Physical activity and exercise in pediatric oncology: conceptual distinctions and clinical implications

ABSTRACT

Survival in childhood cancers has markedly improved, yet many children experience treatment-related difficulties such as persistent fatigue, muscle weakness, reduced endurance, and impaired quality of life. As interest in non-pharmacological approaches grows, movement-based strategies, ranging from general physical activity to structured exercise, have become increasingly prominent in pediatric oncology care. This review aims to clarify the conceptual and practical differences between physical activity and structured exercise, and to summarize current evidence on movement-based interventions used during active treatment and survivorship in children and adolescents with cancer. Drawing on quantitative and qualitative studies published between 2000 and 2025, it shows that priorities shift across treatment phases: safety and feasibility are emphasized during active therapy, whereas long-term health and functional recovery gain importance in survivorship. The findings highlight the need for clearer terminology, coordinated multidisciplinary practice, meaningful family involvement, and consistent outcome measures with longer-term follow-up in future research.

Progress in chemotherapy, radiotherapy, surgical methods, and supportive care has significantly increased survival rates among children with cancer, resulting in a rising number of long-term survivors.^[1] Today, long-term survival has become a realistic expectation for many patients, with five-year survival rates exceeding 80% in several parts of the world.^[1] However, the success of modern oncology brings new challenges. Many children continue to experience treatment-related effects, sometimes persisting well beyond the completion of therapy, such as fatigue, muscle weakness, reduced endurance, peripheral neuropathy, decreased bone mineral density, and increased cardiometabolic risk.^{[2, 3, 4]} These lingering effects may restrict involvement in everyday tasks, impede emotional and social well-being, and reduce overall quality of life (QoL) throughout both the active treatment phase and survivorship.^{[1, 2]} In response to these challenges, interest has grown in rehabilitation strategies that complement medical treatment through non-pharmacological means. Movement-based approaches, ranging from everyday physical activity to structured exercise programs, are increasingly recognized as important components of pediatric oncology care.^{[3, 5]} However, the terms “physical activity” and “exercise” are often used interchangeably in the literature despite referring to conceptually distinct constructs. Physical activity encompasses any bodily movement produced by skeletal muscles that results in energy expenditure, including play, walking, climbing stairs, or household tasks.^[6] Exercise is a subset of physical activity that is planned, structured, and repetitive, carried out with the intention of improving or maintaining physical fitness.^[7] In pediatric oncology, exercise programs typically combine aerobic, resistance, flexibility, and balance training, with parameters adapted to each child’s medical status, energy level, and developmental needs.^[8]

Therefore, this review aims to clarify the conceptual and practical distinctions between physical activity and structured exercise in pediatric oncology. While physical activity generally refers to a broad range of daily or play-based movements, structured exercise involves planned, repetitive, and goal-oriented programs designed to improve or maintain specific aspects of physical function. Based on this distinction, the review summarizes current evidence on movement-based approaches during active treatment and survivorship, and discusses their implications for terminology, individualized rehabilitation planning, and multidisciplinary clinical practice.

CLINICAL AND RESEARCH CONSEQUENCES

Physical activity interventions

Interventions involving physical activities in pediatric oncology are grounded in earlier evaluations of physical performance in multiple domains. These domains include endurance and strength of muscles and cardiovascular capabilities (Table 1). Cancer treatment-related physical activity in children undergoing cancer treatment usually reflects their ordinary daily movements rather than participation in structured physical activities. The number one objective is to recommend simple, exciting activities that can last the entire treatment. These activities are used on a day-to-day basis and help to reduce sedentary behavior and can help with social participation, emotional well-being and functional independence. Physical activity is much less prescribed than exercise, but it needs careful planning to make sure that sports are safe and feasible as treatment-related needs vary.^{[5, 8]}

TABLE 1 Physical performance assessment tools used in pediatric oncology.

