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Physical activity during treatment in children with leukemia: A pilot study

Article  in  Applied Physiology Nutrition and Metabolism · August 2006

DOI: 10.1139/h06-014 · Source: PubMed

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 407

Physical activity during treatment in children with

leukemia: a pilot study
Susana Aznar, Anthony L. Webster, Alejandro F. San Juan, Carolina Chamorro-
Viña, José L. Maté-Muñoz, Susana Moral, Margarita Pérez, Javier Garcı́a-Castro,
Manuel Ramı́rez, Luis Madero, and Alejandro Lucia

Abstract: The purpose of this pilot study was to measure physical activity (PA) levels in children undergoing treatment
for acute lymphoblastic leukemia (ALL) and to compare the results with those from age-matched healthy children. We
used the MTI Actigraph accelerometer to determine PA (during a 1 week period) in children (n = 7; age = 4–7 y) under-
going maintenance treatment for ALL and in age-matched controls (n = 7). The number of children accumulating at least
60 min of moderate-to-vigorous physical activity (MVPA) for 5 or more days of the week was 3 for the control group,
whereas no children with ALL met this criterion. Significantly lower levels of total weekly time of MVPA were seen in
children being treated for ALL (328 ± 107 min) than in controls (506 ± 175 min) (p < 0.05). When weekday data was an-
alyzed, the ALL patients also had significantly lower mean daily times of MVPA (49 ± 23 min vs. 79 ± 25 min). It is
thus important that young ALL sufferers are encouraged to participate in appropriate sports, games, and physical activities
both in the family and school environments that will prime them with positive attitudes to PA during the critical early
years of life.
Key words: exercise, quality of life, cancer, disease.
Résumé : Cette étude pilote se propose de mesurer le niveau d’activité physique d’enfants traités pour la leucémie aiguë
lymphoblastique (ALL) et de comparer ces observations à celles d’enfants en santé du même âge. Pour obtenir cette me-
sure, nous avons demandé à sept enfants sous traitement âgés de 4 à 7 ans et à sept autres (groupe témoin) du même âge
de porter pendant 7 jours un accéléromètre de marque Actigraph MTI. Trois enfants du groupe témoin pratiquèrent au
moins 60 min d’activité physique qualifiée de modérée à vigoureuse (MVPA), en 5 jours ou plus comparativement à aucun
dans le groupe ALL. Les enfants traités pour l’ALL ont accumulé significativement moins de temps de MVPA en une se-
maine (328 ± 107 min) que les enfants du groupe témoin (506 ± 175 min) (p < 0,05). Les enfants traités pour l’ALL ont
également consacré significativement moins de temps de MVPA du lundi au vendredi (49 ± 23 min) que les enfants du
groupe témoin (79 ± 25 min). Il importe d’encourager tous les enfants aux prises avec l’ALL à pratiquer, en tenant compte
de leur condition, de l’activité physique, du sport et à jouer à des jeux tant à la maison qu’à l’école afin de développer
une attitude positive envers l’activité physique à un moment critique de leur vie.
Mots clés : activité physique, qualité de la vie, cancer, maladie.
[Traduit par la Rédaction]

Introduction drome (MetS) (Oeffinger et al. 2001; Ventham and Reilly

Improvements in combination therapies have contributed
to high success rates in the treatment of acute lymphoblastic
leukemia (ALL) (Lucia et al. 2005). Unfortunately, this may
directly impact future quality of life through various mecha-
nisms including anthracycline-induced cardiotoxicity, sarco-
penia, or osteopenia (Lucia et al. 2005; van Brussel et al.
2005). Another potential consequence of childhood leukemia
therapy is increased risk of obesity and the associated spec-
trum of diseases known collectively as the metabolic syn-
1999). Although the increased prevalence of obesity in sur-
vivors of ALL is likely multifactorial, a major contributor is
reduced total energy expenditure as a result of physical inac-
tivity (Oeffinger et al. 2001; Reilly et al. 1998; Ventham
and Reilly 1999; White et al. 2005).
Current physical activity (PA) guidelines state that
healthy children should be accumulating at least 1 h but up
to several hours of moderate-to-vigorous PA (MVPA) on all
or most days of the week (Cavill et al. 2001). Unfortunately,

Received 6 September 2005. Accepted 17 January 2006. Published on the NRC Research Press Web site at http://apnm.nrc.ca on 19 July
2006.
S. Aznar. Faculty of Sports Sciences, University of Castilla-La Mancha, Spain, and European University of Madrid, 28670 Madrid,
Spain.
A.L. Webster, A.F. San Juan, C. Chamorro-Viña, J.L. Maté-Muñoz, S. Moral, M. Pérez, and A. Lucia.1 European University of
Madrid, 28670 Madrid, Spain.
J. Garcı́a-Castro, M. Ramı́rez, and L. Madero. Department of Haematology and Bone Marrow Transplantation, Children’s Hospital
Niño Jesús, Madrid, Spain.
1Corresponding author (e-mail: alejandro.lucia@uem.es).

