Expectations of physiotherapy intervention to a child with brain tumor, cerebral palsy and blindness.

Irene was born in January of 2015. When she was eight months old, she appeared nystagmus, she suffered sleepiness and tiredness and she was diagnosed with brain tumor on her optic nerve chiasma. Since then, she started physiotherapy sessions and currently she is on a two times per week intervention program. The purpose of this case study is to determine whether physiotherapy helps Irene improve on both physical and cognitive development

Keywords

hemiplegia, cerebral palsy, brain tumor, pediatric physiotherapy, motor development, sensory systems, hearing sense, tactile sense, oral sense, neuro-rehabilitation

Introduction

Cancer is the second cause of death in children. There was a 0,6% increase from 2007 up to 2011. The causes are unknown. Even so, brain cancer is more difficult to deal with. The whole procedure depends on the type of the tumor and the condition of the child. Also it requires great patience from the child, from the parents and from the treating doctors as well. Families are not only affected in psychological ways but in financial as well. Many times the children suffer from social exclusion caused by fear and they don’t really experience childhood.

Another thing that they have to deal with is the relapses which are very common and can be fatal for the patient. The optimist news is that 77% of children with cancer today have up to 5 years without any relapse.

This case report is about a girl, Irene, who suffers from cancer, cerebral palsy and blindness.

Medical History

Irene is 4 years old now and her condition is stable the past six months. When she was eight months old, she appeared nystagmus, she suffered sleepiness and tiredness and she was diagnosed with a brain tumor on her optic nerve chiasma. She got operated in Hamburg to specify the type and stage of the tumor. The diagnosis was pilocytic astrocytoma grade 1. During the operation the 85% of the tumor was removed but Irene came out of surgery blind.

One month after the surgery, the MRI showed that the tumor was in the same condition and size as before the surgery. The doctors, at that time, assumed that she won’t live long enough so they didn’t recommend chemotherapy.

In September of 2015, she suffered a cerebral hydrocephalus and she had an operation to place a brain valve. The surgery brought forth hypotonia, lack of will and bad mood, probably caused by fatigue. At this time, Irene, couldn’t even roll or sit, even if she was placed in that position.

Her parents decided she has to have physiotherapy intervention in order to boost her physical condition and the improvement was immediate.

Cancer in Childhood

We decided to search the bibliography about cancer in childhood and physiotherapeutic intervention during and after the chemotherapy or radiotherapy.

Cancer the second cause of death in children’s lives and there is an increase 0.6% cancer in childhood since 2011. Today 75% of children with cancer have up to 5 years without relapse. The causes of children’s cancer are unknown (Kloni Panagiota et.al, 2015). Family is also deeply affected by the situation both mentally and financially in addition to  the social exclusion of the child caused by fear or secondary side effects of the treatment. Most of the times it’s a life without anything that characterizes childhood

Jung M et al 2016 stated, CRF is underestimated in pediatric oncology and it is very crucial to identify the symptoms. This could lead to an improvement in quality of life. Exercise training improves physical functioning and fitness in pediatric BT survivors. Exercise interventions that ameliorate adverse physical effects and promote health in long-term survivors are highly recommended in this vulnerable population(Piscione PJ1  et al 2017). In addition to that, training is an effective means for promoting white matter and hippocampus recovery and improving reaction time in children treated with cranial radiation for brain tumors (Riggs L, et al 2017)

In a study, T1 significant differences between groups were found in motor performance and physical well-being. Improvements in motor performance, QoL and fatigue were found in both groups. The conclusion was that different preconditions must be considered. Childhood cancer patients as well as healthy siblings benefit from a family-oriented rehabilitation program. (Däggelmann J et al 2017).

An in-hospital exercise program for pediatric cancer patients with solid tumors undergoing neoadjuvant treatment increases muscle strength despite the aggressiveness of such therapy. (Fiuza-Luces C, et al 2017). The aim of the study was to investigate the effects of a 4-wk inpatient rehabilitation program on postural control and gait in pediatric patients with cancer. The results indicate benefits of an inpatient rehabilitation program comprising standard physical therapy as well as aquatic and hippo therapy on postural control and gait after treatment of pediatric patients with cancer. (Müller C et al 2017). Children with brain tumors (BTs) experience fatigue and decreased quality of life (QOL). Physical activity (PA) is recommended during and after cancer treatment. We explored whether a fitness tracker intervention combined with tailored coaching by a physical therapist (PT) increased PA and QOL and decreased fatigue in children with BTs. This is a feasible intervention that may contribute to an increase in PA and improve fatigue in children with BTs.(Ovans J et al 2018)

