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Physical Activity, the Childhood Cancer Symptom Cluster–Leukemia, and Cognitive Function: A Longitudinal Mediation Analysis

Hooke, Mary C., PhD, APRN, PCNS, CPON; Rodgers, Cheryl, PhD, RN, CPNP, CPON; Taylor, Olga, MPH; Koerner, Kari M., MPH, CHES; Mitby, Pauline, MPH; Moore, Ida, PhD, RN, FAAN; Scheurer, Michael E., PhD, MPH; Hockenberry, Marilyn J., PhD, RN, PPCNP, FAAN; Pan, Wei, PhD

doi: 10.1097/NCC.0000000000000634

Background Children undergoing leukemia treatment report co-occurring symptoms of fatigue, sleep disturbances, pain, nausea, and depression as a symptom cluster. Physical activity (PA) is essential for development and may influence symptom severity. Children with leukemia are at risk of cognitive impairments from central nervous system therapies. Using a longitudinal parallel-process model, relationships among function and symptom clusters were explored.

Objective This study examined the longitudinal mediation effects of PA on cognition via a symptom cluster during leukemia treatment.

Methods Symptoms, PA, and cognitive function of 327 children aged 3 to 18 years were measured over 4 intervals during the first year of leukemia treatment. Children 7 years or older self-reported and parents reported for younger children. Parents completed cognitive function measurements for all children. The influence of the first time point and the subsequent change between all 4 time points of PA on the symptom cluster were explored. Analysis determined whether the symptom cluster mediated the effect of cognition over the treatment period.

Results Patients with a higher PA at time 1 reduced their symptom cluster severity over the measurements. However, when PA increased over the measurements, symptom cluster severity also increased. When the symptom cluster was more severe at time 1, cognitive function was lower at time 1, and cognitive function decreased over time. When symptoms became more severe over time, cognitive function declined.

Conclusions The symptom cluster acted as a mediator between PA and cognition.

Implications for Practice Symptom management during treatment may be an additional strategy for protecting cognitive function.

Author Affiliations: School of Nursing, University of Minnesota, Minneapolis (Dr Hooke); School of Nursing, Duke University, Durham, North Carolina (Drs Rodgers, Pan, and Hockenberry); Texas Children's Cancer and Hematology Centers/Baylor College of Medicine, Houston (Ms Taylor and Dr Scheurer); College of Nursing, University of Arizona, Tucson (Ms Koerner and Dr Moore); Children's Minnesota Cancer and Blood Disorders Program, Minneapolis (Ms Mitby and Dr Hooke).

This was study supported by a National Institutes of Health grant (RO1CA1693398) and the Alex's Lemonade Stand Foundation.

The authors have no conflicts of interest to disclose.

Correspondence: Mary C. Hooke, PhD, APRN, PCNS, CPON, School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455 (

Accepted for publication May 10, 2018.

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