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Physical exercise training interventions for children and young adults during and after treatment for childhood cancer

  1. Katja I Braam1,
  2. Patrick van der Torre2,†,*,
  3. Tim Takken2,
  4. Margreet A Veening1,
  5. Eline van Dulmen-den Broeder1,
  6. Gertjan JL Kaspers3

Editorial Group: Cochrane Childhood Cancer Group

Published Online: 30 APR 2013

Assessed as up-to-date: 5 MAR 2012

DOI: 10.1002/14651858.CD008796.pub2


How to Cite

Braam KI, van der Torre P, Takken T, Veening MA, van Dulmen-den Broeder E, Kaspers GJL. Physical exercise training interventions for children and young adults during and after treatment for childhood cancer. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD008796. DOI: 10.1002/14651858.CD008796.pub2.

Author Information

  1. 1

    VU University Medical Center, Department of Pediatrics, Division of Oncology/Hematology, Amsterdam, Netherlands

  2. 2

    Wilhelmina Children's Hospital, University Medical Center Utrecht, Child Development and Exercise Center, Utrecht, Netherlands

  3. 3

    VU University Medical Center, Department of Paediatrics, Division of Paediatric Oncology/Haematology, Amsterdam, Netherlands

  1. Joint first authorship with Katja I. Braam

*Patrick van der Torre, Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, PO Box 85090, Utrecht, 3508 AB, Netherlands. p.vandertorre@umcutrecht.nl.

Publication History

  1. Publication Status: New
  2. Published Online: 30 APR 2013

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This is not the most recent version of the article. View current version (31 MAR 2016)

 
Characteristics of included studies [ordered by study ID]
Hartman 2009

MethodsDesign: single-centre RCT

Setting: the Netherlands

Department: paediatric oncology/haematology, paediatric physiotherapy, paediatric endocrinology

Randomisation: blinded for investigators and treating physicians

Stratification: not mentioned

Study duration: 3 years. Duration of the intervention: 24 months. Follow-up duration: 12 months

Timing: inclusion started directly after diagnosis, at the beginning of their chemotherapy treatment

End point measurements: at diagnosis, 32 weeks after diagnosis, 1 year after diagnosis, at the end of treatment (and 2 years after diagnosis), 1 year after the end of treatment. There was 1 additional measurement 6 weeks after diagnosis


Participantsn = 51

Diagnosis: ALL (ALL non-high risk n = 34, ALL high risk n = 17)

Age at start study: median age: 5.4 years (range 1.3 to 17.1 years)

Sex: 30 boys, 21 girls

Exclusion criteria: children with low cognitive impairment and those which could not understand the Dutch language


InterventionsThe intervention consisted of an exercise programme of 2 years. The programme consisted of a hospital-based programme performed by paediatric physiotherapists. During these sessions, the physiotherapist measured the motor function to ensure an optimal level of motor functioning. In addition, there was a home-based exercise programme. Parents were supplied with an exercise list, enabling them to select exercises most appropriate for their child's age and also to vary exercises. The exercise programme included exercises to maintain ankle dorsiflexion mobility and short-burst high-intensity exercises, to prevent reduction of BMD. In addition, there were exercises to maintain hand and leg function. The hand and leg function exercises were performed once a day; stretching and jumping exercises twice daily. The duration of an exercise session was not mentioned

When necessary the exercise programme was adjusted during these sessions

The control group received care as usual


OutcomesPhysical fitness:

Body composition: BMI, lean body mass, and percentage body fat. The lean body mass and body fat were measured by DXA (lumbar spine and total body)

Flexibility: passive ankle dorsiflexion; the range of motion past the neutral position received a positive notation and less than neutral a negative notation.

