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German Journal of Exercise and Sport Research

, Volume 48, Issue 3, pp 387–394 | Cite as

Participation in organized sports, physical education, therapeutic exercises, and non-organized leisure-time physical activity: how does participation differ between childhood cancer outpatients and healthy peers?

  • Julia Daeggelmann
  • Vanessa Rustler
  • Katharina Eckert
  • Vivian Kramp
  • Sandra Stoessel
  • Wilhelm Bloch
  • Freerk T Baumann
Main Article
  • 37 Downloads

Abstract

Most childhood cancer survivors are insufficiently active. Researchers are focusing on strategies to increase physical activity (PA). However, a detailed understanding of participation in specific types of PA is missing, meaning current strategies may lack relevant information. Thus, our study sought to analyze participation in different types of PA commonly engaged in by children: organized sports, physical education in school (PES), therapeutic exercise, and non-organized leisure-time PA. Thirty-eight childhood cancer outpatients and 51 healthy children completed questionnaires. Compared to healthy children, childhood cancer outpatients, especially those who are shortly after cessation of inpatient treatment, participated significantly less often in organized sports and PES and significantly more often in therapeutic exercise compared to the healthy children. Considering organized sports and PES afford children unique social benefits and provide the potential to motivate lifelong activity, future efforts should be placed on ensuring children with cancer can access these types of PA. Educating parents, teachers, and coaches, exploring referral pathways to exercise professionals and providing individual support may enhance participation rates in organized PA and should be investigated.

Keywords

Childhood cancer Outpatient Physical activity Exercise Sport 

Teilnahme an organisiertem Sport, Schulsport, Bewegungstherapie und nicht-organisiertem Freizeitsport: Inwiefern unterscheiden sich die Teilnahmequoten zwischen krebskranken Kindern und Jugendlichen nach stationärer Akuttherapie und gesunden Gleichaltrigen

Zusammenfassung

Kinder und Jugendliche sind nach überstandener Krebserkrankung häufig inaktiv. Die Forschung konzentriert sich auf Strategien zur Erhöhung der körperlichen Aktivität (KA). Doch die Teilnahme an spezifischen Formen von KA ist wenig erforscht, sodass relevante Informationen zur Etablierung erfolgreicher Strategien fehlen. Aus diesem Grund wird in unserer Studie die Teilnahme an altersentsprechenden KA-Formen wie dem organisierten Sport, Schulsport, Bewegungstherapie und nicht-organisiertem Freizeitsport analysiert. 38 Kinder und Jugendliche, die die stationäre onkologische Therapie beendet haben sowie 51 gesunde Kinder und Jugendliche beantworteten Fragebögen. Verglichen mit gesunden Kindern beteiligten sich Kinder und Jugendliche nach onkologischer Akuttherapie signifikant seltener an organisiertem Sport und Schulsport und signifikant häufiger an bewegungstherapeutischen Angeboten – insbesondere wenn die stationäre Behandlung erst kürzlich beendet worden war. Angesichts der besonderen sozialen Vorteile von organisiertem Sport und Schulsport sowie deren Potential, einen langfristig aktiven Lebensstil anzubahnen sollten Initiativen ergriffen werden, um krebskranken Kindern und Jugendlichen die Teilnahme an diesen KA-Formen zu ermöglichen. Die Schulung von Eltern, Lehrern und Trainern, die Entwicklung von Zuweisungspfaden zu Bewegungsexperten sowie die Etablierung von individuellen Beratungs- und Unterstützungsangeboten können die Teilnahme an organisierter KA erhöhen und sollten wissenschaftlich überprüft werden.

Schlüsselwörter

Krebserkrankung im Kindesalter Ambulante Patienten Körperliche Aktivität Bewegung Sport 

Introduction

Physical activity (PA) during childhood is imperative for good health and disease prevention. It is directly linked to children’s physical, psychological, and social well-being (Strong et al., 2005; Eime, Young, Harvey, Charity, & Payne, 2013). There are several different types of PA, which can offer unique benefits to children.

