Pediatr Blood Cancer 2009;53:438–443
Level of Activity in Children Undergoing Cancer Treatment
Corinna Winter, MA,1* Carsten Müller, MA,1 Mirko Brandes, PhD,2 Anja Brinkmann,1 Christiane Hoffmann,
Jendrik Hardes, MD,4 Georg Gosheger, MD,4 Joachim Boos, MD,3 and Dieter Rosenbaum, PhD1
Background. The diagnosis of cancer bears severe implications
for pediatric patients. One immense restriction consists in a reduced
level of activity due to different factors. Physical activity affects
various aspects of development and can be regarded as an essential
part of a child’s life. In the present study physical activity in patients
undergoing cancer therapy was quantified in order to determine the
extent of the restriction and to provide baseline information for the
assessment of possible interventions. Procedure. Physical activity in
80 patients and 45 healthy children matched for age and gender
was measured using the StepWatch 3TM Activity Monitor (SAM,
OrthoCare Innovations). Results. Pediatric cancer patients, at 2,787
gait cycles (gcs) per day, were significantly less active than their
healthy counterparts (8,096 gcs). Patients were significantly more
Key words: bone tumor; childhood cancer; leukemia; physical activity
INTRODUCTION
Cancer and cancer treatment bear severe implications for young
patients. Almost all of the patients experience a reduction in their
level of activity, apart from other restrictions [1]. Even though these
mechanisms are widely recognized very little research has been
conducted on pediatric cancer patients undergoing treatment.
Possible reasons for a limited activity level include the disease
itself, chemotherapy and local therapy, and the patient’s low self-
confidence regarding his/her physical capacity [2]. During inpatient
treatments the patients are restricted to the ward and they are usually
connected to medical devices, so that mobility is further reduced.
The impact of restrictions may vary between diagnostic entities as
treatment regimes differ considerably. One major difference is that
some patients have to undergo surgery while others are treated non-
surgically.
Previous studies investigated either long-term survivors or
leukemia patients on maintenance therapy and mainly used self-
reports as a measuring device [3–5]. Questionnaires have been
found to be very inconsistent, and accelerometry has proven to add
precision to activity measurements [6]. Only one study so far has
used accelerometers in pediatric cancer patients [3].
A positive relationship between physical activity and motor
proficiency as well as self-image and problem behavior in healthy
children has been shown [7,8]. Even though the level of physical
activity in healthy and severely ill children cannot be expected to be
comparable, the extent of the restriction is of great interest and may
shed light on the potential impact of disease-induced inactivity in
these patients.
The present study provides quantitative data on the actual extent
of activity restrictions during treatment and thus establishes a basis
for planning appropriate interventions. Furthermore, an appropriate
tool for assessing the effects of such interventions is presented. The
main research questions asked in this study were: To what extent is
the level of activity reduced in pediatric cancer patients as compared
to a healthy control group? What are the differences, if any, between
inpatient stays and home stays? Does the type of cancer and its
treatment have an influence on the level of activity? Is there a
predisposition to inactivity associated with any particular cancer?
ß 2009 Wiley-Liss, Inc.
DOI 10.1002/pbc.22055
Published online 4 May 2009 in Wiley InterScience
(www.interscience.wiley.com)
MD,
3
active at home than during inpatient stays (3,185 gcs compared to
1,830 gcs), and patients with bone tumors were less active than those
with leukemia regarding both, the amount (1,849 gcs vs. 2,992 gcs)
and the intensity of activity. Conclusion. The present study quantified
an often observed but so far hardly assessable problem. Activity in
cancer patients is considerably reduced and patients with bone
tumors are at increased risk from the detrimental effects of prolonged
inactivity. Both our findings and the accepted fact that activity is an
essential element of child development confirm the need for
interventions tailored to a patient’s needs and abilities during the
course of treatment. Pediatr Blood Cancer 2009;53:438–443.
ß 2009 Wiley-Liss, Inc.
MATERIALS AND METHODS
Subjects
From January 2005 to June 2007, patients between 5 and 18 years
of age admitted to the Department of Pediatric Hematology and
Oncology at the University Hospital Muenster for cancer treatment
were asked to participate in the study, which had been approved by
the local Ethics Committee. Informed written consent was obtained
from the patients and their guardians. The patients were asked
to wear Step Activity Monitor (SAM) for at least seven
consecutive days, preferably during inpatient stays as well as at
home. Due to differences in the duration of hospital stays the exact
number of SAM-equipped days spent in hospital and at home could
not be prescribed for all of the patients. Nevertheless, the effect of
staying in hospital could still be determined. Patients were excluded
if they were unable to walk or if the measurement would have
interfered with their treatment or medical examinations.
Owing to variations in treatment procedures and differences
between treatment protocols activity measurements could not be
taken at the same treatment phase in all patients. A total of
123 patients were asked to participate in the study. Eight patients
refused to take part because of an assumed low level of activity or
——————
Abbreviations: SAM, Step Activity Monitor; gcs, gait cycles.
1
Motion Analysis Laboratory, University Hospital Muenster,
Muenster, Germany; 2Institute of Sports Sciences, University of
Bremen, Bremen, Germany; 3Department of Pediatric Hematology and
Oncology, University Children’s Hospital Muenster, Muenster,
Germany; 4Department of Orthopedics, University Hospital
Muenster, Muenster, Germany
None of the authors has to report any conflict of interest.
Grant sponsor: Else Kröner Fresenius Stiftung; Grant number: P46/05//
A68/04//FO; Grant sponsor: Deutsches Stiftungszentrum, Karl-Heinz
Frentzen Stiftung; Grant number: T328/15887/2006.
*Correspondence to: Corinna Winter, Funktionsbereich Bewegungsanalytik,
Domagkstr.3, 48149 Muenster, Germany.
E-mail: winterco@uni-muenster.de
Received 7 November 2008; Accepted 11 March 2009
 Daily Activity of Pediatric Cancer Patients 439

