IJTRR 2017; 6 (2):137-145

Original Research Article doi: 10.5455/ijtrr.000000255

International Journal of Therapies & Rehabilitation

E-ISSN
Research
2278-0343
http://www.scopemed.org/?jid=12

Impact of Aerobic Exercise on Physical Fitness and Fatigue in Children with

Acute Lymphoblastic Leukemia
Amal. M. Abd El Bakya, Sahar. M. Adel Elhakkb
a
Physical Therapy Department for Surgery ,Faculty of Physical Therapy, Cairo University, Giza, Egypt &
Physical Therapy and Rehabilitation Department ,Faculty of Applied Medical Science (CAMS), Majmaah
University, Kingdom of Saudi Arabia
b
Physical Therapy Department of Basic Science, Faculty of Physical Therapy, Cairo University, Giza,
Egypt & Physical Therapy and Rehabilitation Department, Faculty of Health and Rehabilitation Sciences-
Princess Nourah Bint Abdul Rahman University, Kingdom of Saudi Arabia

ABSTRACT

Background: Acute lymphoblastic leukemia (ALL) is one type of childhood cancer. In the past decades,
cure rates of ALL have increased and the survivor’s quality of life and physical fitness have become a
growing concern. Furthermore cancer-related fatigue (CRF) is reported to be the most distressing symptom
in cancer. Objective: We aimed to examine the effect of aerobic exercise on the physical fitness and
fatigue in children suffering from ALL. Methods: Thirty patients of 8 to 16 years with ALL participated in
this study. Participants were randomized to study group (Group A), who participated in supervised aerobic
exercise program in addition to home program, and control group (Group B), who were instructed to
maintain their usual level of activity in addition to home program. Measurement of physical fitness and
fatigue were done at the baseline and after 16 th weeks. Results: Post measurement results suggested that,
there was significance difference between both groups (P< 0.05). The percentage of improvement of
physical fitness and fatigue level for group A was 31.06% and 21.56% respectively, while the percentage of
improvement for group B was 4.16 % and 2.78% respectively. Conclusion: Aerobic exercise is effective in
improving physical fitness and management of CRF in children with ALL.
Key Words: Acute lymphoblastic leukemia, Cancer related fatigue exercise training, Physical fitness.

INTRODUCTION physical fitness commonly represented during and after

Acute Leukemia is a malignant disease that childhood cancer treatment [6, 7, 8]. In addition to, it is
affects bone marrow and results in the accumulation of suggested that low physical fitness may be a cause of
immature, functionless cells in the marrow and blood fatigue [9]. Maximal oxygen consumption (VO2 max) has
[1]. It is reported that ALL is a common form of been used to assess physical fitness [10].
childhood malignancy. ALL is classified into Acute Various physical therapy techniques are used
Myelocytic Leukemia (AML) and Acute Lymphoblastic to reduce fatigue and improve physical fitness in cancer
Leukemia (ALL) [2, 3]. patients such as aerobic exercises, stretching, or
Patients suffering from cancer, especially who strengthening exercises [11,12]. Aerobic exercise is
are receiving chemotherapy, mostly experience fatigue. defined as "sub maximal, rhythmic, repetitive exercise
Today, it is observed that fatigue is the untreated side of large muscle group, during which the needed energy
effect for cancer [4]. Moreover it is suggested that it is supplied by inspired oxygen" [13]. It is considered to
also affects the patient's physical performance and be valuable in the management of cancer-related
daily activities [5]. physical outcomes as well as the quality of life in other
Physical fitness is considered as an important forms of cancer [14,15].
health marker for functional status of different body This study was conducted with the aim of
functions. It has been reported that impairment of determining the efficacy of adding moderate intensity
 IJTRR 2017; 6 (2):137-145

