Abstract
BACKGROUND
Pediatric posterior fossa tumor (PFT) survivors experience a range of cognitive and motor impairments that require timely rehabilitation of these functions. In Russia, rehabilitation services are only just beginning to be formed; therefore, it is necessary to test rehabilitation protocols for children surviving cancer.
AIM
To evaluate the efficacy of short-term cognitive and motor training (CMT) aimed on visual-motor integration in PFT survivors using training devices.
DESIGN
“Single center” quasi randomized controlled experiment.
SETTING
Outpatients of the Russkoe Pole Rehabilitation Center.
POPULATION
The 63 children cancer survivors between the ages of 6 and 17 years.
METHODS
The baseline level of cognitive and motor functions was assessed in all participants. Then the sample of patients split into two subgroups of equal sex, age, and diagnosis. The intervention subgroup received six sessions of CMT for two weeks, and the other subgroup underwent ‘empty’ two weeks with no intervention. Reassessment of motor and cognitive functions was conducted in all participants. Then the subgroups changed: the first subgroup underwent ‘empty’ two weeks, and the second subgroup completed the CMT, and further reassessment was provided.
RESULTS
The primary results demonstrate an increase in gross and fine motor skills, motor coordination, visual-motor integration, and visual processing after CMT. Secondary results show that the age at onset is an important factor in the subsequent decline in cognitive, motor functions, and eye movements. Children with medulloblastoma perform worse on motor tests than children with astrocytoma. A tumor in the IV ventricle is the most harmful, and a tumor in the cerebellar hemispheres is the least harmful to a child’s cognitive and motor development.
CONCLUSIONS
This study shows the effectiveness of a short-term CMT program for children who survived PFT. The study also found that cognitive, motor, and visual-motor functions are affected by the tumor’s localization, malignancy, and the child’s age at onset.
CLINICAL REHABILITATION IMPACT
Short-term rehabilitation methods can be useful in pediatric oncological practice. Reconstruction of cognitive functions can occur during the training of more “simple” functions, such as hand-eye integration. The study makes a significant contribution to the methods of short-term rehabilitation in children who survived cancer.
Key words: Child, Posterior cranial fossa, Brain neoplasms, Cerebellum
Tumors of the central nervous system in children are the most common neoplasms in the world after hemoblastosis (leukemia and lymphomas), accounting for about four per 100,000 of the child population in Russia, which is comparable to international data: 5.95 per 100,000 in the USA;1 3.61 per 100,000 in Japan;2 3.46 per 100,000 in Italy;3 four per 100,000 in Great Britain.4 Tumors of the posterior fossa (PFT) account for about 60% of all childhood intracranial tumors.5 The most common tumors of the posterior fossa are medulloblastoma (40%), astrocytoma (20-35%), and ependymoma (10%). These three types of tumors require different treatment regimens, including different combinations of surgery, chemotherapy, and radiation therapy.6 Survival rates for children vary widely, ranging from 30-70% for ependymoma,7, 8 90% for medulloblastoma9 and almost 100% for low-grade gliomas.10
The PFT tumors themselves11 and treatment factors can cause the impairment of motor and cognitive functions, which influence negatively on speech, academic achievements, and quality of life.12-16
One of the most essential consequences of the disease is cognitive deficits or impairments in the areas of attention, working memory, and executive functions.17, 18 The cerebellum pathology often causes deficits of motor skills.19, 20 Considering that motor system has a hierarchal organization, PFT can cause the impairment of all the system, starting with gross motor skills and ending in the finest eye movements.21, 22 The cerebellum has been shown to control voluntary eye movements, particularly such parameters as accuracy and velocity of saccades, fixation duration, etc.23 Given the effect of probable deficits on a child’s daily life, the issue of cognitive and motor remediation programs is in the spotlight today. There is some evidence that interventions targeting cognitive functions (e.g. working memory, short-term memory, attention, planning) and motor skills (gross and fine motor skills, muscle strength, agility) can be effective in these patients.24-26 However, only few of remediation programs focus on visual-motor co-ordination and saccadic eye movements system, despite the fact that they provide the basis for higher level executive functions, such as sustained attention, working memory, and planning.
The previous research conducted in Russkoe Pole Research Center (of the Dmitry Rogachev National Medical Research Center Of Pediatric Hematology, Oncology and Immunology) has revealed that treatment gains in the areas of motor skills, and specifically saccadic eye movements, are positively associated with the enhancement of attention and working memory.27, 28 Given this, we can hypothesize that this improvement is connected with the reduction of extra saccadic movements and consequently the decrease of irrelevant information to be processed. This mechanism can be generalized to the other executive functions, such as shifting, inhibition, and planning.27-29 This trial will allow us to determine potential feasibility of rehabilitation training targeting motor and cognitive functions, as well as the saccadic system, in PFT survivors. The training is based on developing sensorimotor automated reactions and processing that could improve executive functions (inhibitory control, including interference control or selective attention, working memory, and cognitive flexibility also called set-shifting), turning on principles of cerebellar feedforward mechanisms, not feedback. The main aim of the study is to estimate the efficacy of cognitive and motor training (CMT) in PFT survivors. In addition, in our work, we evaluate cognitive and motor functions (in particular, the saccadic system) in relation to disease factors (age of onset, diagnosis, and tumor location) in these patients.
