments with regular in-patient stays and ages between 6 and 17 years. The criteria exclude those unable to understand German and those who have a severe intellectual disability. Patients that gave consent to participate in the study were asked to participate at the end of their treatment, which is said to be ±2 weeks as close in time to their last in-patient cycle of chemotherapy of intensive treatment.
The MOON test was used to assess the motor performance as it has previously been proven feasible for various cancer patients. This includes bone tumor patients, orthopedic restrictions like amputations or endoprosthetic replacements, and reduced general condition and mobility limited by crutches and infusion stands.

##### MOON test consists of eight subtests:

* Inserting pins (measures hand-eye coordination under time pressure)
* Static stand (measures static balance/whole body posture on a wooden bar)
* Reaction test (measures speed/reaction time on optical stimuli)
* Throwing at a target (measures coordination with the precision of the upper extremity)
* Stand and reach (measures the flexibility of ischiocrural musculature and spinal erectors)
* Medicine ball shot (measures muscular explosive strength of the upper extremity)
* Sit-to-stand (measures muscular endurance of legs)
* Hand-held dynamometry (measures isometric maximum handgrip strength)
The overall duration of this test is approximately 20min, age and gender-matched reference values are available for 6 to 17-year-olds. The test items for upper extremity coordination are only limited to patients between 6 and 11 years old. This is due to the availability of reference values in the test.

## What were the basic results?

These were the mean results in all eight exercises of the MOON test, which unsurprisingly fell below the age and gender-matched reference values. Impairments were seen in 50 to 91% of the study participants, depending on the test item. There were significant reductions in motor performance identified for hand-eye coordination, flexibility, muscular explosive strength, handgrip strength, static balance, speed, and muscular endurance of the legs.
Table of results :
| Motor ability | Test item | No. | Absolute value | Percentage Value | P Value | No. of study participants scoring below reference value |
| Hand-eye coordination | Inserting pins | 47 | +6.1±7.4 s | −13.7 ± 15.5 | <0.001 | 87% |
| Static balance | Statics stand | 44 | +5.4±8.9 contacts | - | 0.003 | 55% |
| Speed | Reaction test | 47 | +0.008 ± 0.03 s | −3.6 ± 10.9 | 0.012 | 57% |
| Coordination of the upper extremity | Throwing at a target | 16 | −2.0±6.5 points | −19.6 ± 50.4 | 0.172 | 50% |
| Flexibility | Stand and reach | 46 | −14.6±10.8 cm | - | <0.001 | 89% |
| Muscular explosive strength | Medicine ball shot | 33 | −1.6±1.5 m | −27.4 ± 22.1 | <0.001 | 85% |
| Muscular endurance of the leg | Sit-to-stand | 42 | +1.2±2.7 s | −13.3 ± 31.3 | 0.035 | 60% |
| Handgrip strength | Hand-held dynamometry (kg) | | | | | |
| | Right | 45 | −8.0±8.0 kg | −33.6 ± 25.9 | <0.001 | 91% |
| | Left | 46 | −5.9±7.1 kg | −30.2 ± 27.0 | <0.001 | 89% |
In some of the patients, single motor test exercises had to be skipped. The static balance was taken out in three patients who were at a high risk of falls. The flexibility test wasn’t assessable in one of the patients who couldn't stand on the wooden device for testing. Muscular endurance of legs test could not be determined in one patient who wasn't permitted to do knee bends and in four patients who were not able to lift from a 90 degree sitting position and was therefore too weak to participate in that test.

## What conclusions can we take from this research?

Studies have shown that even basic exercises during cancer treatment can significantly improve the patient’s attitude to increase their motor performance, which in turn will have a positive effect on their cognitive health. This is because motor skills play a vital role in carrying out daily tasks such as carrying a backpack, being social with friends, and participating in sporting activities. The test's conclusions indicated that early child-oriented exercise interventions during cancer treatment are essential to improve motor performance. Though it remains unclear if the physical activity during the treatment has led to superior results in two of the tests, if others have been keeping "active," or if some patients have just experienced fewer physical side effects of the treatments.

## Practical advice

Many factors should be considered to improve one’s motor performance at the end of cancer treatment. Further research should be conducted with a larger cohort to conclude more confidently the factors associated with coordination of the upper extremities and muscular explosive strength. Additionally, a longer intervention duration at the end of treatment would increase the likelihood of achieving a better outcome.

## Further information/resources

Childhood Cancer and Treatment Effects on Motor Performance
Motor Performance in Children Diagnosed with Cancer: A Longitudinal Observational Study
MOTOR PERFORMANCE FOLLOWING CHEMOTHERAPY FOR CHILDHOOD CANCER

## References

* ↑ PETERSON, J. and DARLING, T., 2018. Childhood Cancer and Treatment Effects on Motor Performance. [online] Digitalcommons.wku.edu. Available at: <https://digitalcommons.wku.edu/cgi/viewcontent.cgi?article=2222&context=ijes> [Accessed 10 September 2021].
* 1 2 Armstrong GT, Liu Q, Yasui Y, Neglia JP, Leisenring W, Robinson LL, Mertens AC. Late mortality, among 5- year survivors of childhood cancer: A summary from the childhood cancer survivor study. American Society of Clinical Oncology 27(14): 2328-2338, 2009.
* ↑ Geenen M M, Cardous-Ubbink M C, Kremer L C, van den Bos C, van der Pal H J, Heinen R C, ... van Leeuwen F E. Medical assessment of adverse health outcomes in long-term survivors of childhood cancer. Jama 297(24): 2705-2715, 2007.
* ↑ Hudson MM, Mertens AC, Yasui Y, Hobbie W, Chen H, Gurney JG. Health status of adult long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Jama 290(12): 1583-1592. 2003.
* 1 2 3 4 5 6 Miriam Götte, Sabine V. Kesting, Corinna C. Winter, Dieter Rosenbaum & Joachim Boos . Motor performance in children and adolescents with cancer at the end of the acute treatment phase. https://link.springer.com/content/pdf/10.1007/s00431-014-2460-x.pdf (accessed 18 August 2021 ).
* ↑ Rinaldo Bellomo, Stephen J Warrillow, Michael C Reade. Why we should be wary of single-center trials. https://pubmed.ncbi.nlm.nih.gov/19789447/ (accessed 8 September 2021).
* ↑ Götte M, Kesting S, Winter C, Rosenbaum D, Boos J (2014) Comparison of self-reported physical activity in children and adolescents before and during cancer treatment. Pediatr Blood Cancer 61:1023–1028. doi:10.1002/pbc.24898
* 1 2 3 Götte M, Kesting S, Albrecht C, Worth A, Bös K, Boos J (2013) MOON-test—determination of motor performance in the pediatric oncology. Klin Padiatr 225(3):133–137. doi:10.1055/s-0033-1343411
* ↑ Baumann FT, Bloch W, Beulertz J (2013) Clinical exercise interven- tions in pediatric oncology: a systematic review. Pediatr Res 74:366– 374. doi:10.1038/pr.2013.123