aerobic exercise to home program on both physical effort was achieved the test was terminated [15,17].
fitness and cancer related fatigue in children with Acute During GXT, the patient breathed through a face mask
Lymphoblastic Leukemia. (Hans Rudolph Inc, Kansas City, MO, USA) that
connected to a calibrated expired gas analysis system
(Zan-680 Ergospiro Ergospirometry System,
METHODS manufactured by ZAN Me Bgerate GmbH, Germany).
Study Design: Gas analyzers and flow meter were connected to a
This is a prospective, randomized controlled computer and calculate oxygen uptake. Heart rate (HR)
study. It was conducted in the Cardiorespiratory Lab at was monitored continuously during the graded exercise
Faculty of Physical Therapy, Cairo University, Giza, test. VO2max was calculated as the average value over
Egypt. The study was approved by Postgraduate the last 30 seconds during the exercise test [18].
Institutional Ethical Committee at Faculty of Physical Table -1: The Modified Borg Scale for
Therapy. Each patient and their parents individually Breathlessness,(Adapted from Deturk et al.,) [16]
received written and verbal information about the study. 0 Nothing at all
Written informed consent was obtained from the
parents or legal guardian of each patient, and also from 0.5 Very very slight
each patient aged 12 years and older. 1 Very slight
Participants
Of 36 eligible patients, 30 patients (boys and 2 Slight
girls) with Acute Lymphoblastic Leukemia agreed to 3 Moderate
participate in this study. The patients were referred by
an Oncologist from Children's Cancer 4 Somewhat sever
Hospital Foundation 57357 to participate in this study. 5 Sever
They were chosen on the basis of the following criteria:
6
1) Patients' age from 8 to 16 years, 2) Patient
complained from fatigue, 3) There were absence of 7 Very sever
musculoskeletal disturbances that may limit
8
participation in the exercise training program, 4)
Preserved cardiac structure and function, as assessed 9 Very very sever (almost maximal)
by an echocardiogram, 5) Ambulant without need for 10 Maximal
human assistance in addition to 6) The elapsed time
since their last chemotherapy had to be at least 6
months. Children were excluded when they suffered Fatigue measurement:
from cardiovascular disease, acute or chronic Fatigue level was assessed by the subscale
respiratory disease, acute or chronic bone, joint, or fatigue of The Checklist Individual Strength (CIS) [19].
muscular abnormalities, or immune deficiency that Earlier the CIS was used to investigate cancer survivors
might compromise the patient’s ability to participate in [20,21]. It is reported as a useful and a valid multi-
the exercise rehabilitation program. dimensional instrument, for both assessment and
Participants who had fulfilled the eligibility scoring. CIS is designed to measure four aspects of
criteria were randomized using simple randomization fatigue; subjective experience of fatigue, concentration,
method to either study group (Group A) (n= 15, 8 boys motivation, and physical activity. It consists of eight
and 7 girls), who participated in supervised moderate items scored on a seven-point Likert Scale, with scores
intensity aerobic exercise program in addition to a ranging from eight to 56 (with 1 indicating best and 7
home-based exercises program, and control group worst function) [22,23].
(Group B) (n= 15, 9 boys and 6 girls), who were
instructed to maintain their usual level of activity as well Exercise Intervention
as to perform home-based exercises, Fig. 1 Aerobic exercise:
Measurement procedures Group (A) started aerobic exercise program
Assessment for both physical fitness and fatigue were approximately 24 hours after assessment and lasted for
done at the baseline and after 16th weeks. 16th weeks in addition to home-based exercises. An
Physical fitness measurement exercise session would be only cancelled if a patient
Vo2max was used to measure the patient's was experiencing fever (temperature > 38°C/100.4°F),
physical fitness. Participants performed a Graded low blood platelet levels (< 50.000 per μl), a neutrophil
Exercise Test (GXT) on treadmill using the modified count lower than 500 cells per μl, marked anemia
Bruce protocol, table (1). (hemoglobin < 8 g/dl) or severe cachexia (i.e., weight
Patients were constantly asked to complete 3 mass loss > 35%) [24]. Patients had participated in a
minutes for each stage and once the peak volitional supervised aerobic exercise program by one of the
 IJTRR 2017; 6 (2):137-145