There is growing evidence that exercise induced experience dependent plasticity may foster structural and functional recovery following brain injury. The efficacy of exercise training for neural and cognitive recovery in long-term pediatric brain tumor survivors treated with radiation has been examined. Overall, the results indicate that exercise training in pediatric brain tumor patients treated with radiation has a beneficial impact on brain structure. There’s been an argument that exercise training should be incorporated into the development of neuro-rehabilitative treatments for long-term pediatric brain tumor survivors and other populations with acquired brain injury(Szulc-Lerch KU et al 2018)

Chronic health conditions and impaired quality of life are commonly experienced in childhood cancer survivors. While rehabilitation clinics support patients in coping with the disease, studies evaluating an inpatient rehabilitation program on promoting physical activity (PA) and health-related quality of life (HRQoL) are missing.
Immediate and sustainable increases in HRQoL indicate that a 4-week rehabilitation program is beneficial for improving psychosocial well-being, while the significant increase in PA levels could be related to general recovery as well. The lack of a control group hampers the evaluation of the rehabilitation program on promoting PA levels in pediatric cancer patients. (Müller C et al 2016)

We investigated whether active video gaming (AVG) could bring about regular, enjoyable, physical exercise in children treated for brain tumors, what level of physical activity could be reached and if the children’s physical functioning improved.  Childhood brain tumor survivors frequently have cognitive problems, inferior physical functioning and are less physically active compared to their healthy peers. Active video gaming (AVG), supported by Internet coaching, is a feasible home-based intervention in children treated for brain tumors, promoting enjoyable, regular physical exercise of moderate intensity. In this pilot study, AVG with Nintendo Wii improved Body Coordination. (Sabel M et al 2016)

Cancer-related fatigue (CRF) is a common and relevant symptom in patients with advanced cancer that significantly decreases their quality of life. The aim of this study was to evaluate the effect of a physiotherapy program on CRF and other symptoms in patients diagnosed with advanced cancer. The physiotherapy program, which included active exercises, myofascial release and PNF techniques, had beneficial effects on CRF and other symptoms in patients with advanced cancer who received palliative care. The results of the study suggest that physiotherapy is a safe and effective method of CRF management. ( Pyszora A et al 2017)

There are more than 13.8 million survivors of cancer living in the United States. Up to 20% of survivors of childhood-onset and 53% of survivors of adult-onset cancer have problems with physical function as a result of their cancer and or its treatment. These problems may be immediately apparent, during, or soon after initial cancer treatment, or may appear days, months, or years later as the cancer survivor ages. Unfortunately, rehabilitation services and providers are not easily or systematically accessible in today’s healthcare system. Rehabilitation services that restore or ameliorate early functional loss or that protect against or minimize the impact of later-onset organ system dysfunction are available, at least in larger comprehensive cancer center settings. This report describes physical function, details the evolution of cancer rehabilitation, and identifies cancer survivors who may benefit from rehabilitation services. Additionally, the evidence for specific approaches to rehabilitation, intervention, and prevention of functional loss are reviewed. Finally, we summarize the mechanisms used to measure physical function and stress the need for additional research to support rehabilitation services for cancer survivors. (Stubblefield MD et al 2013)

This study was performed to estimate the cost-effectiveness of a combined physical exercise and psychosocial intervention for children with cancer compared with usual care. Sixty-eight children, aged 8-18 years old, during or within the first year post-cancer treatment were randomized to the intervention (n=30) and control group (n=38). Health outcomes included fitness, muscle strength and quality adjusted life years; all administered at baseline, 4- and 12-month follow-up. Costs were gathered by 1 monthly cost questionnaires over 12 months, supplemented by medication data obtained from pharmacies. Results showed no significant differences in costs and effects between the intervention and control group at 12-month follow-up. On average, societal costs were €299 higher in the intervention group than in the control group, but this difference was not significant. Cost-effectiveness acceptability curves indicated that the intervention needs large societal investments to reach reasonable probabilities of cost-effectiveness for quality of life and lower body muscle strength. Based on the results of this study, the intervention is not cost-effective in comparison with usual care. Braam KI et al 2017

