Sarah Kruse, PT, DPT, decided on her career path following her younger brother's stay at Seattle Children's Hospital five years ago. During the nearly three months he was recovering from a brain injury on the hospital's rehabilitation floor, his siblings each supported a facet of his recovery. Dr. Kruse's role was to attend his physical therapy sessions.

"Even though I was not familiar with PT at the time, I realized it was the career I wanted to pursue," Dr. Kruse shared. Next, Dr. Kruse homed in on what was to become her specialty in the field of PT.

During the days Dr. Kruse spent on the hospital's rehab unit as her brother recovered, curiosity grew about the mysterious unit across the hall. Behind closed doors plastered with signs about restricted access, germ exposure and infection control, the hospital's cancer and blood disorder unit is often whirling with activity.

"Sometimes the unit's doors would open when I was passing by and I'd see kids riding bicycles and bouncing beach balls in the hallways. The environment seemed exciting and fun even though I knew there had to be more to it than that. I had an overwhelming desire to find out why children with cancer needed PT and what the treatment plan looked like," Dr. Kruse shared.

For this patient population, PT mainly addresses strength, balance, range of motion and endurance during what is often a lengthy hospitalization. The therapists are charged with the duty of devising enjoyable games and activities to address deficits and keep patients as active as possible.

A Caring Team

Each member of the cancer team at Children's-also comprised of Linda Amazeen, PTA, Lauren Hansell, OTR/L, and Lisa Alishio, COTA-matches Dr. Kruse's passion and devotion to these special patients. The team cares for children and young adults with many types of hematology/oncology blood disorders, including problems with blood cells, bone marrow and clotting as well as cancers.

Bone marrow transplants (BMT) are often required for children with leukemia, lymphoma, aplastic anemia and other childhood cancers. "We have developed a specific protocol for this population that has been very effective," shared Cathy Graubert, PT, manager of PT at Seattle Children's.

Seattle Children's is a member of a larger cancer program in Seattle, WA, called the Seattle Cancer Care Alliance (SCCA). Other members include the Fred Hutchinson Cancer Research Center-where bench research and clinical studies occur for adults and children with cancer-and University of Washington Hospital where adult cancer patients are treated.

"The therapists I've met through our SCCA partnership have been helpful and informative," said Amazeen. "The networking opportunities have been invaluable for learning about treatment ideas and sharing issues."

The SCCA unit holds occasional one-day seminars with all related health care professionals to make sure everyone is familiar with the basics of cancer treatment. Some of the topics covered include what to do if patients have uncomfortable sensory complaints and how to address gait abnormalities.

There are a number of clinicians and researchers who work in each of the SCCA locations and also float between the research and clinical areas. "For us, that means that we have amazing resources for families and children and also for the clinicians who are employed here," Graubert said.

If there is ever a question about how a specific medical treatment will affect a child's motor function or susceptibility to other illnesses, the therapists have quick and easy access to experts.

About a year ago, the hospital began an initiative to integrate the adult and pediatric therapists in order to expand their knowledge base and help with the transition of pediatric patients to adult care when appropriate.

"We want our pediatric PTs to know the adult cancer PTs, meet with them to discuss protocols and procedures and share clinical experiences," Graubert explained.

Bone Marrow Protocol

Pediatric patients are first evaluated at Fred Hutchinson to determine if they are candidates for bone marrow transplant. If approved, the patients have their transplants and follow-up appointments at Seattle Children's.

"We evaluate children in our outpatient clinic before the transplants are done," Graubert said. The therapists complete a baseline assessment that involves a standardized assessment of gross motor skills that will be used for comparison post-transplant.

"If we identify deficits, we give the patient exercises for specific muscles or joints to target those deficits," Dr. Kruse said. "But if the patient is active and strong, we encourage them to continue the sports, games and activities they are already engaged in. Then we re-evaluate the child post-transplant and address deficits that arise as they recover."