For the purpose of this paper we defined the following types of PA based on classifications and definitions found in literature (Rueegg et al., 2012; Keats, Courneya, Danielsen, & Whitsett, 1999; Eime et al., 2013; Belanger, Plotnikoff, Clark, & Courneya, 2013; Bailey, 2006) and the German Health Interview and Examination Survey for Children and Adolescents (Opper, Worth, Wagner, & Boos, 2007). Our classification aims to encompass every PA a child or adolescent may participate in. We subdivided leisure-time PA into organized and non-organized PA, as these are the two typical ways children and adolescents are physically active during leisure-time. In addition, we chose physical education in school (PES) as a third type of PA as this is a PA opportunity which is offered to every child in Germany. Considering the specific needs of childhood cancer outpatients, we chose therapeutic exercise as a fourth type of PA. Though all four types have a commonality of increasing PA, which is defined as any bodily movement produced by skeletal muscles that requires energy expenditure (World Health Organization, 2017a), there are distinct differences between each in terms of content and structure. These differences are notable as they result in unique benefits depending on the type of PA engaged in.

Specifically, organized sports are practiced on a regular basis (Rueegg et al., 2012; Keats et al., 1999) and are competitive in nature (Eime et al., 2013; Belanger et al., 2013). They can be performed in a team or as an individual (Eime et al., 2013) in sports clubs, commercial institutions (such as a fitness center, golf club, climbing hall etc.) or within school systems (e. g., after school sports activities other than PES). These can be supervised by professionals or unsalaried coaches and typically, require monetary and time commitments (membership, mandatory registration etc.). Organized sports have been shown to provide unique benefits in terms of improved psychosocial health (i. e., improved self-esteem/self-concept/social relations and fewer depressive symptoms; Keats et al., 1999; Eime et al., 2013).

Similar to organized sports is PES. PES is as well supervised and practiced regularly; however, this type of PA differs from organized sport, as these activities are mandatory physical education classes held during the school day. PES is committed to initiate the understanding and learning of physical abilities through educational experiences and promote sustainable PA while at the same time teaching children social skills by providing important social learning opportunities (Ministry of School and Education, 2014; Eime et al., 2013). As such, participation in PES provides unique benefits in terms of social contacts with peers and the reintegration into school after pediatric cancer treatment (Kesting, Götte, Seidel, Rosenbaum, & Boos, 2016). Moreover, PES is the main institution to develop basic physical and psychosocial skills that are essential in later life while limited participation in PES may be associated with lifelong inactivity (Bailey, 2006).

In contrast to these organized types of PA (i. e., organized sports and PES), another type of PA is ‘non-organized leisure-time PA’. This type of PA is generally accepted as a pleasurable activity (Eime et al., 2013; Opper et al., 2007) that can be performed anytime with friends/family or as an individual (Opper et al., 2007) and is non-competitive. This type of PA is non-supervised and does not require any kind of commitment. Thus, non-organized leisure-time PA provides unique benefits as it has very few barriers to participation. Due to the non-competitive and fun nature, this type of PA is not associated with any expectations in terms of performance.

Another type of PA to consider is therapeutic exercise. This is defined as any kind of physical or exercise therapy (including childhood cancer specific outpatient exercise programs) conducted by a physical therapist or exercise specialist. We included all kinds of therapeutic exercises, which are “purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective” (World Health Organization, 2017a). Research has verified beneficial effects in terms of physical functioning (e. g., endurance, strength, mobility, flexibility), fatigue and quality of life of this type of PA in childhood cancer populations (Baumann, Bloch, & Beulertz, 2013; Huang, & Ness, 2011; Winter, Müller, Hoffmann, Boos, & Rosenbaum, 2010).

Of note, for the purpose of this paper, we defined PA as noticeably accelerating heart rate (moderate PA) and/or causing rapid breathing and a substantial increase in heart rate (vigorous PA) (World Health Organization, 2017b). We did not include lower intensity PA (i. e., playing, active transportation, household chores, gardening). Though we recognize that these low-intensity types of PA have a health benefit as well (World Health Organization, 2017a), the World Health Organization recommends 60 min of moderate to vigorous PA daily for children aged 5–17 years (World Health Organization, 2017a). Therefore, our focus has been on participation in these types of PA.