Appl. Physiol. Nutr. Metab. 31: 407–413 (2006) doi:10.1139/H06-014 # 2006 NRC Canada
408 Appl. Physiol. Nutr. Metab. Vol. 31, 2006

many children fail to reach this level, which is a major con- Table 1. Clinical characteristics of the children with acute lym-
tributory factor to the current youth obesity epidemic in de- phoblastic leukemia (ALL).
veloped countries (Troiano and Flegal 1998). There is a
Time (mos)
critical need to target sedentary youth early in life. Child-
since start of
hood ALL patients and survivors appear to be at particular Subject Sex Age treatment Risk factor
risk of sedentarism and stand to gain greatly from PA ther-
apy (White et al. 2005). A M 6 y, 7 mos 24 Medium
B M 5 y, 9 mos 24 Standard
Four studies (Mayer et al. 2000; Reilly et al. 1998; Till-
C M 7 y, 4 mos 22 Medium
mann et al. 2002; Warner et al. 1998) have investigated PA
D F 4 y, 7 mos 21 Standard
levels in childhood ALL survivors, usually several years
E F 4 y, 4 mos 20 Standard
after therapy. Each concluded that ALL survivors were less
F M 5 y, 5 mos 18 Medium
active than appropriate age-matched controls. The reasons
G F 6 y, 3 mos 24 Standard
for lower PA levels in ALL survivors are not clear. Two ba-
sic schools of thought have emerged in the literature to ex- Note: M, male (boy); F, female (girl); mos, months.
plain this phenomenon, one being physiological in nature
and the other more socio-environmental in nature (Braith parents and the study was approved by the local Human
2005). The first postulates that survivors of ALL are less Investigations Committee. A preliminary screening for sub-
active owing to adverse consequences of therapy such as ject selection was performed in the database of the Onco-
anthracycline-induced cardiotoxicity, impaired pulmonary Hematology Department at Hospital Universitario Niño
function, sarcopenia, osteopenia, and general fatigue. The Jesús (Madrid, Spain). A total of 26 medical records of
second school of thought argues that childhood cancer sur- children treated for ALL were selected. After the corre-
vivors are subject to an insidious ‘‘spectrum of disuse’’ as sponding oncologist provided consent, subjects were in-
a result of an overly cautious approach towards PA by cluded in the study if they met each of the following
concerned parents, physicians, and schoolteachers (Matthys criteria: (i) they were undergoing the last phase of mainte-
et al. 1993; McKenzie et al. 2000; Warner et al. 1998). nance therapy against standard–medium risk ALL follow-
This excessively protective approach leads to a sedentary ing the ALL-BFM 95 protocol (Dworzak et al. 2002)
life style with resulting obesity, skeletal muscle atrophy, (time elapsed after start of treatment ranged between 18
and risk of MetS (Braith 2005). and 24 months), (ii) they were 4–7 years of age and within
Only one study (Tillmann et al. 2002) has employed ac- Tanner’s stage I of maturation, (iii) they had no condition
celerometry to assess PA in ALL survivors. Accelerometry that could contraindicate vigorous PA, such as severe anae-
provides a valid and objective record of PA in children mia (haemoglobin < 8 g
dL–1), fever > 38 8C, severe ca-
(Fairweather et al. 1999; Janz 1994; Puyau et al. 2004; chexia (loss of > 35% premorbid mass), platelet count lower
Welk et al. 2004) partitioned into various intensities, ranging than 50  109
mL–1, neutrophil count £ 0.5  109
mL–1, or
from sedentary behaviour to vigorous PA (Treuth et al. anthracycline-induced cardiotoxicity (Lucia et al. 2005), and
2004). No study has yet used accelerometry to investigate (iv) were currently living in Madrid (Spain).
PA levels in children undergoing treatment for ALL. Such Seven children (4 boys, 3 girls) met all of the aforemen-
data would add valuable information to the existing litera- tioned eligibility criteria and were included in the study
ture, and would allow practitioners to prescribe exercise (Table 1). The maintenance therapy consisted of daily mer-
more effectively for this population. captopurine (50 mg
m–2
d–1) and weekly methotrexate
The purpose of this pilot study was to measure PA levels (20 mg
m–2
week–1) (ALL-BFM 95 protocol) (Dworzak et
in children undergoing maintenance treatment for ALL and al. 2002). None of them were receiving physical therapy or
to compare these results with those from age-matched, were enrolled in any type of rehabilitation program.
healthy controls. We used the MTI Actigraph accelerometer Although 20 potential control children initially entered the
(Manufacturing Technology Inc., model 7164, Shalimar, study, a group of only 7 age-matched, non-athletic, healthy
Fla.), which has the highest reliability among the more children (4 boys, 3 girls; mean (SD) age: 5.6 ± 1.3 y (range:
commonly used accelerometers (Welk et al. 2004). A secon- 4–7 y)) within Tanner’s stage I of maturation were finally
dary purpose was to assess functional capacity of children selected as study controls, i.e., those children in whom we
with ALL (through determination of peak oxygen uptake were able to record complete PA data over the entire week
(VO2 peak) and ventilatory threshold (VT)) in comparison (with no lost data, as explained below). All subjects lived
with controls. This would allow us to determine if the with their parents in Madrid and had a socioeconomic status
functional capacity of ALL patients is high enough to al- similar to the ALL group.
low them to perform vigorous PA. We hypothesized that The anthropometric characteristics of all subjects (height,
young children undergoing treatment for ALL would have mass, body mass index (BMI), and subscapular and triceps
reduced PA levels compared with controls, despite the fact skinfolds (obtained in triplicate for each subject using stand-
that their functional capacity is high enough to allow them ard equipment (Holtain, Crymych, UK)) were also recorded.
to perform vigorous PA.
Children’s report of their health status: child report
Materials and methods form of the child health and illness profile — child
edition (CHIP-CE/CRF)
Subjects A few days before the start of PA measurement (see be-
Informed consent was obtained from each participant’s low), all children completed a CHIP-CE/CRF, which is a
# 2006 NRC Canada
Aznar et al. 409

