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.