Despite the benefits that each subtype and PA in general may offer (i. e., physical, psychological, social), studies report that childhood cancer survivors have reduced levels of PA compared to healthy peers and time before diagnosis and, do not meet recommendations for PA (Ness et al., 2009; Keats, Culos-Reed, Courneya, & McBride, 2006; Florin et al., 2007; Murnane, Gough, Thompson, Holland, & Conyers, 2015; Winter et al., 2010; San Juan, Woolin, & Lucia, 2011). Notwithstanding the contributions of these studies, PA was considered in general and they have not explored participation in the aforementioned specific types of PA. Thus, it is possible that participation rates across these types of PA differ as researchers have already requested to analyze participation rates separately instead of general PA (Belanger et al., 2013). Further, few studies have analyzed PA participation across different points in the cancer trajectory (i. e., before, during, after treatment). However, these studies have analyzed PA in general, as well (Keats et al., 2006; Murnane et al., 2015; Götte, Kesting, Winter, Rosenbaum, & Boos, 2014b). To begin to fill this gap in the literature, participation in different types of PA (i. e., organized sports, PES, non-organized leisure time PA, and therapeutic exercise) engaged in among childhood cancer outpatients in comparison to healthy peers was evaluated. As well, to determine what difference, if any, occurs in PA participation in these specific types of PA across the cancer trajectory, a subgroup analysis was performed based on time since cessation of inpatient treatment.

Materials and methods

Recruitment

Childhood cancer outpatients were recruited from May 2012 to March 2015 at the outpatient clinic for pediatric hematology/oncology, Clinic for Children and Youth Medicine, Children’s Hospital Amsterdamer Straße in Cologne and, from November 2014 to March 2015 at the University Medical Center Mainz and the University Clinic of Leipzig, Department of Pediatric Oncology, Hematology and Hemostaseology. Healthy children were recruited by presenting this study to siblings/friends of participating outpatients, as well as school principals of surrounding schools. Ethics approval was obtained for all study sites and the study was carried out in accordance with the Declaration of Helsinki.

Participants

Childhood cancer outpatients (PG) were eligible if they were (i) between 5 and 18 years of age; (ii) attending school; (iii) treated for an oncological disease; (iv) diagnosed within the last 5 years; (v) completed all inpatient treatment and were currently receiving maintenance or no medical treatment; (vi) willing and able to provide written informed consent prior to study participation (alongside their parents/legal guardians); (vii) able to read and understand German. Healthy children (CG) were eligible if they were (i) between 5 and 18 years of age; (ii) attending school; (iii) not suffering any chronic disease(s); (iv) willing and able to provide written informed consent prior to study participation (alongside their parents/legal guardians); (v) able to read and understand German.

Outcome measures

PA participation rates

For the purpose of this study a questionnaire consisting of five questions, based on a questionnaire used in the German Health Interview and Examination Survey for Children and Adolescents (Opper et al., 2007) was created. Parent-proxy reports were completed for children aged 5–9 years, whereas adolescents aged 10–18 years completed their own questionnaires. All participants (or their parents) were asked the following questions: Are you/is your child currently participating in (1) organized sports (yes or no), (2) therapeutic exercise (yes or no), (3) PES (yes or no), (4) non-organized leisure-time PA (yes or no). As mentioned above, we focused on participation in moderate-to-vigorous physical activity (MVPA). In case, study participants stated to participate in any kind of low-intensity PA, data was excluded. Additionally, study participants were asked: (5) Would you/your child like to participate in PA more often? (yes or no).

Other data collection

Anthropometric data for all study participants, as well as medical information of all childhood cancer outpatients were collected from medical records to describe the sample.

Statistical analysis

The anthropometric variables of both groups were analyzed using descriptive statistics. All non-parametric data was analyzed using the Mann–Whitney U test. Parametric data was compared using the independent t‑test. The Chi-squared test was used to analyze group differences in frequencies. Level of significance was set to p < 0.05. A subgroup analysis was performed based on time since cessation of inpatient treatment (PG1: outpatients less than 12 months post inpatient treatment [n = 25] and PG2: outpatients more than 12 months post inpatient treatment [n = 13]). A cutoff of 12 months was chosen to minimize any seasonal influences on PA participation. Analyses were done with IBM SPSS (version 23.0).