Table 2. Mean ± SD values, percentile, and Z scores for SD (according to age and gender) of the
main anthropometric characteristics of controls and children with acute lymphoblastic leukemia
(ALL).

Statistical
Variable ALL (n = 7) Controls (n = 7) p value power
Height
Mean±SD (cm) 115.2 ± 6.5 117.7 ± 8.7 0.798 0.081
Percentile and Z score for boys 70th, 0.54 97th, 2.02
Percentile and Z score for girls 97th, 2.53 50th, –0.03
Weight
Mean±SD (kg) 24.0 ± 5.8 22.6 ± 4.1 0.701 0.078
Percentile and Z score for boys 90th, 2.04 90th, 1.63
Percentile and Z score for girls 90th, 0.45 25th, –0.02
BMI
Mean±SD (kg
m–2) 18.1 ± 3.1 16.3 ± 0.8 0.159 0.289
Percentile and Z score for boys 97th, 2.70 50th, 0.40
Percentile and Z score for girls 50th, 0.35 25th, –0.30
Triceps skinfold
Mean±SD (mm) 12.5 ± 4.6 7.1 ± 1.7 0.018 0.760
Percentile and Z score for boys 97th, 1.81 25th, –0.35
Percentile and Z score for girls 50th, 0.80 10th, –1.30
Subscapular skinfold
Mean±SD (mm) 8.6 ± 5.0 5.9 ± 1.8 0.200 0.248
Percentile and Z score for boys 97th, 2.39 50th, 0.50
Percentile and Z score for girls 25th, –0.10 25th, –0.60
Note: BMI, body mass index. Percentile and Z scores were obtained with reference data from Spanish children
(Hernandez Rodriguez 1994).