researcher (3 sessions /week with each session lasting Exercise Plans for Physical Fitness’ and was composed
from 20–40 minutes). A RAM model 770 CF electronic of five basic exercises to enhance strength, flexibility
treadmill was used for aerobic exercise. Each and aerobic fitness. At each home training session the
participant exercised at 70–85% of his/her previously children accomplished five exercises a given number of
determined individual VO2max. The exercise program times in 11 min, stepwise increasing intensity and the
was divided into 5 min stretching exercise, warm up number of times during the 16th weeks [25]. The
period, followed by moderate intensity of aerobic children or their parents were asked to record training
exercises, and finishing with a cool down period. frequency and training progression.
Warming-up and cooling down periods were in the form Data Analysis:
of walking on the treadmill for about 5–10 minutes at a Data were analyzed with Statistical Package of
speed of 1–1.5 km/h with zero inclination. In the cooling Social Science (SPSS) version 22.0 (Chicago USA).
down period, the speed was gradually decreased until Normal distributed data (Kolmogorov-Smirnov test, P >
reaching zero [7]. Participants were regularly monitored 0.05) were expressed as mean and standard deviation
throughout the exercise program, and their heart rates (SD). The paired t-test was used to compare variables
were recorded during the exercise sessions. at the baseline and after 16th weeks within each group,
Home program: while independent-t test was used to compare variables
The children in both groups were instructed to between both groups. For fatigue level nonparametric
exercise at home for at least two times per week. The statistical analysis was used including the Wilcoxon
exercises were outlined by photos, and verbally by us Signed Rank test for variable comparison within groups
at the first session. Furthermore parents were asked to and the Mann-Whitney U test for comparison between
supervise the home exercises. The home training groups. All P-values in the analysis were considered
program was based on the ‘Royal Canadian Air Force statistically significant when P < 0.05.

Eligible subjects (n = 36)

Enrollment Family refused (n=6)

Randomized (n = 30)

Study group (GA) n= 15 Control group (GB) n= 15

Completed study (n= 15) Completed study (n= 15)

Figure 1. The Participants Flow Chart

RESULTS recorded between them for group B with 4.16% (P >

Table 2 summarizes the demographic characteristics of 0.05).
the participants in both groups. A total of 30 patients (17 For fatigue scores (CIS), the results
boys and 13 girls) with Acute Lymphoblastic Leukemia demonstrates significance improvement in the post CIS
were involved in this study. No significant differences for group A (P > 0.05) with 21.56 %, while there was no
were observed between both groups regarding age (P=
significant difference between the pre and post
0.853), weight (P=0.935), height (0.57), BMI (P=0.895)
as well as the elapsed time since the patients' last measurements for group B with percentage of
chemotherapeutic treatment (P= 0.798). improvement 2.78% (P > 0.05), Table 4.
Table 3, reports the mean values of the pre and Fig. 2 shows that there was no significant
post VO2max measurements for both groups. There was difference between the pre measurements of VO2max for
a significant difference between the pre and post both groups, while the post measurements represented
VO2max for group A with a percentage of improvement a significance difference with (P> 0.05). As well as, the
31.06% (P > 0.05), while no significant difference was results represents no significance difference between
 IJTRR 2017; 6 (2):137-145

the pre fatigue scores of both groups (p= 0.97), while scores (P> 0.05), fig 3.
there was significance difference in the post fatigue

Table- 2. Statistical analysis of demographic characteristics of patients in both groups

Variables Group M±SD T P

GA 12.51±3.40
Age - 0.185 0.853*
GB 13.2±3.83

GA 1.25±0.2
Height (m) -0.568 0.570*
GB 1.27±0.3

GA 40.59±6.97
Weight (kg) -0.092 0.935*
GB 41.90±9.19

GA 19.70±3.04
BMI (kg/m2) -0.154 0.895*
GB 19.99±2.23

Elapsed time GA 7.90±1.75

-0.269 0.798*
(month)
GB 8.1±1.7

Data are presented as the mean (SD), * not significant

Table- 3. Statistical analysis of aerobic capacity variables within each group

% of
Variables Groups Pre Post
improvement

GA 25.56±4.50 33.50±3.72 31.06 %*

Vo2max
(ml/kg/min) GB 25.25±4.69 26.30±4.70 4.16 %

Data are presented as the mean (SD),*Significant (P < 0.05) improvement between the pre and post measurements.