Results

Study sample

Forty-one childhood cancer outpatients and 56 healthy children were eligible for participation. (Twentythree childhood cancer outpatients and 53 healthy children were recruited in Cologne, six outpatients were recruited in Mainz and 12 outpatients and 3 healthy children were recruited in Leipzig.) However, questionnaires of 3 outpatients and 5 healthy children could not be analyzed due to missing values. Thus, data from 38 childhood cancer outpatients and 51 healthy children were analyzed.

Characteristics of the PG and the CG, as well as both subgroups (PG1/PG2) are presented in Table 1. Groups did not differ significantly in terms of age, gender, weight, height and education, except for significant differences in gender between PG1 and CG. The cancer sample was comprised of childhood cancer outpatients with different kinds of oncological diseases (acute lymphocytic leukemia [ALL]: n = 13, acute myeloid leukemia [AML]: n = 5, lymphoma: n = 6, tumor of the central nervous system [CNS]: n = 3, germ cell tumor: n = 3, bone tumor: n = 3, other: n = 5) being 0.94 ± 0.97 years (range 0.01–4.18 years) after cessation of inpatient treatment.
Table 1

Characteristics of all study participants

 

Patient group (n=38)

Patient subgroup1(n=25)

Patient subgroup2(n=13)

Comparison group (n=51)

PG vs. CG

PG1 vs. PG 2

PG1 vs. CG

PG2 vs. CG

Age, years

Mean±SD

12.82 ± 3.49

13.37 ± 3.25

11.76 ± 3.81

12.13 ± 3.28

0.344

0.182

0.126

0.727

(Mdn)

(13.61)

(14.24)

(12.92)

(12.51)

[IQR]

[9.69–15.45]

[10.63–15.70]

[7.52–14.93]

[9.45–14.69]

Gender

Female

20 (52.6%)

15 (60.0%)

5 (38.5%)

17 (33.3%)

0.084

0.307

0.047*

0.752

Male

18 (47.4%)

10 (40.0%)

8 (61.5%)

34 (66.7%)

Weight, kg

Mean ± SD

50.87 ± 21.07

53.45 ± 22.66

45.89 ± 17.37

45.03 ± 15.41

0.135

0.300

0.060

0.861

(Mdn)

(50.60)

(53.00)

(46.00)

(43.00)

[IQR]

[33.75–61.38]

[37.25–62.75]

[29.50–60.50]

[31.00–58.50]

Height, cm

Mean ± SD

154.40 ± 19.34

158.48 ± 18.84

146.55 ± 18.47

153.28 ± 18.16

0.781

0.070

0.251

0.238

(Mdn)

(159.00)

(163.00)

(153.00)

(158.00)

[IQR]

[133.50–170.00]

[149.50–171.00]

[128.00–164.00]

[140.00–168.00]

Education

Elementary school

11 (28.9%)

6 (24.0%)

5 (38.5%)

15 (29.4%)

1.000

0.457

0.786

0.523

Secondary school

27 (71.1%)

19 (76.0%)

8 (61.5%)

36 (70.6%)

CG comparison group, IQR interquartile range, mdn median; n sample size, SD standard deviation, PG patient group, PG1 childhood cancer outpatients less than 12 months post inpatient treatment, PG2 childhood cancer outpatients more than 12 months post inpatient treatment

*Significant difference; statistical analysis: independent t‑test and Chi-squared test (p-value)

PA participation rates

With regards to organized sports and PES childhood cancer outpatients participated significantly less often in both (p = 0.001 and p < 0.001, respectively) compared to healthy children. In fact, 84.3% of the healthy group compared to 52.5% of the childhood cancer outpatients performed organized sports, while 96.1% of the healthy group participated in PES compared to 60.5% of the outpatient group. When exploring participation in therapeutic exercise, childhood cancer outpatients participated more often (47.4%) than healthy children (2.0%), which was a significant difference (p < 0.001). No significant differences between outpatients (55.3%) and healthy children (68.6%) were found with regards to non-organized leisure-time PA (Table 2). When asked if they wished to engage in more PA, 78.9%, of childhood cancer outpatients and 64.7% of the healthy children answered “yes”.
Table 2