Table 3. Scores (Mean ± SD) of the children’s report of their performed at least one previous familiarization session.
health status. Starting at a treadmill speed of 1.0 km
h–1 (or 1.5 km
h–1
for the oldest participants) with an upgrade of 5.0%, both
Controls Statistical
treadmill speed and inclination were increased (by
Domain ALL (n = 7) (n = 7) p value power
0.1 km
h–1 and 0.5%, respectively) every 15 s. The tests
Satisfaction 37.0 ± 3.8 38.8 ± 3.8 0.389 0.125 were stopped upon volitional fatigue of the children and
Comfort 37.3 ± 11.1 54.8 ± 2.1 0.003 0.929 (or) when they showed loss of coordination to maintain the
Resilience 29.3 ± 5.3 33.0 ± 2.8 0.044 0.294 required workload. All of the children were verbally encour-
Risk avoid- 29.4 ± 7.4 33.7 ± 3.1 0.350 0.222 aged with no visual access to their parents. Gas-exchange
ance
data were measured breath-by-breath using open-circuit spi-
Achievement 25.6 ± 5.7 28.5 ± 3.3 0.426 0.174
rometry and specific pediatric face masks (Vmax 29C, Sen-
Note: ALL, acute lymphoblastic leukemia. Satisfaction, comfort, resili- sormedics, Yorba Linda, Calif.). VO2 peak, peak respiratory
ence, risk avoidance, and achievement are as defined in the CHIP-CE/CRF. exchange ratio (RERpeak), peak ventilation (VEpeak), and
peak heart rate (HRpeak) were recorded as the highest value
self-report health status instrument for children less than obtained for any continuous 20 s period.
11 y old (Riley et al. 2004). The CHIP-CE/CRF includes 5 All of the exercise tests were performed under similar en-
domains: satisfaction (with self and health), comfort (con- vironmental conditions (20–24 8C, 45%–55% relative hu-
cerning emotional and physical symptoms and limitations), midity) and at the same time of the day (10:00–13:00).
resilience (positive activities that promote health), risk Heart rate (HR) was continuously monitored during the tests
avoidance (risky behaviors that influence future health), and using a 12 lead ECG.
achievement (of social expectations in school and with
peers). In our study, after obtaining permission from the au- The workload eliciting the VT was determined using the
thors and the corresponding institution (see Acknowledge- criteria of an increase in both the ventilatory equivalent of
ments section), we used the Spanish version of the CHIP- oxygen (VE
VO2–1) and the end-tidal pressure of oxygen
CE, which is also appropriate for children under the age of (PetO2) with no increase in the ventilatory equivalent of car-
11 y (Rajmil et al. 2004). bon dioxide (VE
VCO2–1) (Lucia et al. 2003).
All the children consumed their usual breakfast (cereals,
Exercise test for determination of VO2 peak and VT milk, and fruit juice) 3 h before the tests.
Each child performed a graded exercise test on a treadmill
(Technogym Run Race 1400HC; Gambettola, Italy) in Feb- Measurement of physical activity
ruary 2005 for the determination of VO2 peak after having Children’s levels of PA were measured in February 2005
# 2006 NRC Canada
410 Appl. Physiol. Nutr. Metab. Vol. 31, 2006

Table 4. Mean ± SD values of physiological variables during the treadmill tests in controls
and children with acute lymphoblastic leukemia (ALL).

Statistical
Variable ALL (n = 7) Controls (n = 7) p value power
VO2peak (mL
kg–1
min–1) 25.2 ± 5.9 31.2 ± 4.0 0.110 0.536
VEpeak (L
min–1) 34.3 ± 11.5 31.1 ± 4.4 0.848 0.095
RERpeak 1.02 ± 0.06 0.98 ± 0.03 0.072 0.337
HRpeak (beats
min–1) 182 ± 6 182 ± 11 0.528 0.054
VO2 (mL
kg–1
min–1) at VT 15.8 ± 3.3 19.2 ± 2.2 0.116 0.548
%VO2 max at VT 62.7 ± 9.3 61.5 ± 4.0 0.338 0.057
Note: VO2 peak, peak oxygen uptake; VEpeak, peak ventilation; RERpeak, peak respiratory exchange
ratio; HRpeak, peak heart rate; VO2, oxygen uptake; VT, ventilatory threshold.

Table 5. Mean ± SD levels of physical activity during 7 consecutive days (Monday–Sunday) in

controls and in children with ALL.