operates without providing feedback to the user thus minimizing test

bias.
Patients and control subjects were instructed to wear the SAM
for 7 days during waking hours. The time periods were additionally
documented in a log list.

Fig. 1. Recruitment of patients (including drop-out and non-
inclusion).
lack of interest, and 35 patients had to be excluded for incomplete-
ness of measurements. A total of 80 patients could thus be evaluated
(Fig. 1).
Healthy children recruited in and around the city of Muenster
served as control group. The controls had an age and gender
distribution similar to the patient group and were comparable with
respect to height, weight, and BMI.
Step Activity Monitor (SAM)
The level of activity was quantified by the number of gait cycles
(gcs) measured with the StepWatch 3TM Activity Monitor (SAM,
OrthoCare Innovations, Seattle, WA). This device is a small
7.5 cm
5 cm
2 cm, light-weight (43 g), uniaxial accelerometer.
It is attached to the ankle with an elastic strap and is unobtrusive to
the user.
The SAM counts and stores the number of gcs in 1-min intervals.
One gc consists of two steps. Furthermore, the SAM distinguishes
different movement intensities by recording the number of gcs
per minute. Three levels of intensity can be distinguished: low
(1–20 gcs per min), moderate (21–40 gcs per min), and high (more
than 40 gcs per min). A count above 40 gcs per min requires
continuous walking so that this level can be considered a relevant
threshold for actual physical activity [9]. The monitor was validated
in several studies in adults as well as children and achieved about
99% accuracy [10]. It has been used successfully in studies
involving children with different diseases [11,12]. Before measure-
ment, the unit is programmed to the patient’s height and gait
dynamics, that is, the patient’s usual walking speed (normal, fast, or
slow) as well as his/her range of walking speeds. Manipulation of
data, for example, by shaking or moving the device is hardly
possible. The SAM monitors and saves data over several weeks and
Data Analysis
The Statistical Package for the Social Sciences (SPSS, version
15.0) was used for all statistical analyses. Differences between tumor
entities or between patients and healthy controls were assessed with
the Kruskal–Wallis test and the Mann–Whitney U-test. For
intragroup comparisons the Friedman Test and the Wilcoxon Test
were used. All results are given as mean  standard deviation. The
level of statistical significance was set at P < 0.05 for the intragroup
comparisons and at P < 0.001 for comparing different groups, after
Bonferroni adjustment for multiple post hoc pair-wise comparisons.
Outliers and extreme values shown in the figures are defined as
follows: Outliers are values between 1.5 and 3 box lengths from the
75th resp. 25th percentile; extreme values are those beyond 3 box
lengths from the 75th resp. 25th percentile.
RESULTS
A total of 80 patients participated in the study, including
29 patients with bone tumors, 20 with leukemia, 15 with lymphoma,
12 with brain tumors, 3 with germ cell tumors, and 1 with
neuroblastoma. All of the patients were under active treatment
according to the appropriate protocols for their disease. Between-
group comparisons were made for the two largest patient groups,
that is, bone tumor and leukemia patients. SAM measurements in
the leukemia group were taken during the induction phase in 11
patients and during consolidation in 9. Bone tumors affected the
upper limb in 6 patients and the lower limb in 23. Sixteen patients
were measured before surgery for tumor removal and 13 patients in
average 12 weeks after surgery. Seven patients underwent prosthetic
limb replacement, in three patients the limb had to be amputated,
and in further three patients the tumor was solely removed. Forty-
five healthy subjects were recruited for the control group.
Anthropometric data of all patients in the different groups and the
control group are shown in Table I.
Number of Gait Cycles Per Day
Patients reached only 23% of control group’s gcs per day during
inpatient stays and 40% during home stays (P < 0.001; Table II,
Fig. 2). Patients with bone tumors reached 16% while in hospital and
27% at home, and leukemia patients, 30% during inpatient periods
and 44% at home (P < 0.001; Table II).

