INTRODUCTION AND PURPOSE
Children hospitalized with oncological diagnoses are at high risk for developing decreased mobility, fitness, balance, and strength due to decreased functional activity as they undergo treatment.1,2 Induction therapy is the first step in cancer treatment, which is followed by additional therapies such as chemotherapy, radiation, and stem cell transplants. Once cancer is in remission, maintenance therapy is used to prevent a relapse. Children with one of the most common childhood cancers, acute lymphoblastic leukemia, often receive chemotherapy for 2.5 to 3.5 years. Side effects of chemotherapy as a treatment for cancer include delayed growth and development, depression and anxiety, chronic pain, hearing loss, weakness in bone structure, cardiovascular and heart problems because of chemotherapy and radiation to the spine or chest wall, scarring of lung tissue and increased risk of lung inflammation and infection, and muscle wasting and decreased balance in the lower extremities.2–4
Limited information on guidelines for physical activity for children undergoing oncology treatment is available.5 Children are likely to have individualized responses to exercise programs regardless of the type of cancer and stage of the disease and require an individual exercise prescription.6 Participation in a structured therapeutic exercise program can provide a safe environment in which pediatric oncology patients can exercise at a level appropriate for their unique needs.7 Cancer survivors who participate in exercise programs during treatment may be more motivated to continue exercising if regular exercise is experienced as a positive change in quality of life and physical fitness.8,9 Low-impact exercise programs have been beneficial in improving physical activity level and reducing fatigue in cancer patients undergoing treatment for hematological malignancies.10 Children with oncological diagnoses who received stem cell transplants demonstrated improved maximal oxygen consumption as a response to exercise.11 Exercise programs that stress balance have been found to improve lower extremity balance, strength, and proprioception as much as more traditional exercise programs.12,13 Results from previous studies on exercise for pediatric oncology patients suggest that many patients had lower levels of physical activity and perceived quality of life during and after cancer treatment.14 Yoga is a low-impact exercise that has been incorporated into pediatric exercise programs for strength, balance, pain control, and quality of life.15 Studies are needed to determine the efficacy of yoga as part of a low-impact exercise program for children with cancer. Prolonged periods of treatment affect quality of life for children with oncological diagnoses.16 Information on how exercise affects quality of life must be gathered to support the development of appropriate exercise programs for this population.17,18
Bendy Kids Yoga (BKY) (Figure) is a low-impact exercise program, developed by the authors, incorporating stretching, strengthening, balance, breathing technique, relaxation, and body awareness in an hour-long therapeutic yoga session uniquely adapted to individual patients with the help of trained physical and occupational therapists, assistants, and rehabilitation aides.
The BKY program was designed for children with oncological or hematological diagnoses to improve strength, flexibility, endurance, and quality of life. The BKY program took place at Seattle Children's Hospital from October 19, 2004, through October 19, 2006.
Participants and families received information on the BKY program and the yoga study when they were admitted to the oncology/hematology unit at Seattle Children's Hospital. Children and families who chose to participate in the yoga study filled out a PedsQL 4.0 quality of life survey before the initial yoga session and again after 5 BKY sessions over a 2-month period.
The goal of this project was to determine the feasibility of using therapeutic yoga to improve quality of life in children hospitalized with oncological/hematological diagnoses as measured on the PedsQL 4.0 quality-of-life measure (Table 1).
Participants and Setting
Six children (Table 2) and 4 parents/caregivers participated in this study. The sample included 2 children (aged 6 and 10 years) with acute lymphoblastic leukemia, 1 child (aged 5 years) with acute myoblastic leukemia, 1 adolescent (aged 19 years) with acute lymphoblastic leukemia status post–bone marrow transplant, 1 adolescent (aged 15 years) with Ewing sarcoma, and 1 adolescent (aged 12 years) with Fanconi anemia status post–bone marrow transplant. Participants had no comorbid disease or developmental disorders and were not in the induction phase of treatment. Participants were hospitalized a minimum of 5 weeks and were seen for therapeutic yoga once per week. The 6 youths were receiving physical or occupational therapy services 1 time per week while in the BKY program. The sample was heterogenous with respect to race/ethnicity with 2 white/non-Hispanic, 2 Hispanic, 1 Asian/Pacific Islander, and 1 African American participating in the study.
