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Feasibility and benefits of a videoconferencing‐based home exercise programme for paediatric cancer survivors during the coronavirus disease 2019 pandemic

Abstract Objective We aimed to determine the feasibility and benefits of a videoconferencing‐based home exercise programme to improve health‐related quality of life (HRQOL), posttraumatic growth and physical strength levels of paediatric cancer survivors during the coronavirus disease 2019 (COVID‐19). Methods Eight paediatric cancer survivors participated in the intervention for 8 weeks. The programme comprised home exercise sessions administered using Zoom, a videoconferencing platform. The supervised exercise sessions were performed two times per week; the participants were taught to perform joint exercises at home for the remaining 5 days of the week. HRQOL, posttraumatic growth and physical strength levels were assessed at baseline and after the intervention. Results The rates of recruitment, retention and attendance were 52.9%, 88.9% and 98.4%, respectively. There were no cases of adverse events. The programme significantly improved flexibility (z = −2.21, p = 0.03), muscle strength (z = −2.67, p = 0.01) and power (z = −2.41, p = 0.02) among five domains of physical fitness measured using a physical activity promotion system and also improved total physical strength (z = −2.67, p = 0.01). Posttraumatic growth decreased slightly, whereas HRQOL improved slightly; however, the change was not statistically significant. Conclusion The study findings present preliminary evidence of the feasibility and benefits of this videoconferencing‐based home exercise programme among paediatric cancer survivors.


| INTRODUCTION
The survival rates of patients with paediatric cancers are steadily increasing owing to advances in medical technology. A recent report indicated that the 5-year relative survival rates of patients with major paediatric cancers ranged from 84.5% to 85.3% (Howlader et al., 2013;Korea Central Cancer Registry, National Cancer Center, & Ministry of Health and Welfare, 2020). As a result of the increased cure rates of paediatric cancers, greater attention is now being paid to the quality of life (QOL) of survivors.
Most acute problems, such as neutropenia, nausea and vomiting, associated with paediatric cancer have been largely resolved (Erickson et al., 2013). However, patients are still subject to damages of the endocrine, nervous, cardiopulmonary and musculoskeletal systems (e.g., limited functional mobility, flexibility and range of motion) during the process of cancer treatment (Goodenough et al., 2021;Wilson et al., 2015). Damage of these systems contributes to reduced engagement in physical activities by paediatric cancer survivors (Schindera et al., 2020). Paediatric cancer survivors engage in significantly less physical activity than the general paediatric population (Antwi et al., 2019). Furthermore, 45% of paediatric cancer survivors fail to meet the level of physical activity recommended by the World Health Organisation (Schindera et al., 2020). In addition, paediatric cancer survivors experience physical problems such as limited physical strength after completing treatment (Lim, 2018). As body movement is extremely limited during an extended hospital stay and when patients are bedridden, underactivity may persist even after treatment completion (Wilson et al., 2015). The fact that concerns regarding physical strength persist after treatment is undesirable for both survivors and their caregivers (Kim et al., 2018). This highlights the need for physical activity programmes to enhance the physical fitness of paediatric cancer survivors. Regular physical activity improves cardiopulmonary health, reduces fatigue, facilitates psychological well-being and strengthens the immune system, the most critical aspect for paediatric cancer survivors; thus, physical activity has protective effects against recurrence in cancer survivors (Cheung et al., 2021;Li et al., 2018;Manchola-González et al., 2020;Winker et al., 2021). Previous studies of exercise interventions for paediatric cancer survivors showed that these interventions are safe and feasible and are effective in improving flexibility, muscle strength, physical strength and health-related QOL (HRQOL) (Howell et al., 2018;Kim & Park, 2019).
Furthermore, exercise interventions have been reported to effectively promote posttraumatic growth among paediatric cancer survivors (Kim & Park, 2019). Posttraumatic growth refers to affirmative changes in the life of an individual following an adversity. These affirmative changes include inner strength, gratitude for life, positive changes in interpersonal relationships and psychological growth. Posttraumatic growth is important because it is associated with better perceived physical health and a healthier immune system in patients with cancer (Ramos et al., 2018). In addition, it contributes positively to HRQOL (Liu et al., 2020). Thus, the effects of non-face-to-face exercise interventions on posttraumatic growth and HRQOL in paediatric cancer survivors are worth investigating.
Reduced engagement in physical activity owing to the coronavirus disease 2019 (COVID-19) pandemic and its consequent negative effects on health are evident worldwide (Caputo & Reichert, 2020).
Paediatric cancer survivors have been affected by this pandemic as well and may be at an elevated risk for COVID-19 infection owing to their weakened immune systems (Cheung et al., 2020). To reduce the risk of exposure to COVID-19, parents of paediatric cancer survivors usually prefer having their children stay at home and not engage in outdoor activities (Cheung et al., 2020). Thus, prolongation of the COVID-19 pandemic can further extend the lifestyle limitations of paediatric cancer survivors (Forster & Schulte, 2021). Considering these challenges, a home exercise programme designed in consideration of the preventive measures of the COVID-19 pandemic, such as social distancing, is warranted for paediatric cancer survivors (Dwyer et al., 2020).
A previous study indicated that barriers in exercises for paediatric cancer survivors include a lack of an appropriate time and place (Kim et al., 2018). However, the non-face-to-face lifestyle that has become the norm during the COVID-19 pandemic could allow for safe involvement in physical activities at home. Thus, this study aimed to develop and evaluate the feasibility and benefits of a videoconferencing-based home exercise programme, which has few restrictions on time and place for paediatric cancer survivors during the COVID-19 pandemic.