Statistical
Variable ALL (n = 7) Controls (n = 7) p value power
% of total waking 40.9 ± 17.7 42.4 ± 10.7 0.777 0.179
time sedentary
Total weekly time 328 ± 107 506 ± 175 0.048 0.563
of MVPA (min)
Total weekly counts 2 921 035 ± 790 603 3 381 551 ± 706 874 0.406 0.185
Total weekly steps 92 316 ± 19 844 98 839 ± 13 686 0.406 0.101
Note: MVPA, moderate-to-vigorous physical activity. See text for explanation of the determination of counts
and steps.

with the MTI Actigraph. This is a small (4.5 cm  3.5 cm 
1.0 cm), light (43 g), uniaxial accelerometer that detects ver-
tical accelerations ranging in magnitude from 0.25 to
2.50 Hz. Movement in a vertical plane is detected as a com-
bined function of the frequency and intensity of the move-
ment. Only normal human movement is detected; high-
frequency movements such as vibrations produced by cars,
buses, trains, etc. are electronically filtered and rejected.
The filtered acceleration signal is digitized and the magni-
tude summed over a specific time interval (epoch). At the
end of each epoch, the activity counts are stored in the
memory and the accumulator is reset to zero. A 1 min epoch
was used in this study. We measured both steps and total ac-
tivity counts. Additional engineering specifications for the
MTI Actigraph are available elsewhere (Tryon and Williams
1996).
The MTI Actigraphs were issued to parents and guardians
of each study participant with detailed oral and written in-
structions regarding correct usage. The monitors were worn
on the right side of the waist during all waking hours (ex-
cept during swimming or bathing) in a nylon pouch at waist
level secured by an elastic belt with velcro closure. For data
to be considered valid 2 criteria were established: complete
data for a period of 7 consecutive days (Monday–Sunday)
and a minimum of 10 registered hours of data per day
(Riddoch et al. 2004). Counts provided by the accelerome-
ter were analysed to obtain how many minutes of light,
moderate, and vigorous PA children performed.
In this study, we used the following accelerometer count
ranges (counts
min–1) to define the different intensity cate-
gories: £100, sedentary behaviour (Treuth et al. 2004); 101–
1952, light activity; 1953–5724, moderate activity; and
‡5725, vigorous activity (Freedson et al. 1998). Sleeping
hours of each subject were noted for each day of the data-
collection period and the time engaged in sedentary behav-
iour (£100 counts min–1) was expressed as a percentage of
waking hours. This allowed a more meaningful comparison
between subjects with differing sleep patterns.
Data analysis
Differences between controls and diseased children in
anthropometric characteristics, CHIP-CE/CRF, cardiorespir-
atory variables during the treadmill tests (VO2peak, VT, etc.),
and levels of PA were assessed using the Mann–Whitney
test. All the data are presented as mean ± SD. The level of
statistical significance was set at p < 0.05.
Results
Children’s anthropometric characteristics are shown in
Table 2. Except for a higher triceps skinfold in patients
(p < 0.05), no other significant differences were found.
Children’s self report of comfort (concerning emotional
and physical symptoms and limitations) and resilience (pos-
itive activities that promote health) were significantly de-
creased in patients with ALL (p < 0.01 and p < 0.05,
respectively) (Table 3).
Mean values of VO2 peak tended to be lower in the ALL
group than for the controls, although statistical significance
was not reached (p > 0.05) (Table 4). Similarly, no signifi-
cant differences were encountered in the other physiological
variables recorded during the treadmill exercise tests, in-
cluding the VT. Particularly, the lack of differences between
groups in mean values of VEpeak, RERpeak, and HRpeak sup-
ports the findings that the subjects from both groups per-
# 2006 NRC Canada
Aznar et al. 411

Table 6. Mean ± SD levels of physical activity during week days (Monday–Friday) in controls and in
children with ALL.

Statistical
Variable ALL (n = 7) Controls (n = 7) p value power
% of waking time sedentary/ 40.8 ± 13.4 40.2 ± 10.4 0.937 0.100
weekday
Mean time of MVPA/ 49 ± 23 79 ± 25 0.041 0.424
weekday (min)
Mean total counts/weekday 419 197 ± 103 023 521 727 ± 87 932 0.035 0.453
Mean total steps/weekday 13 752 ± 2226 15 647 ± 1729 0.085 0.374
Note: MVPA, moderate-to-vigorous physical activity. See text for explanation of the determination of counts
and steps.

Table 7. Mean ± SD levels of physical activity during weekend days (Saturday and Sunday) in
controls and in children with ALL.