Motor performance of children less than 3.5 years of age was assessed by the use of the Dutch BSID-II; ≥ 4 years old by the use of the Dutch version of the Movement-ABC

Secondary outcomes:

None of the secondary outcomes were assessed.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "At diagnosis randomisation into the intervention or the control group was carried out in randomly permuted blocks of randomly chosen size, using sealed envelopes prepared by the statistician"

Allocation concealment (selection bias)Unclear riskInsufficient information to permit judgement of 'low risk' or 'high risk'. The use of assignment envelopes are described, but it remains unclear whether envelopes were sequentially numbered, or opaque

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and parents were not blinded for randomisation; this was unclear for physiotherapists

The investigators and treating physicians were blinded for the study randomisation

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors who performed the study outcome tests were blinded for study randomisation

Incomplete outcome data (attrition bias)
All outcomes
High riskThe study authors used a simple imputation method: for children who did not complete the study, data prior to elimination were included. No further information was provided on the imputation of some value for missing data

Selective reporting (reporting bias)Low riskAll primary and secondary outcome measures were listed in the methods section and reported in the results section

Other biasLow riskThere was no baseline imbalance found, the baseline differences between both groups were not significant. In addition, the number of measurements did not differ for the intervention group or control group

Macedo 2010

MethodsDesign: single-centre RCT

Setting: Brazil

Department: paediatric oncology/haematology

Randomisation: random assignment but no further specifications available

Stratification: not mentioned

Study duration: 10 weeks

Timing: inclusion of the study started during maintenance therapy of the childhood ALL treatment

End point measurements: in the intervention group at baseline plus an evaluation every alternate week. In the control group at baseline and 10 weeks thereafter


Participantsn = 14

Diagnosis: ALL

Age at start study: mean age of the whole group was 8.3 ± 2.6 years (range 5 to 14 years). The mean age of the intervention group was 7.0 years and that of the control group 9.0 years

Sex: 5 boys and 9 girls

Exclusion criteria: children with a chronic lung disease, neuromuscular disease, or those receiving or having received radiotherapy treatment


InterventionsThis study investigated an inspiratory muscle training programme. They studied the effects of a domiciliary inspiratory muscle training with a duration of 15 minutes, performed twice a day, for 10 weeks. The training was performed with a threshold device using a load of 30% of the maximal inspiratory pressure.

The control group received care as usual


OutcomesPhysical fitness:

Muscle endurance/strength: respiratory muscle strength (maximal inspiratory pressure and maximal expiratory pressure) assessed with a digital manometer

Secondary outcomes:

None of the secondary outcomes were assessed


NotesArticle was written in Portuguese


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskChildren were randomly selected and randomly assigned to 2 groups, but the exact randomisation methods were not reported

Allocation concealment (selection bias)Unclear riskThe exact randomisation methods were not reported. It was not clear whether the researchers used sealed envelopes, central allocation, or another method

Blinding of participants and personnel (performance bias)
All outcomes
High riskThe study did not address the blinding of participants and personnel. However, due to the nature of the interventions blinding was virtually impossible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe study did not address blinding of outcome assessment

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskInsufficient reporting: the authors stated that sample losses occurred; however, they did not report the reasons for these sample losses, neither did they provide information on the used imputation methods

Selective reporting (reporting bias)Low riskRespiratory muscle strength was the primary outcome. By assessing and reporting on (changes over time of) both the maximal inspiratory pressure and maximal expiratory pressure there was no selective reporting of the study data

Other biasHigh riskDifferential diagnostic activity: the intervention group and the control group received an unequal number of measurements.

However, this study was free of baseline imbalance; the baseline differences between the control group and intervention group on outcome related items were not significant

Marchese 2004

MethodsType of study: single-centre RCT

Setting: USA

Department: paediatric rehabilitation, paediatric oncology, paediatric physiotherapy

Randomisation: primary investigator offered the children an envelope to select assignment into the intervention or control group

Stratification: children were stratified according to their childhood cancer risk group and first versus second part of the maintenance therapy

Study duration: 4 months

Timing: inclusion of the study started during maintenance therapy

End point measurements: at baseline and 4 months later


Participantsn = 28

Diagnosis: ALL

Age at start study: median age of the whole group was 7.7 years (range 4.3-15.8 years). The median age of the intervention group was 7.6 years (range 4.3-10.6 years) and of the control group 8.6 years (range 5.1-15.8 years)

Sex: 20 boys and 8 girls

Exclusion criteria: a history of antecedent neurological, developmental, or genetic disorders and those receiving a physiotherapy intervention at the start of the study


InterventionsThe intervention programme included 5 hospital-based physiotherapy sessions (week 0, 2, 4, 8, and 12) of 20-60 minutes. The first session was performed immediately after the baseline testing