The purpose of this study was to assess the effects of an in-hospital exercise intervention during neoadjuvant chemotherapy on the inflammatory profile and immune cell subpopulation in 20 children with solid tumors (control [n = 11] and exercise group [n = 9]). Although no significant interaction (group × time) effect was found with an analysis of variance test, we found a trend toward an interaction effect for natural killer cells expressing the immunoglobulin-like receptor KIR2DS4, with their numbers remaining stable in the exercise group but increasing in controls. Our data support that exercise interventions are safe in pediatric cancer patients with solid tumors during chemotherapy treatment despite its aggressive, immunosuppressive nature (Fiuza-Luces C  et al 2017).

Pediatric patients undergoing cancer therapy. Exercise interventions are being created in response. This review summarizes current exercise intervention data in the inpatient pediatric oncology setting. Two independent reviewers collected literature from three databases, and analyzed data following the PRISMA statement for systematic reviews and meta-analyses. Ten studies were included, representing 204 patients. Good adherence, positive trends in health status, and no adverse events were noted. Common strategies included individual, supervised, combination training with adaptability to meet fluctuating patient abilities. We recommend that general physical activity programming be offered to pediatric oncology inpatients. (Rustler V et al 2017)

Exercise and adapted physical activity during and after treatment for childhood cancer have a large potential to diminish several side and late effects of treatment. However, the prevalence of such interventions is low. The aim of this investigation is to identify interventions in the clinical setting in Germany and to examine their quality and structural characteristics. The majority of childhood cancer patients in Germany do not have access to adapted physical activity during treatment or aftercare. The body of evidence for exercise therapy in the pediatric oncology setting is growing, as well as the network between exercise scientists/therapists in this field. To date, an exercise manual for pediatric oncology in German and a comprehensive financing option of such interventions via health insurance is not available. Söntgerath R et al 2017.The improved treatment protocols and subsequent improved survival rates among childhood cancer patients have shifted the focus toward the long-term consequences arising from cancer treatment. Children who have completed cancer treatment are at a greater risk of delayed development, diminished functioning, disability, compromised fundamental movement skill (FMS) attainment, and long-term chronic health conditions. The aim of the study was to compare FMS of childhood cancer patients with an aged matched healthy reference group. This study highlighted the significant deficits in FMS within pediatric patients having completed cancer treatment. In order to reduce the occurrence of significant FMS deficits in this population, FMS interventions may be warranted to assist in recovery from childhood cancer, prevent late effects, and improve the quality of life in survivors of childhood cancer. (Naumann FL et al 2015)

Physical therapy intervention for children with ALL receiving maintenance chemotherapy improved two body functions important for normal gait. Physical therapy programs initiated earlier in treatment and with greater emphasis on endurance activities may also improve stamina and quality of life (Victoria G et al 2003)

Young children in the maintenance phase of treatment against ALL can safely perform both aerobic and resistance training. Training results in significant increases in measures of aerobic fitness, strength, and functional mobility. During detraining, strength and functional mobility are well maintained, whereas V˙O2peak and VT are partially maintained (Alejandro San Juanet al 2007).

We demonstrated that an in‐hospital‐ and home exercise physical therapy program during the first four phases of medical treatments is feasible for children with ALL. Future randomized studies are needed to confirm whether an initial physical therapy program at diagnosis in children with ALL will limit functional impairments, improve overall fitness and increase health‐related quality of life. Shadi Farzin Gohar MD et al 2011 

Exercise in cancer

Exercise in general in cancer we know that helps a lot (Ovans JA et al. 2018 ) . After chemotherapy many researchers have shown that the expectations of life are better to patients who followed an exercise program (Riggs  L et al. 2017, Piscione PJ et al. 2017,Fiuza –Luces C. et al. 2017). Also patients who followed treatment and physiotherapeutic program had better perspective in life (Braam KI et al. 2017, Muller  C et al. 2016,).Patients after therapy for cancer who followed an exercise program had better organic and psychological results ( Szulc-Lerch KU et al. 2018, Sabel M. et al. 2016, Pyszora A et al. 2017, Daggelmann J et al. 2017) Exercises always have positive reaction to the body chemistry increasing endorphins and have also positive effectiveness to fatigue(Bhardwaj T. 2017, Jung M. 2016, Darcy L. et al, 2015)