| Study design
This was a pilot study conducted using a one-group pretest-posttest experimental design to assess the feasibility and benefits of a home exercise programme for paediatric cancer survivors administered using Zoom (Zoom Video Communications Inc., San Jose, CA, USA), a videoconferencing platform.

| Study participants
The study population comprised children diagnosed with paediatric cancer who completed treatment or were undergoing maintenance chemotherapy at a general hospital in Korea. All participants' parents or guardians provided written-informed consent to participate in this study. Potential participants who met the following criteria were included in the study: (i) diagnosed with paediatric cancer and completed treatment or was undergoing maintenance chemotherapy; (ii) aged 9-12 years and able to read and answer questionnaires; (iii) willing to participate in an exercise programme and (iv) signed an informed consent form. The exclusion criteria were as follows: (i) history of abdominal surgery, (ii) current fracture or (iii) inability to participate in the exercise programme twice a week.
The study participants were recruited by posting an announcement on the bulletin board at the outpatient paediatric department of a general hospital in Korea and by posting an announcement on the paediatric cancer patient group blog. Additionally, healthcare professionals at the hospital introduced us to potential candidates for recruitment (via 'consent to contact' forms). Considering the limited data available and the feasibility of the study, no sample size was calculated.

| Ethical considerations
The institutional review board of the first author's university approved this study. This study was performed in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The participants were informed of the purpose and method of the study and their right to withdraw from participation at any time. In addition, the participants and their parents or guardians were informed that any information they provided would be kept strictly confidential. Data collection was conducted once the patients' parents or guardians voluntarily signed informed consent forms. standing on a mat with eyes closed, pulling a band, sitting to standing and touching legs with a partner and sitting and standing while holding a band behind the body. The amount of exercise was adjusted depending on each participant's state and needs. The programme was designed with some flexibility such that physical activity could be promoted in consideration of the child's mood, emotions and physical status but in compliance with the overall flow of the programme. Prior to being implemented, the programme was reviewed through consultation with an expert panel. The panel comprised a paediatric haematology-oncology specialist, paediatric oncology nurse, oncology nurse and physical education professor to enhance safety and ensure the programme would adequately target both psychosocial and physical health outcomes.

|
The intervention was administered twice a week by the authors and a sports medicine expert (certified clinical exercise physiologist) via Zoom. Additionally, a step-by-step video of joint exercises was provided for all participants to follow at home (30 min per day for 5 days) during the remaining days of the week to maintain physical activity. During the 8-week intervention, we called or texted the participants' parents every week to encourage them to make use of the step-by-step video of joint exercises and to participate in the programme, as well as to check for and resolve any issues. Participants who were absent from the programme received phone calls and the others received text messages (e.g., 'How are you doing?', 'Have you performed the exercises in the 30-minute step-by-step video of joint exercises this week?' and 'Are there any difficulties or injuries due to the program?'). All participants performed the step-by-step exercises 5 days per week for the 8 weeks.
In addition, the sports medicine expert checked the appropriateness of the exercise intensity by applying the Borg Rating of Perceived Exertion (RPE) 6-20 (Borg, 1982), which can be used to assess the role of exercise in paediatric cancer (Klika et al., 2018). The Borg RPE 6-20 was shown via zoom, and the participants were then asked to assess their perceived exertion before warm-up, in the middle of the main session and at the end of cool-down. The exercise intensity was set to be of low to moderate intensity (40-60%; 10 to 12 of RPE) during the main session, considering the participant's health status.
The participants were instructed to continue with any exercises or activities that they had been performing before the intervention programme but not to start a new type of exercise other than the intervention. One had been playing badminton, and the others did not participate in any exercises during the 8-week period. At baseline and after the intervention (within 1 week of completing the 8-week intervention), the HRQOL, posttraumatic growth and physical strength levels of the participants were assessed.