Next to the hospital-based programme, the programme also included an individualised home exercise programme. This programme consisted of ankle dorsiflexion stretching exercises (30 seconds, 5 days a week), bilateral lower extremity strengthening exercises (3 sets of 10 repetitions, 3 days a week), and aerobic exercise (daily). The aerobic exercise could be walking, cycling, or swimming; chosen by the participant

The control group received care as usual


OutcomesPhysical fitness:

Cardiorespiratory fitness or peak work rate: 9-minute run-walk test and the timed up-and-down stairs test

Muscle endurance/strength: knee extension strength and ankle dorsiflexion strength both tested with a hand-held dynamometer. This study also used the time up-and-down stairs test and the 9-minute run-walk test

Flexibility: ankle dorsiflexion range of motion

Secondary outcomes:

Health-related quality of life: PedsQL version 3.0

Adverse events: any negative effect from the exercises or experienced complications attributed to the physical programme


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskThe children were stratified by risk group and by whether they were in the first or second half of the maintenance therapy. After that the primary investigator offered the children an envelope to select assignment into the intervention or control group

Allocation concealment (selection bias)Unclear riskInsufficient information to permit judgement of 'low risk' or 'high risk'. The use of assignment envelopes is described, but it remains unclear whether envelopes were sealed, sequentially numbered, or maybe opaque

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and parents were not blinded for randomisation; for personnel this was unclear

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe outcome assessors for hand-held dynamometry , the timed up-and-down stairs test and the 9 minute run-walk test were blinded for study randomisation. Therefore these items had a low risk for detection bias

The PedsQL (quality of life) questionnaires were filled in by both parents and children. Parents and children were not blinded for the study randomisation and therefore the quality of life assessment was found to be of high risk for detection bias

We judged the overall risk of detection bias for this item to be low because the researchers blinded outcome assessors as much as possible

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThe authors reported missing data for daily logs of activity and heart monitor. But no information was reported on methods used for data imputation in case of missing data

Selective reporting (reporting bias)Low riskAll the prespecified primary and secondary outcomes of the study were listed in the methods section and reported in the results section

Other biasUnclear riskThe non-significant baseline differences were reported for patient characteristics, however, not for study outcome measures. It remains unclear whether the mean differences between the control group and the intervention group at baseline were significant or not

Furthermore we checked for differential diagnostic activity. During the study all children were pretested and post-tested. The number of measurements did not differ for the intervention group or control group

Moyer-Mileur 2009

MethodsType of study: single-centre RCT

Setting: USA

Department: paediatric oncology

Randomisation: not mentioned

Stratification: not mentioned

Study duration: 12 months

Timing: the inclusion of the study started during the ALL maintenance chemotherapy

End point measurements: measures of physical size were obtained at baseline and every 3 months, physical activity was measured at baseline and at 6 and 12 months


Participantsn = 14

Diagnosis: standard-risk ALL

Age at start study: mean age (± SD) of the intervention group was 7.2 ± 0.7 years and the mean age of the control group was 5.9 ± 0.7 years

Sex: 7 boys and 6 girls; 1 unknown (drop-out)

Exclusion criteria: not mentioned


InterventionsThe intervention included a 12-month home-based exercise and nutrition programme

Children were prescribed to perform a minimum of 3 'fifteen to twenty-minute' sessions of moderate-to-vigorous activity per week. Activity examples were provided on the pyramid for youth and parents were asked to record the type and amount of physical activity, immediately after the activity was performed

Children received nutrition education materials on the basis of the United States Department of Agriculture Food Guide Pyramid and nutrition-related activities monthly

The control group received care as usual


OutcomesPhysical fitness:

Cardiorespiratory fitness or peak work rate: progressive aerobic cardiovascular endurance run

Muscle endurance/strength: push-ups, the sit-and-reach test

Body composition: BMI, muscle mass (measured by the analysis of the tibia using peripheral quantitative computed tomography

Flexibility: sit-and-reach distance test

Level of daily activity: pedometer combined with an activity diary (monthly, 2 weekdays and 1 weekend day) and the ACTIVITY GRAM questionnaire

Secondary outcomes:

None of the secondary outcomes were assessed


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe method of randomisation was not provided in the article

Allocation concealment (selection bias)Unclear riskThe method of randomisation was not provided in the article