Statistical
Variable ALL (n = 7) Controls (n = 7) p value power
% of waking time 36.8 ± 23.7 51.1 ± 13.3 0.196 0.332
sedentary/weekend day
Mean time of MVPA/ 53 ± 18 57 ± 34 0.949 0.055
weekend day (min)
Mean total counts/ 479 852 ± 145 356 386 458 ± 144 333 0.277 0.199
weekend day
Mean total steps/ 13 659 ± 4265 10 301 ± 3056 0.180 0.344
weekend day
Note: Abbreviation: MVPA (moderate-to-vigorous physical activity). See text for explanation of the deter-
mination of counts and steps.

formed the cardiorespiratory evaluations at a comparable ef-
fort.
Accelerometry records were successfully obtained for all
of the participants, i.e., no single data was lost for any of
them over the entire 7 d recording period. The number of
children accumulating at least 60 min of moderate-to-
vigorous physical activity (MVPA) for 5 or more days of
the week was 3 for the control group (2 girls and 1 boy)
and none for the ALL group. Subjects’ mean levels of PA
and sedentary behaviour for 7 consecutive days, for week-
days and weekend days, are shown in Tables 5, 6, and 7, re-
spectively. Significantly lower levels of total weekly time of
MVPA were seen in children being treated for ALL
(Table 5). When weekday data were analyzed, the ALL pa-
tients had significantly lower mean daily times of MVPA
and mean daily counts (Table 6), whereas weekend days
failed to produce significant differences between groups
(Table 7). No differences were seen in the percentage of
time spent in sedentary behaviour for the full 7 d period
(Table 5), for weekdays (Table 6) or for weekend days
(Table 7).
Discussion
The results of our study reveal that the amount of time
spent performing MVPA during a 7 d period was signifi-
cantly reduced in very young patients with childhood ALL
when compared with age-matched controls. ALL patients
demonstrated significantly lower intensity and reduced
amounts of total activity during weekdays. These results cor-
respond with previous investigations (Mayer et al. 2000; Re-
illy et al. 1998; Tillmann et al. 2002; Warner et al. 1998)
that have shown that PA levels in survivors of childhood
leukemia tend to be lower than in healthy controls. All of
the previously mentioned studies investigated young individ-
uals who had completed treatment for ALL, whereas the
subjects of this study were children of 4–7 years of age
undergoing maintenance treatment. Our results are also in
line with those of previous studies showing that children
with other chronic diseases (e.g., cystic fibrosis) engage in
less vigorous physical activities than their healthy peers, de-
spite having good overall physical capacity (Nixon et al.
2001). The present report is the first to suggest that the ma-
jor difference in activity patterns of young ALL patients and
controls may be the intensity at which they are performed
rather than the quantity per se (see below).
Current PA guidelines for healthy children recommend
accumulation of at least 1 h and up to several hours of
MVPA on all or most days of the week (Cavill et al. 2001).
None of the ALL patients accumulated 60 min of MVPA for
5 or more days of the week and only 3 subjects in the con-
trol group (less than 50%) achieved this guideline. Total
weekly accelerometer counts and total weekly steps were
not statistically different between groups, indicating that
there were no significant differences in the amount of total
activity performed in a 7 d period. This is an interesting
finding which, when combined with the results on MVPA,
lead us to conclude that the key difference between the
groups is the intensity rather than the quantity of the activity
performed over a full week.
Interesting patterns of PA emerged between groups when
the data were broken down into weekdays and weekend
days. No differences were seen between groups during
# 2006 NRC Canada
412
weekend days. However, on weekdays, the significantly
lower time of MVPA and total daily counts for the ALL pa-
tients indicates that they engaged in lower intensities of ac-
tivity and also in a lower total amount of activity than their
healthy peers, most likely owing to a lower level of involve-
ment in school-related activities and games. The children
with ALL were attending regular schools with the exception
of 1 girl, who attended the intra-hospital school. Although
they participated in most school indoor activities and games
(including a weekly physical education class), as did their
healthy peers, they did not usually participate in outdoor ac-
tivities and games mostly because of their parents’ and
teachers’ concern of increased risk of upper respiratory in-
fections owing to exposure to cold. The girl who attended
the intra-hospital school did not participate in any physical
education classes.
As pointed out by Oeffinger et al. (2001), the peak inci-
dence of age of diagnosis for ALL is between 2 and 5 y, fol-
lowed by approximately 30 months of therapy. The timing
of the diagnosis and the length of the treatment coincides
with a period of life when children are introduced to organ-
ized sports, e.g., soccer. When one considers that childhood
activity patterns may continue into adulthood (Corbin 2001;