Measurement criterion	Tools/tests	Purpose/goal	References
Cardiovascular capacity	VO2 peak test, 6-minute walk test (6MWT), Borg perceived exertion scale	Assess cardiovascular endurance and oxygen consumption	[9,10]
Muscle strength & endurance	Grip strength test, 1-minute sit-to-stand (STS), jump height measurement	Objective measurement of muscle strength and endurance	[9]
Physical function & mobility	Functional mobility tests, balance and postural stability assessments	Evaluate motor control and daily functioning	[11]
Body composition & metabolic health	BMI, waist circumference, lean mass & bone mineral density (DXA), blood pressure, lipid profile, glucose	Monitor body composition and metabolic health	[9,11]
Psychosocial & QoL outcomes	Quality of life surveys, fatigue and depression scales, motivation questionnaires	Assess psychosocial well-being and adherence	[10]

VO₂: Oxygen consumption; BMI: Body mass index; DXA: Dual-energy X-ray absorptiometry; QoL: Quality of life.

The implementation of physical activity in pediatrics is based on several considerations: (i) enjoyment and involvement, (ii) flexibility and adaptability, (iii) integration into daily routines, (iv) involvement of family and friends, and (v) safety monitoring. Activities are to be interesting, age-appropriate and intrinsically motivating in order to promote common participation. Because of the range of strengths and treatment-related outcomes, intensity and duration may also need frequent adjustments. Support from mothers, fathers, siblings, and peers can strengthen engagement and contribute to making habits. Activity should be guided by a general assessment of fatigue, pain, contamination hazards, and treatment-unique precautions. Examples of commonly used activity types and their potential advantages are given in Table 2.^{[3, 12, 14]}

TABLE 2. Physical activity interventions in pediatric oncology.

Category	Examples	Frequency/duration	Key benefits	References
Play-based	Active play, exergaming	Daily, 10-20 min bouts	↑ Engagement, ↓ fatigue, ↑ motor skills	[12,15]
School/community	Adapted sports, active transport	Several times/week	↑ Mobility, ↑ participation	[3,11]
Daily lifestyle	Walking, stair climbing, chores, gardening	≥60 min/day (accumulated)	↑ Energy expenditure, independence	[6,16]
Technology-supported	Wearables, mHealth apps	Continuous monitoring	↑ Motivation, adherence	[17, 18, 19]
Family/peer-involved	Parent–child play, peer groups	Embedded in routines	↑ Adherence, psychosocial support	[13,14]

mHealth: Mobile health; min: Minute.

Frequency

Most children receiving cancer treatment benefit from regular daily movement, although the amount and pattern often differ from the World Health Organization’s general recommendation of 60 min of moderate-to-vigorous activity for healthy youth. In pediatric oncology, activity frequency is adjusted to each child’s tolerance, treatment phase, and clinical status.^[6]

Intensity

Activity levels generally vary during the course of treatment. For days where energy or symptoms are particularly low, stretching or slow walking may be beneficial. Other activities like brisk walking, dancing, and cycling can be introduced once a child has recovered completely. These activities should be introduced where limits allow.^[8]

Duration

Long, sustained bouts are virtually never practical during treatment. Breaking each session into bouts of 10-15 minutes at a time, repeated throughout the day, remain realistic and beneficial to the overall therapeutic activity.^[13]

Progression

Progress does not necessarily mean increasing workload. For many children, improvements arise from moving more often, experimenting with different types of activities, and finding options they enjoy. These elements can support adherence and help maintain participation over the longer term.^[3]

Implementation principles

There are several clinical considerations that are important before recommending or initiating physical activity. Firstly, fatigue, pain and infection risk should be assessed. Children may have variable energy, neuropathic symptoms, and immune function. A quick preactivity check helps identify what is safe and appropriate on a given day.^{[3, 8]} Secondly, activities should be fun and developmentally appropriate.

Programs incorporating play or activities that are age-appropriate for the child are generally more widely accepted and generally more likely to continue over time.^{[12, 15]} Lastly, family involvement should be encouraged. When movement is treated as a shared endeavor with parents, caregivers, and siblings, it is carried out more consistently and integrated into customary daily activities.^{[13, 14]} Basic monitoring methods should be used when necessary.

Some families can report involvement and see improvement with activity diaries, caregiver logs, and the use of wearable technology, although there are little data to support the value of these methods after the initial intervention period.^{[17, 18, 19]} In closing, positive feedback should be given.

