leukemia

Introduction

Acute lymphoblastic leukemia is a malignant proliferation of white blood cells that begins in the bone marrow and spills over into the blood stream, involving other organs in the process. The leukemic cells crowd out normal blood cells, Resulting in anemia, susceptibility to infection, and bruising (Wright et al., 2005).

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy accounting for approximately 26% of all childhood cancer (San Juan et al., 2007). 

Cure rate exceeding 80 % have been achieved with the use of protocols using multiage chemotherapy and prophylactic central nervous system (CNS) interventions (Wright et al., 2005).

As survival rates have increased for children with acute lymphoblastic leukemia (ALL). There is increasing attention to short term –complication and long –term out comes from cancer itself or the antineoplastic agents. neuromuscular and musculoskeletal complications include pain , parathesias, reduced deep tendon reflexes , muscle cramps , muscle weakness , reduced ankle dorsiflexion , impaired gross and fine motor performance ,  decreased energy expenditure , learning disabilities , avascular necrosis , osteopenia , and osteoporosis   (Marchese et al ., 2003).

Fatigue is the most frequently reported symptoms by persons with cancer, the problem affects up to 96 % of patient receiving chemotherapy, 78% of patient receiving radiotherapy and up to 80% of patient with advanced malignancy (Al-Majid and McCarthy, 2001).

Physical therapy intervention for children with ALL receiving  maintenance chemo therapy  improved body function important to normal gait  , physical therapy programs initiated earlier in treatment and with greatest emphasis on endurance activities may also  improve stamina and quality  of life ( Marchese et al ., 2003 ).

The physical fitness (as reflected by VO2  peak level) of ALL surviving tend to be reduced compared to healthy children impaired physical fitness lead to early fatigue during activities and can severely deteriorate the quality of life (QOL) of all survivors which suggest the need  for these  children to engage in regular physical activities .Exercise physiologist could assist oncologists in prescribing exercise program for attenuating cancer related fatigue and help Improve the physical fitness and QOL of children surviving cancer .Furthermore there are scientific indication that exercise training improve the function of immune system component ,and can attenuate tumor development (Brussel et al.,2005).

Statement of the Problems:

The ALL is a very prevalent socially disabling problem and is the most commomn childhood malignancy that lead to early fatigue and impairment of physical fitness during daily activities and severely deteriorate the quality of life. Therefore, from the rehabilitative point of view the problem of this study was stated in a questionery form:

 Does the exercise program play a vital role in treatment of children with acute lymphoblastic leukemia?  

Purpose of the Study:

The aim of this study was to evaluate the therapeutic efficacy of exercise training as a type of physical therapy approach in improving the cardiopulmonary endurance, the muscle strength, the cancer related fatigue and quality of life (QOL) by using three methods of assessment which were exercise test, hand-held dynamometry and Iowa fatigue scale.   

Significant of the Study:

The need for the present study developed from lack of quantitative information in the published literatures related to ideal and benefits of exercise therapy in cases of acute lymphoblastic leukemia. The importance of this study arises from the severity of lymphoblastic leukemia which leads to serious problems such as neuromuscular and musculoskeletal complications include pain, fatigue, muscle weakness, impaired gross and fine movement motor reflex.

Leukemia accounts for 30% of cases in children 0 to 14 and 25% of cancer occurring before age 20. Acute lymphoblastic leukemia (ALL) is the most child hood cancer (Ladha et al., 2006).

A malignant disease or its treatment may cause long term impairment in intellectual, emotional, and physical domains that diminish function (performance limitation). Performance limitation can restrict the survivors' ability to participate fully in daily activities necessary for self care, home management, or work participation restriction, delayed consequence of therapy of physical interest in children with cancer because of the potential remaining years of life that may be affected (                Ness et al., 2005).  

This present study assists to prove that physical therapy procedures especially exercise program is very effective and important line in the treatment package of acute lymphoblastic leukemia.

Delimitation:

This study was delimited to the following respect:

Subjects:

Forty children with acute lymphoblastic leukemia participated in the study; their ages were ranged from 6 to 12 years.

Equipment and Tools:

Measurement Tools:

·        Exercise test used to measure maximum functional capacity and endurance of cardio respiratory system.

·        Hand-held dynamometry(HHD) have been used to assess the  muscle strength  of both upper and lower body.

·        Iowa fatigue scale has been used to assess the fatigue.

Therapeutic Equipment and Tools:

·        Strength training include exercise engaging the major muscle groups (bench press , shoulder press , leg press, leg press, abdominal crunch , low back extension , arm curl , elbow extension).

·        Stretching exercises of the muscle involved in the previous exercises was performed.

·        Aerobic exercise consisted of pedaling a cyclic ergometer, running and walking on treadmill.

Limitations:

 This study was limited by the following factors:

·        The effect of environmental variable during treatment time such as unmentioned diseased or infection.

·        Psychological status of the patients at the times of measurement and treatment might affect the results.

·        Individual difference in patients and their influence on treatment program.

·        Possible human error in measurement.

·        Co-operation of child with therapist was a vital factor of level of understanding and the degree of awareness of the treatment.

·        Cancer pain might affect the performance of the child.

Hypothesis:

It was hypothesized that exercise training as a physical therapy intervention are not effective treatment approach in

·        improving the  cardiopulmonary endurance and physical fitness ,

·        improving the muscle strength ,

·        Improving the cancer related fatigue and quality of life (QOL).

Basic Assumptions:

It was assumed that

·        All information that has been taken from the patients was correct.

·        All patients received the same routine of medical treatment and equivalent care.

·        The patient of the study group received equal time of treatment.

·        All patients followed the instructions and advices during treatment.

·        All patients were under the same psychological and mental conditions and situations.

·        Both evaluative and therapeutic tools were valid.

Definition of Terms:

The following terms are defined for a clear understanding of the terminology used in the present study:

Acute Lymphoblastic Leukemia:

Acute lymphoblastic leukemia is a malignant proliferation of white blood cells that begins in the bone marrow and spills over into the blood stream, involving other organs in the process. The leukemic cells crowd out normal blood cells .resulting in anemia, susceptibility to infection, and bruising (Wright et al., 2005).

Aerobic Exercise:

Defined as the rhythmical contraction and relaxation of large masses over an extended time (Dimeo et al., 1997).

Cancer -Related Fatigue:

Cancer –related fatigue (CRF) has been operationally defined by the national comprehensive cancer network (NCCN) as a persistence, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning (Mock et al., 2001).

Muscular Strength:

          Muscular strength is a force or torque produced by muscle during a maximal voluntary contraction (Deusen and Brunt, 1997).

Quality of Life:

          The term ''quality of life and more specifically-related quality of life ''refer to the physical and social domains of health that are influenced by disease process (Testa and Simonson, 1999).