Table-4. Statistical analysis of fatigue within each group

% of
Variable Groups Pre Post Z
improvement

34.20±4.94
43.60±4.5
GA -2.823a 21.56 %*
Fatigue (37-51) (30-44)

CIS-score 42±5.34
43.20±5.4
GB -1.732a 2.78%
(38-54) (38-54)

*Significant (P < 0.05) improvement between the pre and post measurements, a. Wilcoxon Signed Ranks Test
 IJTRR 2017; 6 (2):137-145

Figure 2. Statistical analysis between Pre and Post VO2max between both groups

Figure 3. Statistical analysis between Pre and Post Fatigue between both groups

DISCUSSION maintenance therapy. They failed to show improvement

in the cardiovascular response assessed by a nine
The main findings of the present study reported minute run walk test. Moreover, Takken et al.,[14] found
a significant improvement of both physical fitness and no cardiopulmonary response to 12-week community-
fatigue level in children who survived ALL by adding of based exercise training program in 9 children with ALL
a 16-week of aerobic exercise training program to home (aged 6–14 years) as assessed by standardized
exercise program. cardiopulmonary exercise testing. Recently, Alibhai et
There is growing evidence for the positive al.,[33] decided significant improvements in 6MWT
effects of aerobic exercise training on physical fitness, distance post-exercise (p=0.006) within group but no
fatigue and physical well-being of children during and significant improvement were recorded for Vo2max
after treatment for cancer [19, 26, 27, 28]. (p=0.486).
Regarding the physical fitness, a study This inconsistency across the literatures might
conducted by San Juan et al., [7] supported our results, be related to the variability in the population's age,
as he reported positive results of a 16-week supervised evaluation time post chemotherapy treatment, the
aerobic exercise program among children with ALL. intensity, and duration of the intervention.
Moreover, Adamsen et al., [29] showed that a high- It was suggested that increasing in aerobic
intensity exercise program for 6 weeks led to capacity by aerobic exercise program may due to the
improvement in VO2max by 16% in patients who effect of aerobic exercise on respiratory function and
suffering from cancer including leukemia. Earlier, the stroke volume of the heart. These respiratory
Sharkey et al.,[30] examined the efficacy of a 12-week adaptations help facilitation of oxygen supply to tissues
aerobic training program on the peak oxygen uptake which lead to the improvement of respiratory fitness
among childhood cancer survivors and he also reported [34].
an improvement in the patients' peak oxygen uptake. Our results are in consistent with prior studies
Furthermore a pilot study conducted by Kolden et al., that reported highest level of fatigue during and
[31] on women who had breast cancer, they suggested immediately following cancer treatment [35]. Moreover
significant improvement in cardiorespiratory fitness after it was determined that improvements in aerobic fitness
completion of a 16-week exercise training. have been accompanied with improvement in fatigue
In contrast Marchese et al., [32] evaluated the level [29, 36, 37]. These agreed with the findings of
effect of four months of exercise on cardiovascular Adamsen et al., [29], where they reported significant
response in children with ALL who received improvement of cardiovascular capacity (VO2max) of
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Acknowledgement
patients undergoing allogenic SCT. Bone Marrow
We would like to acknowledge the contribution
Transplant, 2009; 43(9):725–737.
of physical therapy faculty’s members to accomplish
[12] Speck RM, Courneya KS, Masse LC, Duval S,
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Schmitz K. An update of controlled physical activity
Children's Cancer Hospital Foundation 57357 for their
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The authors have no conflicts of interest to disclose. Exercise in adults and pediatric hematological
cancer survivors: an intervention review.
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