| Feasibility
The feasibility of the programme was the primary outcome of this study and was assessed based on recruitment, retention, attendance and adverse events. Recruitment was defined as the number of eligible participants who were recruited by a healthcare professional or via the recruitment announcement and were enrolled in the programme. Retention was defined as the number of participants who completed the 8-week programme. Attendance was defined as the number of survivors who participated in each session of the exercise programme. Adverse events were defined as any negative outcomes during the 8-week programme.

| Potential benefits
The secondary outcome was the potential benefits of the programme. This was assessed by evaluating changes in HRQOL, posttraumatic growth and physical strength levels of survivors. HRQOL was assessed using the Korean version of the Pediatric Quality of Life (PedsQL) 4.0 Generic Core Scale (Varni et al., 2002) (self-report questionnaire for children aged 8-12 years) (Chung & Yang, 2012). This is a 23-item Likert-type response scale (0 for never a problem, 1 for almost never, 2 for sometimes, 3 for often and 4 for almost always), with higher scores indicating better functioning. The score for each item is converted as follows: a score of 0 = 100, 1 = 75, 2 = 50, 3 = 25 and 4 = 0. The scale comprises four subscales: physical functioning (eight items), social functioning (five items), emotional functioning (five items) and school functioning (five items).
Posttraumatic growth was assessed using the Korean version (Song et al., 2009) of the Post-traumatic Growth Inventory (Tedeschi & Calhoun, 1996). This is a 16-item Likert-type response scale with responses ranging from 1 for I did not experience this change as a result of my crisis to 5 for I experienced this change to a very great degree as a result of my crisis. Higher scores indicate better growth.
Physical strength levels were measured using age-specific fitness

| Data analysis
Given the exploratory nature of the study, a repeated measures within-subjects design was selected. Statistical significance was set at 0.05 for all analyses, and two-tailed tests were used. The normality of each parameter was tested, and non-normally distributed data were analysed using nonparametric tests. Sociodemographic and clinical characteristics of the participants were analysed using descriptive statistics. The feasibility of the programme was described in terms of recruitment, retention and attendance rates. Changes in HRQOL, posttraumatic growth and physical strength levels after the intervention compared to baseline values were analysed using Wilcoxon signed-rank tests. The collected data were analysed using the SPSS 21.0 software (IBM Corp., Armonk, NY, USA).

| Participant characteristics
The general and clinical characteristics of the participants who completed the programme are described in Table 1. Eight participants (four boys and four girls) completed the programme. The participants' ages were 9 (n = 2), 10 (n = 4), 11 (n = 1) and 12 (n = 1) years. Their diagnoses included acute lymphoblastic leukaemia (n = 5), acute myeloid leukaemia (n = 1), non-Hodgkin's Lymphoma (n = 1) and severe aplastic anaemia (n = 1). Six participants underwent only chemotherapy, whereas two participants underwent chemotherapy, radiation therapy and stem cell transplantation. Time since diagnosis ranged widely, from 11 to 43 months. Three participants were undergoing maintenance chemotherapy at the time of this study.

| Feasibility
The recruitment process is outlined in Figure 1. All participants' parents or guardians signed a 'consent to contact' form and were introduced by a healthcare professional for enrolment. A total of 17 survivors were referred or contacted the research coordinator and were assessed for eligibility. Among them, three were excluded for different reasons, including bone pain and inability to participate in the programme regularly. Five others declined to participate for reasons such as concerns regarding COVID-19. Nine participants were enrolled, resulting in a recruitment rate of 52.9% (9/17). Among the nine participants enrolled, eight (88.9%, 8/9) completed the 8-week programme. All participants who completed the 8-week programme completed all assessments (100%, 8/8). The participant who did not complete the programme (11.1%; 1/9) attended the baseline T A B L E 1 General and clinical characteristics of the study participants