Blinding of participants and personnel (performance bias)
All outcomes
High riskThe study did not address this item. However, due to the nature of the interventions blinding was virtually impossible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe study did not address this item

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAlthough authors reported that 1 child withdraw after 3 months (caused by lack of interest and data of this child were not taken into analysis), the information provided was insufficient to decide whether there this withdrawal could have had influence on the study outcomes

Selective reporting (reporting bias)Low riskThe article presented both the mean (plus confidence interval or SD) of all outcome variables and figures including the individual changes of the participants

Other biasLow riskThere was no baseline imbalance found, the baseline differences between both groups were not significant

Furthermore we checked for differential diagnostic activity. During the study all children were pretested and post-tested. The number of measurements did not differ for the intervention group or control group

Yeh 2011

MethodsType of study: single-centre CCT feasibility study (quasi-experimental)

Setting: Taiwan

Department: paediatric oncology

Randomisation: not performed

Stratification: the intervention group and controls were matched by age and sex

Timing: the inclusion of the study started during the ALL maintenance chemotherapy (1 week after completion of the dexamethasone treatment)

Study duration: 10 weeks

End point measurements: at baseline, once weekly during the 5-week intervention, at the end of the intervention and 1 month after the intervention


Participantsn = 24

Diagnosis: ALL

Age at start study: mean age intervention group 11.0 ± 3.56 years, mean age of the control group 12.5 ± 3.86 years

Sex: 12 boys and 10 girls; 2 unknown (drop-outs)

Exclusion criteria: children who were unwilling to perform an aerobic exercise, or those with physical and developmental impairment


InterventionsThe intervention consisted of a home-based aerobic exercise instructed by video. 1 session included a warm-up of 5 minutes, aerobic exercise of 25 minutes and a cooling down period of 5 minutes. The exercises were performed at least 3 times a week, over a total of 6 weeks. In addition, children recorded their physical activity and heart rate data during the exercises in a physical activity log for 3 days with 24 1-hour blocks

The aerobic exercise sessions aimed to increase 40-60% of the child's heart rate reserve

The control group received care as usual


OutcomesPhysical fitness:

None of the physical fitness outcomes were assessed

Secondary outcomes:

Fatigue: PedsQL multidimensional fatigue scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskThe researcher-team used a quasi-experimental design that had no random assignment

Allocation concealment (selection bias)High riskThe researcher-team used a quasi-experimental design that had no random assignment

Blinding of participants and personnel (performance bias)
All outcomes
High riskThe study did not address this item. However, due to the nature of the interventions blinding was virtually impossible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe study did not address this item

Incomplete outcome data (attrition bias)
All outcomes
Low risk2 types of analyses were conducted: ITT analysis used the data of all children, and the per-protocol analysis, which included only those children who adhered to the exercise prescription

Selective reporting (reporting bias)High riskNot all the prespecified primary outcomes have been reported. In addition, adherence was mentioned to be extra or a secondary outcome. However, in the results the authors focused in this item

Other biasUnclear riskThe non-significant baseline differences were reported for fatigue study outcomes. However, it remains unclear whether the intervention and control group had different baseline scores on the other study outcomes: physical activity log, OMNI walk/run scale, and the stages of change.

Furthermore we checked for differential diagnostic activity. The number of measurements did not differ for the intervention group or control group. Therefore this study was free from differential diagnostic activity

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Chamorro-Vina 2010The exercise intervention was offered less than 4 weeks

Hinds 2007The exercise intervention was offered less than 4 weeks

Speyer 2010Cross-over randomised trial without data presentation after the first intervention period (before cross-over)

Te Winkel 2008This study presents pilot data of a study that was reported by Hartman et al (2009). Hartman et al. was already included in the review (Hartman 2009)

 
Characteristics of studies awaiting assessment [ordered by study ID]
Elkateb 2007

MethodsType of study: single-centre CCT

Setting: Egypt

Department: paediatric oncology

Randomisation: not performed

Stratification: not included

Timing: children were during chemotherapy treatment for cancer

Study duration: not mentioned

End point measurements: at baseline, daily in the first week, after the first week, in the third week and in the sixth week