Expectations

  • Having knowledge of her self
  • Self perception in space
  • Knowing the environment in and out of the house
  • Aware of danger in any case
  • Safe  walking in the house
  • Walking independently wherever she needs to
  • Common knowledge of what to do outdoor
  • Adjust to every challenge in her life
  • Life without risk
  • Psychological recovery for all
  • Purpose for life
  • Quality of life

Goals

  • Self awareness
  • Cognition of the environment
  • Awareness of the word meaning 
  • Self guidance to space around her by using her hearing sense
  • Knowledge of her body sides so she can follows oral guidance
  • Self orientation in the environment
  • Estimate dangerous around her
  • Standing in straight position without aid
  • Walking with oral guidance (1,2 step…stop, etc)
  • To be able to stand up without any help when she falls down
  • Cognitive mapping of her house via tactile perception
  • Stick assisted walking 
  • Moving anywhere without guidance
  • Be able to use her hand in gross and fine motor activity
  • Ability to stand on one leg
  • Normal walking
  • Climbing on stairs
  • Self-reliant

Tasks

  • Regain her ability to use her right hand
  • Cross the mid-line with her hand
  • Developed body awareness using her hands
  • Awareness of space using her tactile system
  • Balance of her body in standing position
  • Moving forward and backward with voice guidance
  • Knowledge of basic things in daily life activities
  • Use of two hands in daily activities
  • Walking without asymmetry and independently 

Intervention

We started physiotherapy on December of two thousand fifteen. After our first session she managed to keep the sitting position if she had been placed in this position. Physiotherapeutic sessions were three times per week. We intended to keep this schedule as long as she could even at the time she was in the hospital. We had the full collaboration of her parents and they totally had faith on what we were doing. In June of two thousand sixteen after six months of physiotherapy, Irene was able to walk independently and her vision was partially restored. Unfortunately, her second relapse was in August of the same year. Suddenly from one day to the next, she was unable to stand up, her right leg and hand got gradually very stiff, and she lost gross and fine motor abilities. All of this was because she suffered an ischemic stroke caused by the increase of the brain tumor’s size. Her blindness was back again and she was diagnosed with right hemiplegia. At that time she had the third operation, this time in Athens and the doctors removed fifty percent of the tumor. This time the doctors were optimistic. They recommended chemotherapy for the next 2 years. She had lost her ability to keep the sitting position once again! During that time she had two more surgeries, one for cerebral hydrocephalus and the other for cranial decompression. During this period of chemotherapy we decided to continue physiotherapy sessions for three times per week if her condition was good, but never less than one time per week, with the doctors’ approval. If necessary we would have our sessions in the hospital. Chemo lasted until July of 2018. In that time she was more symmetrical and independent. At the end of July, she diagnosed with brain valve inflammation and she had two more operations. Because of that, we had to stop physiotherapy for two months.

Since that period until now she had regained gross and fine motor activity, which she had lost. We are very proud to say that she is able to walk independently since January of 2019.

Achievements

At this time Irene is able to be fully aware of herself and the surroundings object of the environment. She can accomplish that by utilizing the hearing and tactile sense which have been used for guidance in every specialized activity according to her needs. She is completing both gross and fine motor activities in daily life bimanually and she is finally able to sit, stand up and walk individually. In addition she can perform the previous mentioned tasks with instructions like “stop walking now, ok very good start again” or “stop walking and lift your foot to climb the stair, very good Irene”. She needs assistance only to climb the stairs. Apart from all the motor developments, it is clearly obvious that Irene has grown in psychological terms as well. She is far calmer and patient when she is being instructed during motor tasks and daily activities.

Conclusion

The purpose of this case report was to present how we managed to deal with Irene’s case which is a complex one and what were the benefits of our physiotherapeutic intervention. Irene first came to us with no eyesight and really confused because of this loss. She was unable to interact with her close environment and deal with daily activities both in motor and psychosocial terms. Our physiotherapy intervention aimed to improve psychomotor development by interpreting her developmental needs into physiotherapeutic tasks. Her achievements after 3 years of physiotherapy are really valuable to us and especially her family and her well-being. Taking into account the fact that she had relapses in her medical condition resulting in many pauses to her intervention, we assume that our program which was based on the most current bibliography was well structured and properly executed for the individual case of Irene.

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