TABLE I. Anthropometric Data of the Patients and Control Group

Age Height Weight BMI

n Mean  SD MD Mean  SD MD Mean  SD MD Mean  SD MD Female Male

All patients 80 13.2  3.8 12.9 1.59  0.19 1.62 48.6  18.8 45.0 18.7  4.0 18.1 33 47
Bone tumor 29 15.1  3.2 14.8 1.68  0.15 1.66 55.8  17.2 54.0 19.3  3.8 18.7 13 16
Leukemia 20 12.0  3.6 12.8 1.54  0.20 1.62 44.8  13.0 41.5 18.7  2.8 17.6 6 14
Control group 45 13.0  3.2 13.0 1.59  0.2 1.64 48  17.4 47.0 18.3  2.9 18.0 18 27

SD, standard deviation; MD, median.

Pediatr Blood Cancer DOI 10.1002/pbc

440 Winter et al.

Fig. 2. Comparison of gait cycles of all patients (inpatient and home

stays) and control group (median, 25th and 75th quartile, outliers * and
extreme values *).

During inpatient stays patients reached 58% of the activity shown
at home, with a significantly smaller number of gcs per day
(P < 0.001). The corresponding values were 59% in the bone tumor
group (P < 0.001) and 67% in the leukemia group (P < 0.001)
(Fig. 3).
Patients with bone tumors are distinctly less active than leukemia
patients and the patient group as a whole during both inpatient
periods and home stays (Table II). However, the differences between
the diagnostic groups regarding both settings were not significant.
Patients with bone tumors measured before surgery achieved
78% of the gc count seen in patients measured 12 weeks after
surgery. The difference is not significant. Furthermore, no
significant differences were found when comparing measurements
collected during the induction and consolidation phase of treatment
in leukemia patients.
Intensity
The analysis of the number of gcs per day showed distinct
differences in the patients’ activity readings. Activity was then
further analyzed by determining the intensity levels, defined as gcs
per minute. Walking intensity is more informative regarding
patterns of activity than the step count. Conclusions can be drawn
on whether gc counts were accumulated by short bouts interrupted
by breaks or by bouts of continuous activity. Functional mobility can
Fig. 3. Inpatient versus home stays in patients with bone tumors and
leukemia (median, 25th and 75th quartile, outliers * and extreme
values *).
thus be investigated and the activity can be further characterized,
which helps to determine the true extent of restriction in a patient.
Percentages spent on each activity level are given in Table III. The
results regarding the high intensity level will be further described
and discussed.
Significant differences were found for the high intensity level
where patients were 69% less active (P < 0.001) than the control
group during inpatient stays and 60% less active (P < 0.001) when at
home. When comparing the two diagnostic groups with the control
group, a similar distribution was detected for both, inpatient time
and time at home. Both of the patient groups spent a lower
percentage of time at high intensity (P < 0.001).
For all intensity levels, differences detected when comparing
inpatient stays and time at home were only minor, even though they
did reach significance. Patients spent a significantly smaller
percentage of time on the high intensity level during inpatient stays
(P < 0.01).
There were no significant differences between the groups.
Still, the percentage of time on the high intensity level seen in
patients with bone tumors was clearly smaller. Again, no significant
differences were found in the leukemia (induction and consolida-
tion) or bone tumor (before and after surgery) subgroups.