Malina 1996), the possible long-term detrimental effects of
ALL diagnosis on the individual’s future PA participation
and health status are evident, even if the primary therapy
for ALL is successful. The importance of establishing sound
PA habits during the first decade of life is further underlined
by studies showing that vigorous PA during the pre-pubertal
years can result in increased bone mass during adulthood.
Kannus et al. (1995) showed that, at least in females, the ef-
fects of vigorous training (such as tennis or squash) on bone
mass of the playing extremity is almost twice as great when
training starts before menarche.
The reasons for lower activity levels in ALL patients are
not entirely clear. However, 2 basic schools of thought
have emerged in the literature to explain this phenomenon,
one being physiological in nature and the other more socio-
environmental in nature (Braith 2005). The former postu-
lates that survivors of ALL are less active as a result of
adverse consequences of chemotherapy and radiotherapy.
Such consequences include anthracycline-induced cardio-
toxicity, impaired pulmonary function, sarcopenia, osteope-
nia, and general fatigue. The latter school of thought argues
that childhood cancer survivors are subject to an insidious
‘‘spectrum of disuse’’ as a result of an overly cautious ap-
proach towards PA by concerned parents, physicians, school-
teachers, etc. (Matthys et al. 1993; McKenzie et al. 2000;
Warner et al. 1998). This excessively protective approach
may alter the child’s perception of their actual capacity for
physical activity, resulting in fear of overexertion or low
self-confidence (self-efficacy). This in turn can perpetuate
sedentarism with resulting obesity, skeletal muscle atrophy,
and risk of MetS (Braith 2005).
In the present study, children’s self report of comfort
(concerning emotional and physical symptoms and limita-
tions) and resilience (positive activities that promote health)
were significantly decreased in patients with ALL. Previous
pioneer research in the field of cardiac rehabilitation for
adult cardiac patients has shown that low self-efficacy can
indeed negatively affect physical function. Low physical
Appl. Physiol. Nutr. Metab. Vol. 31, 2006
performance was positively associated with patients’ or rela-
tives’ (e.g, wives) low self-efficacy (Ewart et al. 1983; Tay-
lor et al. 1985). For example, participation in treadmill
testing early after acute myocardial infarction is an effective
means for reassuring spouses about the capacity of their
partners to safely engage in physical activities (Taylor et al.
1985). Similarly, the results of the present treadmill tests
showing no significant impairment in patients’ physical ca-
pacity should reassure their parents, guardians, and school
teachers of the capacity of these children to safely engage
in physical activities. Although mean VO2 peak values tended
to be higher in controls, we found no significant differences
between groups, which reflected minimal functional limita-
tion in the ALL patients. Admittedly, the lack of statistical
differences between the groups must be interpreted with
caution owing to the small group sizes, which limited statis-
tical power.
Given the difficulty (and ethical concerns) of testing such
young subjects to total exhaustion, we also determined VT
as a submaximal indicator of aerobic capacity (Meyer et al.
2005) and found no significant differences between groups.
Furthermore, there is no medical contraindication for chil-
dren undergoing maintenance therapy against ALL to en-
gage in physical activities or exercise programs (Lucia et al.
2005). Therefore, overall, our results suggest that socio-
environmental influences may play a bigger part in the
differences found and that children in the last phase of
treatment against ALL should be encouraged to engage in
physical activities. To this end, their parents and guardi-
ans should adopt a less protective attitude towards their
participation in all types of physical exercise.
In conclusion, using accelerometry, we found that young
children undergoing maintenance treatment for ALL per-
formed significantly less MVPA during a 7 d period than
healthy age-matched controls. In addition, during weekdays,
the ALL patients demonstrated significantly lower mean
daily times of MVPA and total daily counts in comparison
to their healthy peers. It is important that young ALL pa-
tients be encouraged to participate in appropriate sports,
games, and physical activities both in the family and the
school environment that will prime them with positive atti-
tudes to PA during the critical early years of life.
Acknowledgements
This study was supported by a grant from the European
University of Madrid (ref. No. UEM/2005/1). We are grate-
ful to Juan José Salinero Martı́n and Germán Ruiz Tendero
for their assistance during data collection. We also ac-
knowledge Agència d’Avaluació de Tecnologia i Recerca
Mèdiques (AATRM) (Barcelona, Spain) for permission to
use the Spanish version of the Child Report Form of the
Child Health and Illness Profile — Child Edition (CHIP-
CE/CRF).
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