Participantsn = 50

Diagnosis: childhood cancer

Age at start study: preschool- and school-aged children

Sex: not mentioned

Exclusion criteria: not mentioned

InterventionsUndefined exercise programme for the intervention group

Undefined programme for the control group

OutcomesPhysical fitness:

Level of daily activity: observational checklist for recording activities

Secondary outcomes:

Fatigue: observational checklist for sleeping conditions

NotesThis study was published as a conference paper. Based on the currently available information it was not possible to decide if this study was eligible for inclusion in this review

 
Characteristics of ongoing studies [ordered by study ID]
Braam 2011

Trial name or titleQuality of Life in Motion: A Combined Physical Exercise and Psychosocial Training Program to Improve Physical Fitness in Children with Cancer

MethodsType of study: multicentre RCT

Setting: Netherlands

Department: paediatric oncology/haematology

Randomisation: independent assistant manage a randomisation list. The researcher calls the independent assistant after the baseline measurement than the randomisation is performed

Stratification: the participants are stratified by (i) cancer (haematological versus solid cancer), (ii) sex and age (boys under 12 vs. ≥ 12 years and girls under 11 years vs. ≥ 11 years) and (iii) during or after cancer treatment

Timing: children are during or within the first year following childhood cancer therapy. Children who are during treatment should be treated on an outpatient basis, without overnight hospital staying.

Study duration: 12 months

End point measurements: At baseline, 4 months, 7 months and 12 months

Trial register: www.trialregister.nl/trialreg/admin/rctview.asp?TC=1531 (accessed 6 March 2013)

Participantsn = 100

Diagnosis: childhood cancer (treated with chemotherapy, radiotherapy, or both)

Age at start study: 8-18 years

Exclusion criteria: receiving a bone marrow transplant as a part of the childhood cancer treatment, receiving growth hormones as a part of the childhood cancer treatment, permanent wheelchair use/inability to ride a bike, retardation/inability to make a self reflexion and follow sports instructions

InterventionsThe 12-week intervention consists of a combined physical exercise (twice per week) and psychosocial support programme (once every 2 weeks) followed by a 1-day booster session

The physical exercise programme includes a protocol with both cardiorespiratory and muscle strength training. The sessions are guided by a paediatric physiotherapist and performed at a local paediatric physiotherapist institute. The psychosocial support programme (6 child and 2 parent sessions) contains psychoeducation and cognitive-behavioural therapy (given by a paediatric psychologist and performed at the treating hospital)

The control group will receive care as usual

In addition, parents are asked to fill in a cost-diary over the whole period of the study

Non-responders characteristics, physical activity level, and quality of life will be assessed in a survey including three important questionnaires of the study, to determine whether the study population represents the entire population

OutcomesPhysical fitness:

Cardiorespiratory fitness or peak work rate: cardiopulmonary exercise tests (CPET and SRT) on a cycle ergometer to measure VO2 peak, and peak work rate

Muscle endurance/strength: hand-held-dynamometer

Body composition: DXA and BMI

Activity energy expenditure: accelerometry

Level of daily activity: activity questionnaire and activity diary (4 x 4 days over 1 year)

Time spent exercising (more than daily activity): activity questionnaire

Secondary outcomes:

HRQoL: PedsQL Generic

Fatigue: PedsQL Multidimensional Fatigue scale

Anxiety and depression: Children's Depression Inventory

Self efficacy: Youth self report and Child Behavior Checklist

Adverse events

Starting date1 March 2009

Contact informationKatja Irene Braam, VU University Medical Center, Amsterdam, The Netherlands: katja.braam@vumc.nl

Notes

Cox 2011

Trial name or titlePhysical Activity to Modify Sequelae and Quality of Life in Childhood Acute Lymphoblastic Leukaemia (PAQOL)

MethodsType of study: single-centre RCT

Setting: USA

Department: paedaatric oncology

Randomisation: not described

Stratification: not included

Timing: children were in the second to eighth day of the ALL treatment protocol

Study duration: 135 weeks

End point measurements: at baseline (BMD, HRQoL), after 8 weeks (HRQoL), after 15 weeks (HRQoL), and at completion of therapy (BMD and HRQoL)

clinicaltrials.gov/ct2/show/NCT00902213

Participantsn = 208

Diagnosis: newly diagnosed with ALL (immunophenotypic diagnosis of non-B cell ALL)