TABLE II. Gcs of the Patient Groups and Control Group

Total (n ¼ 80) Inpatient (n ¼ 68) Home stays (n ¼ 76)

Mean  SD MD Mean  SD MD Mean  SD MD

a a,b
All patients 2787  2103 2165 1830  1649 1358 3185  2269 2669a
Bone tumor 1849  1112 1312a 1275  1105 943a,b 2145  1422 1490a
Leukemia 2992  1994 2273a 2359  1551 1626a,b 3508  2154 2947a
Control group 8096  2951 7438

SD, standard deviation; MD, median. aSignificant difference to control group (P < 0.001); bSignificant
difference to home stays (P < 0.001).
Pediatr Blood Cancer DOI 10.1002/pbc

TABLE III. Distribution of Percentage of Low, Moderate, and High Intensities
Inpatient
Low intensity Moderate intensity High intensity
Mean  SD MD Mean  SD MD Mean  SD
a,b a,b
All patients 82.7  8.7 82.8 12.9  5.7 13.3 4.4  4.3
Bone tumor 84.6  9.6 84.6a 11.9  6.3 13.6a 3.5  4.7
Leukemia 79.5  5.8 77.8a 14.4  3.8 15.9a,b 6.1  3.7
Control group 65.0  10.1 66.8 20.2  4.1 19.8 14.7  7.2
SD, standard deviation; MD, median. aSignificant difference to control group (P < 0.001); bSignificant difference to home stays (P < 0.05).
DISCUSSION
The present study determined levels and patterns of physical
activity in a large cohort of pediatric patients while undergoing
cancer treatment. It was found that pediatric cancer patients were
significantly less active than healthy children and the intensity of
their activity was significantly lower both at home and during
inpatient stays. Patients were significantly more active at home than
during inpatient stays. Bone tumor and leukemia patients were
found to differ regarding both the amount and the intensity of
activity. Patients with bone tumors were clearly less active during
inpatient stays and at home. These patients appear to be at increased
risk from the detrimental effects of inactivity caused by the
treatment regimes and the physical restrictions associated with
them.
Most previous studies on activity and cancer treatment
concentrated on adult survivors of childhood cancer. Some revealed
reduced activity levels while others also showed that patients
regained good mobility [4,13–15]. Most of these studies used self-
reports to determine the level of activity, which is an insufficient and
imprecise approach to determine the actual amount of activity [16].
Self-reports are influenced by a person’s perception and interpre-
tation. Furthermore, most questionnaires do not assess very low
intensity levels which are quite typical in a patient population.
Physical activity in young children is characterized by short bouts of
activity that are hardly recalled retrospectively [17]. Hence, the need
to measure physical activity objectively is obvious. Accelerometry
has proven to be a good and valid means to this end [6]. Aznar et al.
used accelerometers to assess the activity level of 12 young
leukemia patients up to an age of 7 years undergoing maintenance
treatment. The study found comparable activity levels in patients
and a control group. However, significant differences were seen in
the intensity at which the activity was performed [3]. The results of
that study, which did in fact employ objective tools of measurement,
are not comparable to our findings in that those patients were at an
advanced stage of treatment.
The present study shows the activity level of patients to be
markedly reduced in both amount and intensity when compared to a
control group of similar age and gender. The number of gcs per day
accumulated by the control group corresponds to the average
activity of healthy children [10,18,19]. A positive selection of
patients in this study cannot be ruled out as patients were asked to
agree to the activity measurements. The results might thus reflect a
positively biased picture of patients’ physical activity; if this were
the case it should be noted that even this potentially more motivated
population showed markedly reduced activity levels.
Pediatr Blood Cancer DOI 10.1002/pbc
Daily Activity of Pediatric Cancer Patients 441
Home stays
Low intensity Moderate intensity High intensity
MD Mean  SD MD Mean  SD MD Mean  SD MD
a,b
3.5 78.9  10.3 79.7 15.5  6.6 14.7 5.6  5.2 4.5a
2.1a 83.2  10.4 84.5 12.5  6.1 14.2 4.2  5.5 2.9a
5.7a 76.7  9.4 75.2 18.2  6.9 19.2 5.1  4.0 4.7a
12
Our finding of reduced activity especially on the high intensity level
reflects the fact that patients hardly walk continuously or for longer
distances but rather engage in short bouts of activity. Furthermore,
physical activity is probably more exhausting for patients than
for healthy subjects. Activities classified as moderate in healthy
subjects might thus be graded high in patients, especially in patients
with walking restrictions. More research is necessary to determine
activity levels appropriate for patient populations. Recommenda-
tions for patients should be individually tailored to their abilities
[20].
Whereas patients do become more active when at home their
activity level still remains very low. The limitations caused by
inpatient treatment help to explain the reduced activity while in
hospital. Times at home include those days when blood counts are
low and are needed to recover and regain strength. Physiological
factors caused by chemotherapy and radiotherapy, including, for
example, nausea or general fatigue, as well as socio-environmental
factors may play a decisive role in activity reduction [3]. These are
factors reflecting the overly cautious or even anxious attitude
toward physical activity by the patients’ environment and low self-
