Discussion
Pediatric patients who participated in SPRINT made significant functional gains in the domains of self-care and mobility. These findings are similar to those in studies evaluating functional outcomes of pediatric patients undergoing inpatient rehabilitation. Studies have shown that children and adolescent with oncologic diagnoses make significant functional improvements in self-care and mobility domains after receiving inpatient rehabilitation services.15,16,17 In the domain of social function, functional expression was the only activity that demonstrated a significant gain at the end of SPRINT. While this may be related to the small number of children requiring ST services during SPRINT and possibly under-evaluation of the social function domain by ST as a result, a study by Tsao et al also demonstrated no significant change in a cognition domain of a functional measurement scale that includes language and social tasks in patients with cancer diagnoses undergoing inpatient rehabilitation.
Consisting of a wide range of children in age, race, and hematologic and oncologic diagnoses, SPRINT participants all have experienced significant functional decline during their hospitalizations to require intensive therapies prior to their discharge. The functional deficits of these patients are likely reflective of the cumulative effects of their disease process, treatment side effects, and/or other medical complications. Compared to healthy controls, children with acute lymphoblastic leukemia have demonstrated impairment in balance6, fine and gross motor performance5,9,18,19 before, during, and after cancer treatment. Weakness, gait abnormalities, scoliosis, neurogenic bowel and bladder can be presenting symptoms and sequelae of disease and treatment in children with spinal cord tumors.20 A study of children with brain tumors reported an impaired ability of patients to perform self-care tasks and domestic activities, as well as reduced engagement in play and leisure and interpersonal relationships in the first six months after surgery.21 Neurocognitive dysfunction is also common for children with cancer, with multiple contributing factors related to disease or treatment, personal characteristics, and psychosocial impacts.22,23
Hospitalizations also contribute to reduced mobilization in pediatric patients. In a retrospective study evaluating mobilization patterns of hospitalized children in a Hem-Onc inpatient unit, 43% and 18% patients mobilized between 3-5 days and <3 days per week respectively, and caregiver assistance was required for mobilization 91% of the time. Isolation and fever correlated with later and less frequent mobilization during hospitalizations.10 In another study, pediatric patients with oncologic diagnoses engaged in 58% of activities recorded by accelerometry during inpatient stays compared to home, and in contrast to healthy controls, patients took 23% gait cycles per day during inpatient stays and 40% at home.11 With all SPRINT participants demonstrating generalized weakness or deconditioning, long hospitalizations with a median LOS of 68 days in this study may have contributed to these patients’ functional decline in addition to the effects related to their disease or treatments.
Despite having received PT, OT, and/or ST during the hospitalization prior to SPRINT, children and adolescents in this study still demonstrated significant functional impairments and were recommended for intensive therapies. This highlights the severity of these patients’ functional impairments and possibly reflects the difficulty with making steady functional progress while receiving acute medical care without intensive therapies. Conventionally, inpatient rehabilitation service in acute care hospitals or in stand-alone facilities provide intensive rehabilitation programs to address patients’ functional needs across multiple therapy disciplines. However, considerations for the timing and model of rehabilitative care delivery for patients hospitalized for acute medical care need to incorporate patients’ medical stability and treatment plans as well as their own functional goals. When a patient does not meet criteria to discharge from an acute care service yet demonstrates the ability to participate in intensive rehabilitation, SPRINT is an example of an intensive therapy program that can address functional needs without interfering with the patient’s acute medical care needs.
In addition to daily therapies, the efficacy of SPRINT is likely bolstered by the structure and multidisciplinary involvement of the program, which include a discussion of the patient’s functional goals at the start and end of the program, expectations for active engagement from patients and families, and scheduling of therapy sessions to minimize interruptions. Therapy sessions and exercises outside of therapy sessions are conducted under direct supervision and guidance of SPRINT therapists. In a systematic review and meta-analysis of randomized control trials of exercise training in childhood cancers, adolescents demonstrated better adherence to the training program and training-induced adaptations with supervision.24 In a consensus statement on exercise guidelines for cancer survivors, supervised exercise programs appear to be more effective than unsupervised or home-based programs.25 Receiving direct guidance from therapists likely contributed to the success of SPRINT participants in attaining functional goals. Half of the patients in this study cohort were able to discharge home without requiring additional intensive therapies after SPRINT completion.
Six patients required ongoing intensive therapies after SPRINT to address their functional deficits and were able to eventually transition to inpatient rehabilitation. For many, SPRINT is not a substitute for inpatient rehabilitation, which provides additional services as part of comprehensive rehabilitative care, such as rehabilitation psychology, neuropsychology, therapeutic recreation, and education. The specialists of these services address patients’ adjustment to illness and disability, evaluate neurobehavioral and cognitive deficits, provide opportunities for community reintegration with outings and adaptive leisurely activities, as well as formulate supportive school plans to optimize children’s return to school. Rehabilitation nurses are also essential in providing skilled care and training for patient and families on neurogenic bowel, bladder, and skin management.
While the benefits of SPRINT in patients’ functional gains are delineated in this study, there remain room for improvement in the program and limitations to this study. The two-week length of SPRINT program may be a limitation, as some participants benefitted from a longer duration of intensive therapies to achieve additional functional goals and eventually transitioned to inpatient rehabilitation. The small number of available questionnaire responses from parents and patients likely was insufficient in detecting changes in patients’ subjective symptoms. The brevity and lack of validation of the questionnaire in this study may not have captured the breadth of symptoms and emotions experienced by hospitalized children with oncologic and hematologic diagnoses. Furthermore, parents’ report of their child’s symptoms may also differ from the child’s self report, which would be important to differentiate in order to better understand the effects of intensive therapy on children during hospitalizations.