Comparison of physical activity (PA) participation rates between both groups

 

PG

CG

PG vs. CG

n

Approval rate

n

Approval rate

Participation in organized sports? (% [n])

38

52.6 (20)

51

84.3 (43)

0.001*

Participation in PES? (% [n])

38

60.5 (23)

51

96.1 (49)

<0.001*

Participation in therapeutic exercise? (% [n])

38

47.4 (18)

51

2.00 (1)

<0.001*

Participation in non-organized leisure-time PA? (% [n])

38

55.3 (21)

51

68.6 (35)

0.199

Like to do more sports? (% [n])

38

78.9 (30)

50

64.7 (33)

0.185

CG comparison group, n sample size, PES physical education at school, PG patient group, PG vs. CG Mann–Whitney U test [p-value]

As organized sports and non-organized leisure-time PA incorporate various PAs, the types of exercise that were mentioned by study participants and included for analysis are listed: (1) organized sports include ball games, racquet sports, track & field, swimming, (children’s) gymnastics, dancing, martial arts, fencing, horseback-riding in a team, vaulting, golf and going to a gym while (2) non-organized leisure-time PA includes jogging, strength training at home, ball games and racquet sports on the street/in a park, riding a bike/mountain bike/unicycle or skateboarding/longboarding/rollerblading (not for transportation), playing WiiSports, jumping on a trampoline, swimming with friends/family, horseback riding with family, hiking and bowling.

Subgroup analysis

Childhood cancer outpatients less than 12 months post inpatient treatment participated less often in organized sports (36.0%) and PES (40.0%) compared to outpatients more than 12 months post inpatient treatment (organized sports: 84.6%; PES: 100%). This was a significant difference (p < 0.05). Outpatients less than 12 months post inpatient treatment engaged in therapeutic exercise more often (64.0%) compared to outpatients more than 12 months post inpatient treatment (15.4%), which was a significant difference (p < 0.05). Comparing outpatients less than 12 months post inpatient treatment to healthy children, these significant differences in terms of organized sports, PES and therapeutic exercise were maintained (all p < 0.001).

In addition, childhood cancer outpatients more than 12 months post inpatient treatment accessed therapeutic exercise more often (15.4%) in comparison to healthy peers (2.0%), which was a significant difference (p < 0.05). In terms of organized sports and PES, no significant differences were found between outpatients more than 12 months post inpatient treatment and healthy children.

Moreover, in terms of non-organized leisure-time PA no significant differences were found between groups (Fig. 1).
Fig. 1

Subgroup analysis—Comparison of participation rates between childhood cancer outpatients less than 12 months post inpatient treatment (PG1), childhood cancer patients more than 12 months post inpatient treatment (PG2) and healthy peers (CG): a Organized sports, b therapeutic exercise, c PES, and d non-organized leisure-time sports. n sample size; PES physical education at school. PG1 vs. PG2/PG1 vs. CG/PG2 vs. CG: Mann–Whitney U test [p-value]

Discussion

This study sought to investigate the PA participation rates of childhood cancer outpatients in specific types of PA in comparison to healthy peers. Findings confirm current research results reporting reduced PA participation in childhood cancer outpatients (Winter et al., 2010; Murnane et al., 2015; Keats et al., 2006). Extending previous research, the findings highlight where childhood cancer outpatients engage in significantly less PA than their healthy peers (i. e., organized sports and PES). This study also shows that outpatients participate more frequently in therapeutic exercise and have comparable participation rates in terms of non-organized leisure-time PA.

First, more than 75% of the current outpatient study sample sought to participate in PA more often. In order to enhance PA participation, supportive strategies need to be developed. Generally, survivors report that they would like to receive specific exercise information (Murnane et al., 2015; Zebrack, 2009) and research reports that childhood cancer survivors want to discuss PA with their healthcare team and are more likely to participate in PA according to a physician’s advice (Kelly, 2011; Keats, Culos-Reed, & Courneya, 2007). However, physicians state that although they regard PA as important for childhood cancer survivors, lack of knowledge of resources and inadequate time are relevant barriers to PA counselling (Keats et al., 2007). Another study found that most of the participants who were interested in exercise information indicated that they would have liked to receive this from an exercise physiologist (Murnane et al., 2015). As such, exercise professionals seem to be the key players for PA promotion.