confidence on the child’s part concerning his/her abilities [2]. In
general, malignant diseases and cancer treatments are very complex
and the state of well-being may vary greatly depending on factors
such as surgical procedure, radiotherapy, chemotherapeutical
substances, or disease progression. Hence, conclusions with a view
to particular disease- or treatment-related factors are hardly possible
and will not be discussed in detail.
Nevertheless, some differences were revealed when comparing
different cancers. Depending on the cancer entity, patients undergo
different treatments regarding both local control and chemotherapy.
Patients with bone or brain tumors, unlike those with leukemia or
lymphomas, usually need surgical treatment for tumor removal.
Most patients with bone tumors are advised to offload the
affected limb before surgery in order to prevent fractures. Surgical
intervention usually involves prosthetic replacement of the affected
bone and loss of musculature and in some cases amputation. After
recovery from surgery patients resume walking gradually. This
process is reflected by the results of our measurements. Patients
measured before surgery had fewer gcs than patients measured
12 weeks after surgery, although differences were not significant.
A higher amount and intensity of activity was to be expected
in leukemia patients compared to patients with bone tumors.
Generally, patients with bone tumors appear to be at a higher risk of
suffering adverse effects from inactivity due to surgery and related
restrictions. This patient group in particular needs individually
tailored recommendations and interventions. More research is
442 Winter et al.
needed to determine the impact of tumor site and surgical procedure
on physical activity.
The reduction of physical activity described in the present
study is naturally experienced by the patients themselves as well as
their care-givers in the hospital or at home. It is easily observed
that patients hardly leave their bed on days when they feel especially
fatigued or are suffering from the side-effects of treatment. In
this respect the results of our measurements are not surprising.
However, the present study establishes a quantitative basis by
objectively determining the extent of the restriction. It should be
noted that resting and recovering are important elements in the
treatment of cancer, for example, when side-effects are severe or
patients need to recover from surgery, and patients should not be
expected to reach the activity levels of healthy controls. However,
several studies in adult patient populations demonstrated that
regular physical activity during treatment can help to tolerate
treatment-induced effects and thus contributes to a better quality
of life [1,21–24]. Physical activity has become a well-established
part of cancer care in adults [25,26]. Studies investigating this
issue in pediatric patients are few and far between. San Juan et al.
[27–29] showed beneficial effects of an intrahospital exercise
program for pediatric patients after bone marrow transplantation
and young patients with leukemia during maintenance treatment.
Both our findings and the accepted fact that physical activity is an
essential element of a child’s development confirm the need for
individually adapted interventions, especially in pediatric cancer
patients.
Once we can measure the extent of the problem the claim for
individually tailored interventions especially for children can be
supported. The present data are supposed to be a starting point for
future investigations and may serve to promote activity in this
patient group.
The measuring device used is a simple, well-accepted,
unobtrusive, and objective tool for determining physical activity.
Taking the measurements does not affect the patient nor does
it interfere with treatment. The outcome and possible success of
activity-promoting programs can easily be determined and
confirmed. The value of an intervention can be demonstrated
using the measurement of daily physical activity as a reliable and
objective parameter. The described program, which combines
monitoring with interventions, might be applied not only in
those patients described in this study, but in all kinds of patient
groups.
CONCLUSION
The level of activity is considerably reduced in pediatric
patients undergoing treatment for cancer compared to healthy
controls. Inpatient treatments in particular limit the patient’s
activity. Differences between tumor entities do exist and patients
with bone tumors are at increased risk from adverse effects of
inactivity during treatment. The present data confirm a strong need
for reasonable interventions in this patient group tailored to the
individual needs of the patients. The study represents a first step to
objectively quantifying the actual extent of an often recognized
problem and to our knowledge is the first study to provide this
information. Further research is needed to determine the factors that
influence patients’ activity and to investigate how their activity
develops during the course of treatment and after cessation of
treatment.
Pediatr Blood Cancer DOI 10.1002/pbc
ACKNOWLEDGMENT
Financial support of the following non-profit organizations is
gratefully acknowledged: Else Kröner Fresenius Stiftung (P46/05//
A68/04//FO); Deutsches Stiftungszentrum, Karl-Heinz Frentzen
Stiftung (T328/15887/2006).
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