| DISCUSSION
This study was conducted to analyse the feasibility and benefits of an 8-week play-combined home exercise programme for paediatric cancer survivors during the COVID-19 pandemic. The rates of recruitment, attendance and retention in this study were 52.9%, 98.4% and 88.9%, respectively. The recruitment rate was not high because many candidates were hesitant or declined to participate in the programme due to COVID-19. However, the attendance rate was high, presumably because the programme was designed as a home exercise programme in consideration of the restrictions on outdoor activities during the COVID-19 pandemic. It should be noted that our findings cannot be directly compared to previous research owing to a lack of studies conducted on patients in the same age group during the same period and using the same exercise intensity as in the present study.
A previous pilot study conducted prior to the COVID-19 pandemic in which paediatric cancer survivors engaged in indoor wall climbing had an attendance rate of 57.43% (Däggelmann et al., 2020). Another pilot study of a home-based physical activity intervention for childhood cancer survivors aged 15-35 years had a retention rate of 79% (Le et al., 2017). Moreover, a 75% retention rate was set as the threshold for feasibility in a previous exercise intervention study (Ruble et al., 2016). We speculate that the high retention rate of 88.9% achieved in the present study is attributable to the easy, fun and engaging nature of our home exercise programme. In addition, we did not observe any health-related adverse events. This may be attributable to the fact that we continuously checked the appropriateness of intensity of the exercises and adjusted the routine in accordance with the health status of the survivors. These findings indicate that our home exercise programme conducted through videoconferencing is feasible and can be administered during the COVID-19 pandemic without provoking anxiety among parents of childhood cancer survivors regarding gathering in person to participate in group exercises.
In addition to feasibility, the results of the present study suggest with solid tumours (Fiuza-Luces et al., 2017). In this study, low to moderate intensity exercises that were 10 to 12 of Borg RPE 6-20 were performed. As the regimen was administered flexibly in consideration of the physical states of the survivors and the exercise intensity was not assessed by objective measurements, such as using an actigraph, it is possible that the intervention did not have the appropriate intensity and amount of exercise needed to improve cardiorespiratory endurance (Lee et al., 2017). Nevertheless, this study is significant in that it confirmed that a home exercise programme administered through videoconferencing improves the physical fitness of paediatric cancer survivors during the COVID-19 pandemic.
The exercise programme did not significantly promote posttraumatic growth in childhood cancer survivors. In a previous study of the effects of an exercise intervention on posttraumatic growth in paediatric cancer survivors, which was conducted before the outbreak of COVID-19, posttraumatic growth significantly improved after the intervention (Kim & Park, 2019). In another study in which a mixed intervention, including exercise, was administered to patients with breast cancer, posttraumatic growth improved after the intervention (Bae, 2017). The home exercise programme in this study was con- However, it should be noted that the abovementioned previous studies were not conducted during the COVID-19 pandemic. Future studies are required to identify specific factors responsible for the differences between the outcomes of in-person and non-face-to-face exercise interventions.
HRQOL did not significantly improve in the present study. This finding is consistent with findings of previous studies that involved inperson exercise interventions (Cox et al., 2018;Dubnov-Raz et al., 2015;Fiuza-Luces et al., 2017). As the participants of our programme had relatively good baseline QOL scores, it is possible that the exercise intervention did not lead to further improvement in QOL (Dubnov-Raz et al., 2015). However, our results are contradictory to those of some studies in which in-person exercise programmes or adventure-based training increased the HRQOL of childhood cancer survivors (Kim & Park, 2019;Li et al., 2018). In addition, another previous showed that a web-based physical activity intervention significantly increased the HRQOL of childhood cancer survivors (Howell et al., 2018). However, the intervention in that study (Howell et al., 2018) was a non-face-to-face programme administered using multimedia (internet) and a reward system, in which participants can collect points and exchange them for a t-shirt or gift card. Thus, it is not clear whether the positive effects of the intervention on HRQOL can be attributed to the non-face-to-face aspect of the programme or the reward system. Furthermore, the present study was conducted during the COVID-19 pandemic; thus, the differences between nonface-to-face interaction during the COVID-19 pandemic and prior to the COVID-19 pandemic should also be considered.
Ultimately, although our programme did not significantly improve posttraumatic growth and HRQOL, the survivors and their parents were highly satisfied with the intervention. Although we did not assess the participants' satisfaction through objective measurement, the parents who could tell the effect on their children through their facial expressions, actions, postures and voices at a close distance mentioned that the children grew brighter and happier and were satisfied after completing a regular physical activity. This is in line with the results of a previous qualitative study of the effects of a videoconferencing-based programme, which comprised fitness, yoga, tai chi, dance therapy, music therapy and meditation, on patients with cancer (Emard et al., 2021). The programme strengthened the psychological coping of participants, provided motivation and promoted adherence to health behaviours (Emard et al., 2021).
This study had a few limitations. First, the sample size was small, and the possibility of selection bias cannot be eliminated. Therefore,