Quality of life was the outcome variable used to evaluate the effect of therapeutic yoga on pediatric inpatients with oncology/hematology diagnoses that participated in the study.
The PedsQL 4.0 (www.pedsql.org) is a pediatric Quality of Life Inventory designed to measure health-related quality of life in children and adolescents aged 2 through 18 years. The reliability and validity of the PedsQL 4.0 have been demonstrated in healthy and patient populations.19 The PedsQL 4.0 is a brief quality-of-life measure with parallel parent and child forms and developmentally appropriate versions for children of different ages. Domains measured are physical, emotional, social, and school function. Items are rated on a 5-point Likert scale from 0 (never a problem) to 5 (almost always a problem). Raw scores that trend toward smaller scores indicate improvement in function. Scores are then reverse scored and linearly transformed to a 0 to 100 scale with higher scores indicating better health-related quality of life and more positive change from baseline. The PedsQL 4.0 was chosen since it has been used to assess quality of life in children with cancer20 and includes child and caregiver subjective measures of the child's physical, emotional, social, and school function. Data were obtained regarding school function because children received educational services while hospitalized.
Children and families admitted to Seattle Children's Hospital for treatment of oncology-related diagnoses were invited to participate in the BKY program upon admission. Two hundred fifty-six children and their families participated in the BKY program over a 2-year period.
Participation in the study was limited to children who were able to attend 5 consecutive weekly BKY sessions over a 5-week period. Information was provided to all participants regarding the BKY study to examine effects of therapeutic yoga on pediatric quality of life. Children and families who agreed to participate in the study gave signed consent and were subsequently contacted by the research team. All aspects of the study were approved by the internal review board and Scientific Advisory Committee of Seattle Children's Hospital. After the initial physician order was obtained, participants were cleared medically to participate before each class based on absolute neutrophil and platelet levels established by the medical staff (platelet counts more than 5000, absolute neutrophil count more than 200, and hemoglobin 8–10 g/dL).
BKY instructors and assistants were physical and occupational therapists and assistants employed at Seattle Children's Hospital. All instructors and assistants received specialized training in therapeutic yoga instruction from Seattle area yoga professionals in addition to their own yoga practice. Modifications to yoga poses and physical support were provided at each class so that children of all levels of physical ability could participate. BKY classes took place twice weekly in an open space on the oncology inpatient floor. The yoga space was set up with sanitized floor mats for safety and chairs and bolsters for support. Group classes consisted of up to 6 children and adolescents, 1 instructor, and a positioning assistant. Families and caregivers were encouraged to participate. Children with isolation precautions participated in BKY in their rooms. Classes were 1-hour long, per child tolerance. Classes consisted of breathing exercises, followed by yoga postures, and ended with relaxation/stress management. Classes were modified to accommodate the age of the participants. Breathing exercises typically were designed to improve respiratory capacity and strength of respiratory musculature. Older children participated in yoga positions/asanas, whereas younger children typically played yoga games. Examples of games included using giant hula-hoops held by instructors as props to assist children performing standing yoga poses or more difficult balance activities. Yoga bowling was a favorite where children assumed the butterfly pose and leaned to avoid a beach ball rolling by, without tipping over. Storytelling was also incorporated with children choosing yoga poses to illustrate a story. Music was incorporated into more active yoga sessions including children's favorites, classical music, and live music with music therapists joining and assisting children with musical instruments in yoga sessions. Children of all ages participated in post-yoga relaxation activities ranging from gentle breathing exercises, guided imagery, or modified yoga Nidra (yoga relaxation to decrease tension and anxiety). Children reported that they looked forward to BKY yoga sessions on both good and tough days because they could always find ways to participate at BKY and always felt better afterward.
Data Acquisition and Analysis
Children and caregivers were administered the PedsQL 4.0 before their first BKY class and again after 5 classes were completed in a 2-month period. A summary score was obtained for each of the 4 domains of the PedsQL 4.0 for each child and caregiver who agreed to participate in the study.
