Fractures are a common side effect in children with ALL. Emma Verwaaijen, pediatric physiotherapist at the Sports and Movement Center and a PhD student at the van den Heuvel-Eibrink group, is researching the vulnerability of the musculoskeletal system in children with cancer. She recently published about her research in the Journal of Bone Mineral Research: 'The increased risk of fractures can have several causes: the leukemia itself, the treatment with corticosteroids, but also the nutritional status of a child and restrictions in movement have an influence on this. A previous prospective national study (ALL9) has shown that children with low bone density at diagnosis are more likely to suffer fractures during treatment for ALL.'
Emma says: 'We would rather not do a DXA scan on every child with ALL in the first week after diagnosis. Therefore, using all the available data, we have developed a simple formula that predicts low bone density and thus the expected fracture risk. This formula predicts with 71% certainty the probability of a child having low bone density at diagnosis of ALL, and was successfully validated on a cohort (group with the same characteristic) from Canada. An online calculation tool has also been developed, available from this website. The formula generates a warning signal: this child has a higher risk of fracture.'
A child's score can be used to anticipate the risk of reduced bone density and fractures. Emma: 'The score supports clinical decision-making: should an X-ray or DXA scan be made and/or how do we monitor a child's situation? It is also an extra reminder of the importance of nutritional and exercise interventions. For the latter, we as pediatric physical therapists are important. We can give children therapy from a very young age to strengthen muscles and increase load on bones. We prefer to do this very early in the treatment to prevent immobility. Children often feel sick and then it is important to stay on their feet. And simple: walking up and down the stairs is already good training.’
Moving to the max
Emma indicates the essence: 'It is a daily dilemma but can become a dangerous vicious circle: if a child feels very sick, it wants to stay in bed and lying down quickly reduces muscle strength. So maximum exercise (based on the exercise program of the same name in the Máxima Center) is very important. This applies all the more specifically to children with ALL: by training their muscles, a child keeps in shape and with better muscle strength and motor skills the risk of falling and fractures is also reduced.’