Second, only half of the present outpatient study sample participated in organized sports. This participation rate is particularly low considering population norms reporting that almost 75% of all children aged 3–10 years living in Germany participate in sports clubs (Lampert, Mensink, Romahn, & Woll, 2007). Because of the tremendous psychosocial benefits that organized sports hold (Keats et al., 1999; Eime et al., 2013), and considering that childhood cancer survivors have fewer ‘best friends’ (Rourke & Kazak, 2005), participate less often in activities with peers (Rourke et al., 2005), are more likely to have antisocial behaviors (Schultz et al., 2007), and face challenges in terms of social reintegration post-treatment (Götte, Taraks, & Boos, 2014a), it is imperative that efforts must be made to increase participation in this type of PA. Moreover, only 60.5% of the outpatient sample participated in PES compared to 96.1% of the healthy group. These results are similar to those of Kesting et al., who found a participation rate in PES of childhood cancer outpatients of 75% (Kesting et al., 2016). In addition to the aforementioned physical and social benefits of PES this finding is particularly alarming, considering the potential of PES to provide a foundation for an active lifestyle throughout life (Ministry of School and Education, 2014; Kesting et al., 2016). As the childhood cancer survivor population is known to face challenges in terms of sufficient levels of PA which may aggravate cancer and treatment-related side effects and long-term consequences, promoting livelong PA is especially meaningful. In this context, it must be highlighted that we did not find significant differences in terms of non-organized leisure-time PA. This is potentially due to the very low participation barriers and its non-competitive and fun nature, mentioned above. Previous studies have identified a wide variety of PA participation barriers in pediatric oncology (Arroyave et al., 2008; Ross et al., 2018; San Juan et al., 2011; Wright, Bryans, Gray, Skinner, & Verhoeve, 2013). Among others, frequently mentioned barriers include “being too tired” (Arroyave et al., 2008; Ross et al., 2018; Wright et al., 2013), “lack of knowledge” (Arroyave et al., 2008; San Juan et al., 2011; Wright et al., 2013), “can’t seem to get started” and “can’t see myself stick to anything” (Ross et al., 2018). As non-organized PA does not require any kind of commitment it seems to be easier to overcome these barriers. However, due to its non-committal nature, this type of PA is usually performed less regularly and less often promotes livelong activity. As a consequence, enhancing PA participation in organized sports and PES seems important in order to integrate childhood cancer outpatients into regular and binding types of PA that offer unique benefits in terms of psychosocial health and livelong PA. Thus, supportive strategies to facilitate reintegration into these types of PA must be developed and research on PA in pediatric oncology should focus on the evaluation of these strategies.

A first step towards enhancing PA participation in these types of PA (organized sports and PES) might be to provide information regarding the unique benefits of these types of PA during childhood cancer survivorship as well as referral information to exercise professionals. As such, childhood cancer outpatients and parents as well as providers of organized PA opportunities such as coaches of sports clubs and physical education teachers in school should receive this information. Knowledge translation is important for them in order to create a mindful, encouraging and supportive environment instead of creating overprotection and unnecessary restrictions (Wright, 2015).

Moreover, as researchers have previously highlighted that individual counselling is necessary (Rueegg et al., 2013) a second strategy to facilitate reintegration into organized sports and PES might be the supervision of an exercise professional. For example, these exercise professionals could attend the outpatients’ PE class and/or the child’s preferred type of organized sports along with the outpatient. This would allow for both the child and parent to ask questions as they arise. Further, this individual could potentially reduce the concerns patients, parents, teachers, and coaches have when it comes to PA. Finally, and perhaps most importantly, this individual could provide individually tailored strategies to allow for successful participation as physical constraints and limitations which are common in pediatric oncology may necessitate individual adaptations in order to facilitate reintegration. This type of personal coaching acknowledging the individual preferences and environments, as well as outpatients’ age and physical abilities could be beneficial in order to enhance participation in these types of PA and achieve lifelong active lifestyles (Wright, 2015). These potential strategies should be implemented shortly after cessation of inpatient treatment, as the results from this study report that outpatients less than 12 months post inpatient treatment engage in particularly low levels of organized sports and PES. Therefore, this might be a key time to intervene. However, as it has previously been highlighted that PA promotion should begin as early as possible (Winter et al., 2010), these strategies might even be implemented during inpatient treatment. This would allow for the determination of individual PA preferences and accelerate fast recovery of PA levels after cessation of inpatient treatment.