Noticing effort, small changes, or even the consistency of participation is valuable for motivation and building healthy patterns.^[16]

Exercise programs

Exercise refers to a planned and purposeful type of activity to improve and/or preserve the appropriate level of fitness. Pediatric oncology programs are designed to meet the child’s medical stage and treatment status and developmental needs. Efficient and safe therapy progress is guaranteed by professional supervision.^[8]

Core components of exercise interventions

Aerobic training is the most common modality used in pediatric oncology. Walking, cycling, dancing, or using a treadmill have been common activities. Moderate-intensity work is defined as between 40 and 60% of heart-rate reserve or as a rating of perceived exertion score of 11 to 13, and is associated with advances at cardiorespiratory capacity, reductions in fatigue, and enhanced endurance in children undergoing treatment.^{[5, 20]}

Resistance-based exercise includes elastic bands, light free weights, as well as body-weight movements (squats, push-ups, rope jumping, etc). Most programs involve one to three sets of eight to 12 repetitions, done two or three times a week. These approaches may be useful in maintaining or enhancing muscle strength, promoting bone health, and reducing treatment-related declines in lean mass or risks of sarcopenia.^{[21, 22]}

Children who have had chemotherapy or corticosteroid exposure may benefit from balance, coordination and proprioception exercises to improve stability and coordination, as well as support healthy body alignment and functioning.^{[3, 23]}

A combined multimodal format that includes aerobic, strength, and coordination exercises has also been noted in several studies. Circuit training sessions or structured play activities may offer extensive functional advantages and are often linked to better engagement andadherence.^{[3, 24, 25]}

Implementation principles

Most exercise plans that have been documented last 8 to 10 weeks and involve 2 to 3 sessions a week with a trainer. The sessions last between half an hour and an hour and start with a warm-up, which is based on mobility exercises, then comes aerobic training, resistance work (8-12 repetitions of one to three sets) and balance or coordination tasks.

Usually a cool-down ends the sessions; this can include stretching or breathing techniques.^{[8, 26]} They should be checked regularly. Heart rate, blood pressure, and oxygen saturation levels in addition to pain should be monitored before and after training. When activities are modified according to a child’s clinical condition, adverse events are rare. Study results support the view that graded exercise is safe and feasible at all levels of pediatric cancer rehabilitation.^{[3, 23]}

Table 3 presents a detailed summary of the exercise modalities, session structure and observed outcomes.

TABLE 3. Exercise programs in pediatric oncology.

Type	Examples	FITT principles	Key benefits	Representative references
Aerobic training	Walking, cycling, treadmill, dance	2-3×/week; 20-40 min; moderate (40-60% HRR, RPE 11-13)	↑ Fitness, ↓ fatigue, ↑ endurance	[5,20,26]
Resistance training	Theraband, bodyweight, rope skipping, free weights	2-3×/week; 1-3 sets; 8-12 repetitions; moderate load	↑ Muscle strength, ↑ bone health	[8,21,22]
Balance and coordination	Single-leg stance, yoga, balance board	2-3×/week; 10-15 min	↑ Motor control, ↓ fall risk	[3,23]
Combined/multimodal	Aerobic + resistance + coordination; circuit training	2-3×/week; 45-60 min; 8-10 weeks	↑ QoL, ↑ strength & endurance, ↑ adherence	[4,24]
Implementation framework	Warm-up, aerobic, resistance, balance, cool-down	8-10 weeks; adapted to fatigue/treatment status	Safe, feasible; improves fitness and psychosocial outcomes	[3,8,26]

FITT: Frequency, intensity, time, type; HRR: Heart-rate reserve; RPE: Rating of perceived exertion; QoL: Quality of life.

Interventions by treatment phase

Adjusting interventions based on the stage of treatment becomes crucial in pediatric oncology, particularly because physical condition, safety, and fatigue patterns vary significantly between active therapy and survivorship.^{[5, 8, 22]} In pediatric oncology, movement-based interventions should be tailored according to the child’s treatment phase (Tables 4A and 4B). Each stage of treatment brings changes in energy levels, physical capacity, and rehabilitation priorities, making safety a primary consideration. During active treatment, the focus centers on maintaining mobility, preventing deconditioning, and slowing symptom progression (Table 4A). Once in the survivorship phase, the emphasis shifts toward rebuilding fitness, managing long-term side effects, and establishing sustainable activity habits (Table 4B).^{[3, 5, 8, 22]}

TABLE 4A. Exercise and physical activity during active treatment.