During the first one to two weeks of a child's stay, Amazeen occasionally drops by the room to chat with family members and make sure they begin to recognize her face. A child life specialist collects background information on each child's interests and preferences on toys and activities. Amazeen can apply this knowledge once she begins treating.

"When children arrive for transplants, the family is typically in crisis mode," Amazeen observed. "They meet many health care professionals at once and receive overwhelming amounts of information. I try to make the process less daunting."

The therapists discuss the therapy interventions that will be employed during the transplant process with the family. The staff encourages exercise multiple times a day and the PT can help design activities that make exercise fun.

The hospital's comprehensive, multidisciplinary team of pediatric cancer experts treats about 230 children-from infants to young adults-newly diagnosed with cancer each year. They also provide follow-up care to more than 3,000 children and adolescents.

Incorporating Activity

"The medical status of these children often comes first," Dr. Kruse observed. "But it's important that their physical abilities don't go by the wayside." Spending three months at a time in bed leads to physical deterioration among cancer patients. This deterioration punctuates how important it is to have a PT assess deficits and provide tools and therapy to be active on a daily basis.

"We need to focus on regularly educating the physicians, nurses, patients and families about the importance of therapy, especially when kids are so sick," Graubert said. "Patients who do not participate in physical activity will be incredibly weak and tight. That results in secondary problems once they finally feel better after their chemotherapy or transplant."

According to Dr. Kruse, educating parents about how important therapy is can sometimes be a challenge. "Some parents aren't receptive to therapy at first," she explained. "They might assume that since their child has cancer, he needs only to rest to get better. But we teach them the benefits and fun of PT."

Children get better faster when they are moving, laughing and enjoying life, Dr. Kruse shared.

"Being active gives the patients something other than medications and treatments to focus on. It's something they can control themselves," she said.

The therapists prefer to have scheduled appointments for the patients but multiple procedures and fatigue can often get in the way. Sessions are typically 30 to 45 minutes due to low endurance levels and are mainly carried out at the bedside or on the unit.

If there aren't many people around and the platelet count of a post-BMT patient is above 500 (making infection control less of an issue), the PTs will often do the sessions in the gym. "The change of environment can be great for a patient's outlook," Amazeen said.

Across the board, what works best with these children-who are isolated from peers-is socializing them with other kids even for just a short time. "We have a Wii Fit on a cart so it can easily be rolled into isolation rooms," Amazeen said. "But I try to make it a last resort. The kids crave and miss human interactions so that's what I try to focus on."

One of the favorite activities is Seattle Children's own version of 'Go Fish.' The PTs laminated-so they are washable-colorful cardboard fish and ask patients to "fish" for them around the room. Each fish has an activity listed on the back for the child to do.

"When they fish, they have to walk, reach, bend and twist," Amazeen shared. "These are all activities they should be doing for strength but may not initially want to do if they're not feeling well."

Another room-bound child-friendly activity is building forts with cardboard boxes. This is fun for the patients because they can draw on them and then sit or play somewhere special, other than in bed.

"Beach balls are the most fun and useful toy we have," Amazeen shared. "The kids can bounce them but there's no noise like with a basketball and they won't knock out an IV pole. We use a bat with a beach ball in the hallway or pretend it's a basketball and dribble and shoot at a temporary basket."

"Our patients just want to be kids," Graubert said. "The youngest patients aren't aware of what they are going through. They just know that they feel horrible. The goal is to do as much as we can to keep them as strong as possible and to prevent muscle and joint contractures."

Dr. Kruse described the sadness that can understandably permeate the unit. The therapists try to do everything they can to lift patients' spirits and help them temporarily forget that they have cancer. "The bikes on the floor are sure to bring a smile to the kids' faces," Dr. Kruse said. "I will park one right outside a child's room and then say, 'Hey look, it's a bike. Let's go ride it!'"

The PTs take it one activity at a time with the patients and are always prepared to adjust the plan if necessary.

"I have learned to speak the children's language and develop activities that interest them," Dr. Kruse said. "Kids may not march in place but they sure do love to stomp like a monster!"

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com