Limitations

The strengths and limitations of the present study are related to the study design, the collected data, and the study sample. This study analyzed participation in four relevant types of PA in order to improve PA promotion for childhood cancer outpatients. First, this was a cross-sectional analysis and we did not examine information regarding the outpatients’ activity behavior before diagnosis. They might have been inactive in general. More information regarding PA before and during cancer treatment will be presented in Stoessel et al. Second, data were collected through single modified activity questions that have not been validated. However, the questions asked are typical for evaluating PA participation rates (Belanger et al., 2013; Opper et al., 2007) and based on the unique situation of childhood cancer outpatients, no appropriate validated questionnaire was available. Third, we only analyzed if study participants were participating in the four types of PA described above. We did not analyze other types of PA (that did not fit within these categories; e. g., active transportation, low-intensity PA). Further, we did not analyze how often they participated in each type of PA or whether there were factors outside of their control precluding them from participating (e. g., no sports clubs in their neighborhood). Thus, some children might simply not have access to organized sports.

Conclusion

Childhood cancer outpatients are particularly inactive in terms of organized PA (organized sports and PES). Our results highlight the importance of PA promotion in these types of PA because of their unique social benefits and their potential for sustainable motivation for PA in years to come (Keats et al., 1999; Eime et al., 2013; Ministry of School and Education, 2014; Kesting et al., 2016; Bailey, 2006). Considering the years of survival ahead and the integral role PA plays in the children’s social life (Götte et al., 2014a), finding ways to enable pediatric cancer outpatients to participate in the same types of PA as healthy children do is important. Future studies should continue exploring participation in different types of PA among childhood cancer outpatients in more detail. Moreover, ways to enhance participation rates such as delivery of exercise information and individual PA counselling should be examined. Ultimately, these efforts seek to improve the physical and psychosocial health and wellbeing of children diagnosed with cancer.

Notes

Acknowledgements

The authors would like to thank all participants and their families for participation in this study. We would like to acknowledge Amanda Wurz for her review and edits on the final manuscript and Alexander Schenk for designing the figure. We thank Regine Söntgerath for her support in conducting the study at the University Clinic of Leipzig, Department of Pediatric Oncology, Hematology and Hemostaseology, J. Faber and Marie A. Neu for recruiting patients and conducting this study at the University Medical Center Mainz and A. Prokop for his support in recruiting patients at the outpatient clinic for pediatric hematology/oncology, Clinic for Children and Youth Medicine, Children’s Hospital Amsterdamer Straße in Cologne.

Funding

This study was funded by the German Sports University (Cologne) and I. Laukin-Kleiner (Leipzig).

Compliance with ethical guidelines

Conflict of interest

J. Daeggelmann, V. Rustler, K. Eckert, V. Kramp, S. Stoessel, W. Bloch and F.T. Baumann declare that they have no competing interests.

Ethics approval was obtained for all study sites and the study was carried out in accordance with the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. In the case of underage patients, consent was obtained from a parent or legal guardian.

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Copyright information

© Springer-Verlag GmbH Deutschland, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of Cardiovascular Research and Sport Medicine, Department of Molecular and Cellular Sport MedicineGerman Sport University CologneCologneGermany
  2. 2.Institute of Sport and Sport ScienceUniversity of HeidelbergHeidelbergGermany
  3. 3.Corporate Health ManagementFortbildungsakademie der Wirtschaft gGmbHPlauenGermany
  4. 4.Department of Pediatric Oncology, Hematology and HemostaseologyUniversity Medical Center MainzMainzGermany
  5. 5.Center of Integrated Oncology Cologne/Bonn, Department I of Internal MedicineUniversity Hospital of CologneCologneGermany

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