Age at start study: 4-18 years

Exclusion criteria: age < 4 years or ≥ 19 years at diagnosis, no parents or legal guardian (≥ 18 years) of the study subject who speaks and understands the English language, a diagnosis of cerebral palsy or Down's syndrome, children with a second malignancy, chromosome breakage syndrome, or severe congenital immunodeficiency, inability to obtain written informed consent from parent/young adult and child assent, or females who are pregnant

InterventionsTailored parent- and child-focused physical activity programme

An advanced practice nurse will meet twice weekly with the child and family for the first 4 weeks of the intervention to initiate the motivation-based dialogue and therapeutic interaction; this will be followed by once weekly visits during weeks 5-8 of the intervention; and monthly visits during weeks 9 through to end of therapy

The physiotherapist will meet at least once weekly with the child and family during weeks 1-4 to initiate the prescriptive tailored exercise programme; subsequent visits to reinforce and modify the programme will occur at least once every other week during weeks 5-8, and at least once monthly during weeks 9-135 of the intervention. The physiotherapist will visit at least once weekly during weeks 1-4, at least once every other week during weeks 5-8, and at least once monthly during weeks 9-135. During weeks 9-135 of the intervention, the advanced practice nurse will call between the monthly in-person visits to assure fidelity to the intervention and to provide booster support to the intervention where needed

OutcomesPhysical fitness:

Muscle endurance/strength: muscle strength, range of motion, endurance, gross motor skills, used method is not specified

Body composition: BMD and bone mineral content

Flexibility: range of motion

Secondary outcomes:

Health-related quality of life: method used not mentioned in the protocol

Adverse events

Starting dateNovember 2009

Contact informationCheyl Cox, info@stjude.org

Notes

 
Comparison 1. Cardiorespiratory fitness outcomes after physical exercise training intervention for children and adolescents during or after childhood cancer

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 9-minute run-walk test128Std. Mean Difference (IV, Random, 95% CI)0.33 [-0.42, 1.07]

 2 Timed up-and-down stairs test128Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.64, 0.85]

 
Comparison 2. Body composition outcomes after physical exercise training intervention for children and adolescents during or after childhood cancer

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Bone mineral density151Std. Mean Difference (IV, Random, 95% CI)1.07 [0.48, 1.66]

 2 Body mass index264Std. Mean Difference (IV, Random, 95% CI)0.59 [-0.23, 1.41]

 
Comparison 3. Flexibility outcomes after physical exercise training intervention for children and adolescents during or after childhood cancer

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Flexiblity2Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Active ankle dorsiflexion
128Std. Mean Difference (IV, Random, 95% CI)0.46 [-0.29, 1.22]

    1.2 Passive ankle dorsiflexion
151Std. Mean Difference (IV, Random, 95% CI)0.69 [0.12, 1.25]

 
Comparison 4. Muscle endurance/strength outcomes after physical exercise training intervention for children and adolescents during or after childhood cancer

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Knee strength128Std. Mean Difference (IV, Random, 95% CI)0.25 [-0.49, 1.00]

 2 Ankle dorsiflexion strength128Std. Mean Difference (IV, Random, 95% CI)0.29 [-0.46, 1.04]

 3 Inspiratory breathing muscle strength114Std. Mean Difference (IV, Random, 95% CI)0.33 [-0.77, 1.43]

 4 Expiratory breathing muscle strength114Std. Mean Difference (IV, Random, 95% CI)0.0 [-1.09, 1.09]

 
Comparison 5. Health-related quality of life outcomes after physical exercise training intervention for children and adolescents during or after childhood cancer

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PedsQL - general128Std. Mean Difference (IV, Random, 95% CI)-0.23 [-0.98, 0.51]

 2 PedsQL - cancer128Std. Mean Difference (IV, Random, 95% CI)0.16 [-0.58, 0.91]

 3 Parents PedsQL - general128Std. Mean Difference (IV, Random, 95% CI)0.38 [-0.37, 1.13]

 4 Parents PedsQl - cancer128Std. Mean Difference (IV, Random, 95% CI)0.04 [-0.70, 0.79]

 
Comparison 6. Fatigue outcomes after physical exercise training intervention for children and adolescents during or after childhood cancer