Study	Sample	Intervention	Duration/frequency	Outcomes	Main findings
Masoud et al.[15] 2023 (RCT)	n=45; age 6-14 years	Exergaming vs. PA education	3 weeks; 2×/week; 60 min	Fatigue (PedsQLMFS), 6MWT, PA levels	↓ Fatigue, ↑ functional capacity & PA
Schmidt-Andersen et al.[27] 2022 (RCT protocol; INTERACT)	Age 6-17 years	Supervised neuromuscular training vs. home PA	24 weeks	Strength, endurance, QoL, fatigue	Supervised exercise expected to ↑ outcomes
Pouplier et al.[12] 2024 (RePlay)	n=84; age 1-5 years	Structured active play	24 weeks	Gross motor skills, QoL	↑ Gross motor, ↑ social participation
Zucchetti et al.[26] 2018 (meta-analysis)	Mixed pediatric hematologic cancers	Aerobic + resistance	8-12 weeks	Aerobic capacity, strength, QoL	Exercise safe; ↑ aerobic capacity & QoL
Grimshaw et al.[28] 2024 CanMOVE program	Children on active treatment	Behavior change + PA promotion	~10 weeks	PA levels, HR-QoL	↑ PA participation and function

RCT: Randomized controlled trial; PA: Physical activity; PedsQL-MFS: Pediatric quality of life inventory multidimensional fatigue scale; 6MWT: 6-minute walk test; QoL: Quality of life; HR-QoL: Health-related quality of life.

TABLE 4B. Exercise and physical activity during survivorship.

Study	Sample	Intervention	Duration/frequency	Outcomes	Main findings
Yeh et al.[29] 2011 (Pilot RCT, ALL)	22 survivors 12 intervention, 10 control	Home-based aerobic	6 weeks	Fatigue (self-report)	↓ Fatigue at 1 month (not significant ITT)
Bogg et al.[30] 2015 (HSCT)	n=14; mean age ~10 years	Supervised inpatient exercise	6 weeks; 5×/week	6MWT, core strength, balance, fatigue, QoL	100% completion; stable fatigue; ↓ aerobic fitness
Marchese et al.[21] 2004	n=28; age 4–15 years; ALL	Physical therapy + home exercise program	16 weeks	Ankle ROM, knee extension strength, functional mobility	↑ Knee extension strength; ↑ ankle dorsiflexion ROM
Gaser et al.[31] 2022	n=41; age 4-18 years	Resistance vs. standard exercise	32 weeks	ADL, strength, aerobic capacity	Both ↑ ADL; resistance ↑ explosive strength
Caru et al.[14] 2020	n=40 survivors; mean age 13.6 years; approximately 2.9 years post-treatment	Behavioral PA + phone follow-up	12 weeks	PA behaviors, 6MWT, PROs	↑ PA intensity/duration, ↑ 6MWT
Ha et al.[17] 2021 (systematic review)	n=517; age 4-18 years	Wearable trackers	2-52 weeks	PA levels, health	Some ↑ PA; fitness outcomes mixed
Caru et al.[4] 2024 (pilot RCT)	n=40 survivors	Behavioral PA + follow-up	12 weeks	FITT behaviors, 6MWT, PROs	Feasible, ↑ PA and functional outcomes
Fiuza-Luces et al.[23] 2017	n=49; solid tumors; mean age approximately 10-11 years	Hospital-based aerobic + resistance	19 weeks; 3×/week	Strength, CRF, QoL	↑ Strength (leg press +40%); no adverse events

Active treatment phase

Exercise plans need to be adapted during chemotherapy, radiotherapy and stem cell transplantation.^{[5, 8]} Energy, neuropathy, nausea, fatigue, and other factors can limit participation and change from day to day.^{[3, 8, 22]} The emphasis is not on intensive retraining at this stage. The priority is maintaining fundamental capabilities and facilitating mobility.^{[5, 8]} Strategies centered on play, including exergaming, active play with structure, or light play with supervision, assist in developing the necessary requirements for more advanced rehabilitation with reported benefits in coordination, fatigue reduction, and QoL.^{[12, 15, 24, 32]} CanMOVE and other behavioral models show that low-intensity, enjoyable activities can be safely added to routine care during treatment without added risk.^{[4, 28, 33]}

Survivorship phase

Post-treatment, the focus broadens to restore physical fitness, mitigate late effects, and cultivate sustained exercise habits. Aerobic, resistance, and multicomponent interventions effectively improve endurance, muscle strength, and various psychosocial outcomes, as do technology-assisted methodologies.^{[14, 21, 23]} Technology-assisted methods, in-home follow-up sessions, and routine motivational check-ins may further enhance adherence. This reflects the continued importance of family involvement and monitoring in relation to sustained engagement.