The Wilcoxon signed rank statistic was used to analyze the small participant number (6 children and 4 caregivers). Results are summarized in Table 3 for cumulative transformed PedsQL 4.0 scores. Outcomes were statistically significant (.016) at P < .05 for the child perception of physical function. Scores in the other domains of the PedsQL were not statistically significant for either child or parent/caregiver function but did show a positive trend in all domains (Table 3).
The significant change in scores for child perception of physical function in this feasibility study suggest that 5 weekly yoga classes over a 2-month period may improve the perceived physical function of a child hospitalized with oncological/hematological diagnoses. Significant score changes in the physical domain of the Peds QL 4.0 include positive changes in the categories of walking, running, participating in play, sports, and exercise, lifting heavy objects, bathing, need for help with chores/picking up, level of aches and pains, and energy level (Table 3). These data support the use of a gentle physical activity such as therapeutic yoga, to improve quality of life and physical function in young patients hospitalized for oncological/hematological diagnoses.
Scores on the parent perception of physical function and child and parent perception of emotional, social, and school function sections of the PedsQL 4.0 were not statistically significant but showed positive trends in each category.
Limitations of this feasibility study include small sample size, mainly a female sample, and lack of a control group. Replicating this study on a larger scale, with a similar number of male and female participants, would improve the validity of the findings that therapeutic yoga, adapted to individual children, improves both parent and child perceptions of physical function while children are hospitalized for cancer treatment. A larger sample may also show statistical significance in the areas that showed positive, but not statistically significant, trends in this small sample.
Replicating this study with a control group that did not receive therapeutic yoga would help strengthen the study and rule out confounding factors such as physical activity and other therapies/activities that may have influenced outcome measures. Further studies should also document individual participant's oncological/hematological treatment protocols while they were hospitalized that could affect overall function and quality of life. Including a second objective outcome measure of level of physical function in additional studies would help determine if BKY improves behavior as well as perception of physical function.
A total of 256 children participated in BKY, but only 6 children and 4 caregivers participated in this study. This was mainly due to children being discharged before they attended 5 weekly BKY classes and children being too medically fragile to attend enough classes during hospitalization to participate in the study. Changing the parameters of the study to accommodate a child's short stay and/or medical fragility could increase the number of participants in future studies.
Most studies done so far, including ours, have implemented relatively short-exercise programs (5–16 weeks) for children with oncological diagnoses.1 These children may benefit from exercise programs that last from the time of initial diagnosis and treatment through survivorship, with programs uniquely adapted to each child's physical and mental capability at each phase of their treatment and beyond. Yoga is an activity that can be broadly adapted to include relaxation, imagery, and breathing exercises initially with progression to poses/asanas that challenge strength, balance, and proprioception as a child becomes stronger. Physical therapy with yoga techniques could be easily implemented as an alternative to or in conjunction with more traditional exercise programs 1 to 2 times per week.
Findings of this small feasibility study point to the importance of encouraging physical activity during hospitalization for children with chronic illnesses such as cancer. It is a challenge to find activities children look forward to, despite not feeling well. Therapeutic yoga provides gentle activities to promote strength, balance, and range of motion. It can take place in individual sessions or in small groups to encourage socialization and friendships. Therapeutic yoga can deliver individual attention, support, and positioning to individuals within a group or during individual sessions, so children of all mobility and energy levels can participate. Children can stand, sit, or work from a mat, while practicing breathing exercises, yoga positions, yoga games, and relaxation. Family and friends can watch or join in if they are able. Therapeutic yoga is a joyful activity that encourages mobility, socialization, and participation despite chronic illness. These feasibility study data suggest that therapeutic yoga positively affected the child's perception of gross motor function measured on the Peds QL 4.0. Further studies are needed, including a randomized control trial and larger participant numbers, to clarify and confirm the effect of therapeutic yoga on children hospitalized with cancer.
The authors thank Professor James Varni for the permission to use the PedsQL TM. The authors express gratitude to the children and families who participated in this study, Marcia Ciol for Biostatistics, Gabriel Vila-Blanco and Michael Lyons for the BKY logo, and Seattle Children's Hospital.
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adolescent; cancer; child; oncology; quality of life; therapeutic yoga