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 PedsQl - general fatigue122Std. Mean Difference (IV, Random, 95% CI)-0.04 [-0.88, 0.80]

 2 PedsQl - sleep/rest fatigue122Std. Mean Difference (IV, Random, 95% CI)-0.01 [-0.85, 0.83]

 3 PedsQl - cognitive fatigue122Std. Mean Difference (IV, Random, 95% CI)0.07 [-0.77, 0.91]

 
Summary of findings for the main comparison. Physical exercise training compared with usual care for children and young adults during and after treatment for childhood cancer

Physical exercise training compared with usual care for children and young adults during and after treatment for childhood cancer

Patient or population: children and young adults during and after treatment for childhood cancer

Settings: hospital and non-hospital

Intervention: physical exercise training

Comparison: usual care

OutcomesIllustrative comparative risks* (95% CI)No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Usual care groupExercise group

Cardiorespiratory outcomes

9-minute run-walk test
wheeled distance counter
Follow-up: mean 4 months
The mean 9-minute run-walk test in the control groups was
3304.5 feet (1007.2 m)
The mean 9-minute run-walk test in the intervention groups was
0.33 standard deviations higher
(0.42 lower to 1.07 higher)
28
(1 study)
⊕⊕⊝⊝
low1,2,3
SMD 0.33 (-0.42 to 1.07)

Timed up-and-down stairs test
stopwatch
Follow-up: mean 4 months
The mean timed up-and-down stairs in the control groups was
8.6 seconds
The mean timed up-and-down stairs in the intervention groups was
0.11 standard deviations higher
(0.64 lower to 0.85 higher)
28
(1 study)
⊕⊕⊝⊝
low1,2,3
SMD 0.11 (-0.64 to 0.85)

Body composition outcomes

Bone mineral density
DXA scan
Follow-up: mean 24 months
The mean bone mineral density in the control groups was
-1.1412 standard deviation
The mean bone mineral density in the intervention groups was
1.07 standard deviations higher
(0.48 to 1.66 higher)
51
(1 study)
⊕⊕⊝⊝
low1,2,3
SMD 1.07 (0.48 to 1.66)

Body mass index
Quetlet Index
Follow-up: mean 18 months
The mean body mass index in the intervention groups was
0.59 standard deviations higher
(0.23 lower to 1.41 higher)
64
(2 studies)
⊕⊝⊝⊝
very low1,2,3,4
SMD 0.59 (-0.23 to 1.41)

Muscle endurance/strength outcomes

Ankle Dorsiflexion Strength
Hand-held dynamometer
Follow-up: mean 4 months
The mean ankle dorsiflexion strength in the control groups was
0.22 standard deviation
The mean ankle dorsiflexion strength in the intervention groups was
0.29 standard deviations higher
(0.46 lower to 1.04 higher)
28
(1 study)
⊕⊕⊝⊝
low1,2,3
SMD 0.29 (-0.46 to 1.04)

Health-related quality of life

Health-related quality of life
PedsQl - General questionnaire (version 3.0)
Follow-up: mean 4 months
The mean health-related quality of life in the control groups was
17.5
The mean health-related quality of life in the intervention groups was
0.23 standard deviations lower
(0.98 lower to 0.51 higher)
28
(1 study)
⊕⊕⊝⊝
low1,2,3
SMD -0.23 (-0.98 to 0.51)

Fatigue

General fatigue
PedsQl - fatigue questionnaire
Follow-up: mean 6 weeks
The mean general fatigue in the control groups was
3.4
The mean general fatigue in the intervention group was
0.04 standard deviations lower
(0.88 lower to 0.8 higher)
22
(1 study)
⊕⊕⊝⊝
low1,2,3
SMD -0.04 (-0.88 to 0.8)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in the table. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group.
CI: Confidence interval; SMD: standardised mean difference; DXA: dual-energy x-ray absorptiometry; cmH2O: centimetres of water pressure

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Total population size is less than 400 (a threshold rule-of-thumb value; using the usual α and β, and an effect size of 0.2 SD, representing a small effect).
2 The upper or lower confidence limit crosses an effect size of 0.5 in either direction.
3 Published evidence is limited to a small number of trials.
4 In this study outcome-accessors were not blinded.