Overall perspective

Across all studies, evidence consistently shows that movement-based interventions during cancer treatment serve to maintain stability, manage symptoms, and prevent functional decline. Post-treatment, rebuilding strength and improving fitness become the priorities in order to support lifelong engagement in healthy movement. Regardless of the stage, routine physical activity and structured exercise are both safe and beneficial when tailored to the child’s clinical and psychosocial status.

Interpretation of the evidence

This review synthesizes current evidence regarding movement-based rehabilitation in pediatric oncology, with a specific focus on the conceptual and practical distinctions between physical activity and structured exercise. While both approaches demonstrate strong safety profiles during and after treatment, the field still faces persistent challenges, including inconsistent terminology, varied methodological designs, and poorly defined long-term implementation strategies.

A key contribution of this review is clarifying the ongoing conceptual overlap across the literature. Because physical activity and exercise are not synonymous, a clearer distinction between the two would enhance methodological alignment and better facilitate the translation of research into clinical practice.^{[4, 6, 7]}

Available evidence indicates that activity-based interventions are generally effective and well-received. Most studies report adherence rates exceeding 80%, with virtually no adverse events when sessions are tailored to medical status and appropriately monitored. These findings support integrating both physical activity and structured exercise into routine clinical practice, while underscoring the necessity of pre-participation screenings for fatigue, pain, infection risk, and treatment-specific limitations.^{[3, 8, 23]}

Traditional exercise methods, alongside lifestyle-oriented activities such as active play and exergaming, have demonstrated significant benefits. Across various research designs, documented improvements include aerobic capacity, muscular strength, fatigue mitigation, and QoL. Multimodal interventions may offer additional advantages by combining aerobic, resistance, and coordination-based elements into engaging, adaptable formats.^{[5, 24, 33]} Despite the aforementioned challenges, numerous strategies exist to overcome barriers to participation.

Fluctuations in fatigue, neuropathy, pain, and emotional concerns can disrupt daily routines. However, key facilitators such as family support, engaging activity formats, peer involvement, and professional guidance significantly contribute to sustaining long-term participation.^{[14, 16, 27, 34]} Digital tools, including wearables, mobile apps, and game-based systems, hold exciting promise, though evidence of their long-term impact remains limited.^{[17, 18, 19,35]}

Several methodological barriers also restrict generalizability. Numerous investigations rely on small sample sizes or recruit participants from a single center, while outcome measures vary significantly across studies. To establish stronger evidence-based rehabilitation frameworks in the future, multicenter cooperation, standardized evaluation procedures, and extended follow-up periods serve as promising strategies.^{[16, 36]} Furthermore, a coordinated, multidisciplinary approach involving doctors, nurses, physiotherapists, psychologists, and families is essential to sustainably maintain this rehabilitation continuum.^{[3, 8]}

CONCLUSION

Current evidence demonstrates that incorporating daily physical activity and structured exercise plays a vital rehabilitative role for pediatric cancer patients. Regular movement helps maintain functional capacity, while structured exercise offers targeted opportunities to build strength, improve endurance, alleviate fatigue, and support emotional well-being. During active treatment, clinical priorities center on safety, symptom management, and mobility maintenance. Post-treatment, the focus seamlessly shifts toward recovering optimal physical fitness, mitigating long-term complications, and establishing lifelong exercise habits. Ultimately, active family involvement, multidisciplinary teamwork, and the strategic integration of digital support tools serve as critical pillars to strengthen intervention adherence across all phases of care.

Future studies should focus on refining terminological definitions, developing standardized program criteria, and analyzing long-term outcomes through large-scale multicenter trials. These initiatives will provide a more robust scientific foundation for integrating movement-based rehabilitation into routine pediatric oncology care.