Clinician's Commentary on Ospina and McNeely.

Abstract

Physiotherapists are an essential part of the multidisciplinary team involved in treating children with cancer.2 Physiotherapy (PT) intervention aims to reduce morbidity and address the side effects of treatment that result in functional impairment.3 Cur­ rent research supports the feasibility of PT programmes during and after cancer treatment,4,5 but the question of how the cur­ rent literature informs clinical practice remains. To answer this question, Ospina and McNeely performed a scoping review of the literature. Their goal was to identify the current state of research examining PT techniques that address specific impair­ ments or functional limitations and to identify any gaps in the literature.1 After reviewing all eligible articles, Ospina and McNeely con­ cluded that the current state of the literature did not inform clin­ ical practice.1 They found that translating research findings into practice was impaired because of the use of functional interven­ tions that could not be defined and because of the heterogeneity of the study populations. In addition, the authors acknowledged a lack of input from clinician experts, which would have pro­ vided a unique perspective on the benefits of PT intervention for children with cancer. In this commentary, I provide insight into (1) the challenges associated with carrying out research and im­ plementing research findings and (2) what appears to make PT effective with this unique population. Most PT intervention for children with cancer occurs during acute care management or into survivorship. Children acquire many impairments during the acute stage of therapy, and PT intervention may mitigate them. During acute care, the goal of PT is often to maximize functional independence to ensure a safe discharge home. Functional mobility becomes the priority at this stage, and it may include gait aid training, strengthening for transfers and mobility, and educating parents on ways to help the child improve function. However, this type of interven­ tion does not always translate into concrete techniques that can be defined for research; rather, they are unique to the specific needs of the individual. In addition, the variability of a child’s response to therapy is often a barrier to PT intervention and carrying out research dur­ ing this stage. Although physiotherapists often have more access to children during a hospital admission, this is when children appear to be the most unwell. Regardless of what type of cancer diagnosis a child has, the child may have the challenges of medi­ cation side effects, immune system vulnerability, fatigue, nausea, pain, and poor sleep hygiene. In addition to these challenges, some cancer diagnoses may be associated with other, specific common impairments. Ospina and McNeely suggest that it may be beneficial for research to stratify specific cancer types to help identify com­ mon impairments that would respond to similar interventions,1 at least for some populations. This may be the case for children with standard-risk leukemia. Common impairments are not lim­ ited to but may include osteopenia, central myopathy, and peripheral neuropathy from the combined effects of steroids and chemotherapy.6,7 It is possible, then, that similar outcome mea­ sures can be used for objective PT assessment for most children with this diagnosis. In addition, treatment prescription to address common impairments may involve specific exercises or manual therapy techniques that are clearly defined. In contrast, children with solid tumors or central nervous sys­ tem tumors that require surgery often require much more indivi­ dualized intervention using a hands-on approach that has proven difficult to define in research. Two children with the same tumor may present quite differently after surgery as a result of the variability associated with the exact structures in­ volved, as well as unpredictable complications that can occur during or after surgery. These populations may not have the same impairments, and the same PT techniques cannot always be used on the basis of diagnosis alone. Patient-centred care essentially recognizes differences and supports providing individualized care. It can be defined as de­ veloping healing relationships founded on strong communica­ tion and trust.8 Patient-centred care has been found to improve patient satisfaction and the quality of outcomes.8 As a phy­ siotherapist who works with children who have cancer, my opin­ ion is that developing trusting, therapeutic relationships results in successful treatment sessions that are more likely to produce good outcomes. This is not to say that evidence-based interven­ tion is not valuable; however, each child being treated for cancer requires a unique approach and has unique needs that do not always coincide with research findings. Appreciating the com­ plexity and variability of these children and being flexible in pro­ viding treatment strategies that are tailored to their needs often lead to clinical successes that have a positive impact on their quality of life.