Materials and methods
Trial design
A “single center” quasi randomized controlled experiment was performed to evaluate the efficacy of CMT between February 2017 and May 2018. The study coordinator randomized the cohort of patients into two subgroups aligned by diagnosis (Figure 1). According to the legislation of the Russian Federation, children had been staying in a rehabilitation center for 32 days. In the first phase of the trial, all children were completed cognitive and motor functions assessment (in the first two-three days of being in the center). After the first point of function evaluation the sample of patients was split into two subgroups of equal sex, age, and diagnosis. In the second phase of the trial, one of the patient’s subgroups was received 6-8 sessions of CMT during two weeks; and the other subgroup underwent through ‘empty’ two weeks with no intervention. After this phase, motor and cognitive functions assessment were conducted in all patients once again. In the third phase, the subgroups changed: the first subgroup went through ‘empty’ two weeks, and the second subgroup completed the CMT. After this, motor and cognitive functions assessment were carried out in all patients once again (last two-three days of being in the center).
Figure 1.
—Scheme of enrollment.
Participants
The study involved 63 children between the ages of 6 and 17 years (mean: 11.6±3.4 years, 56% male) (Table I). They were recruited in the Russkoe Pole Clinical Research Rehabilitation Center of Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology among outpatients by an independent neuro-oncologist according to the following inclusion criteria: survivor of posterior fossa tumor; staying in Clinical Rehabilitation Research Center for 32 days; remission period is not less than 36 months; normal vision or corrected by lenses; research participant or legal guardian/representative to give written informed consent. Exclusion criteria included: currently on stimulants or other medications intended to treat motor or cognitive impairment; history of seizures; severe deficits in vision, motor skills, or cognitive functions. Children from the sample were treated about the HIT 2000|2008 or SIOP LGG protocol. The average time of the onset of the lesion was 6 years, ranging from 1 to 16 years. Depending on the type of tumor, children received the following treatment: only the surgery (16 patients, 25%), surgery and radiation therapy (8 patients, 13%), surgery, radiation and chemotherapy (39 patients, 62%). Time of remission was from 36 months to 10 years. The average duration of remission was 3 years. The sample is represented by residents of Russia from various cities and towns. The sample included children who speak Russian well and understand it. Most of the children are schoolchildren and are homeschooled or blended. More than half of the children have a disability group.
Table I. —Factors and levels connected with the disease.
| Factor | Levels |
|---|---|
| Age group | 0: 6-12 years; 1: 13-18 years |
| Diagnosis | 0: medulloblastoma (N.=35); 1: astrocytoma (N.=20); 2: ependymoma (N.=5); 3: ganglioglioma (N.=3) |
| Tumor localization | 0: vermis; 1: brainstem; 2: cerebellar hemispheres; 3: IV ventricle; 4: vermis + IV ventricle |
The study protocol was approved before the experiment by the Ethics Committee of Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology (protocol number 8e/13-17 of 27.10.2017). The chairman of the Committee was prof. N.N. Volodin, MD, PhD. The protocol of interventions is agreed in accordance with the Declaration of Helsinki. All participants signed an information consent, after receiving detailed information about study. Children over 15 years of age signed an informational consent themselves in accordance with the law of the Russian Federation 54 Art. Federal Law No.323-RF. For children under 15 years of age, informed consent was signed by parents, legal representatives or guardians.
Assessment of cognitive and motor functions
For assessment cognitive functions was used Cambridge Neuropsychological Test Automated Battery (CANTAB). Six tests were used: Spatial Working Memory, Spatial Recognition Memory, Pattern Recognition Memory, Spatial Span, Rapid Visual Information Processing, Stocking of Cambridge (Table II). The test was carried out in a computer format, with a psychologist next to the child.30
Table II. —Diagnostic methods and parameters. Measures present the results of first diagnostic session.
| Method | Parameter | Unit of measure (mean±SD) |
|---|---|---|
| Eye tracking | Execution time, s | 8.1±3.9 |
| Number of fixations | 20.6±8.1 | |
| Scan path, ° | 180.1±83.8 | |
| Mean duration of fixations, ms | 276.9±56.9 | |
| Mean saccades amplitude, ° | 7.6±1.7 | |
| Ellipse square, °(2) | 5.9±6.36 | |
| VMI | Visual-motor integration | 90.9±15.2 |
| Visual perception | 87.4±15.9 | |
| Motor coordination | 87.2±16.1 | |
| Dynavision | Reaction time, s | 1.5±0.56 |
| Fitlight | Reaction time, s | 0.76±0.54 |
| Neurotracker | Score | 1.5±0.5 |
| CANTAB | Pattern recognition memory, immediate | 83.1±1.6 |
| Pattern recognition memory, delayed | 76.37±18.2 | |
| Spatial recognition memory | 65.0±16.1 | |
| Spatial working memory (mistakes) | 44.9±25.45 | |
| Spatial working memory (strategy) | 35.6±7.6 | |
| Spatial span | 6.3±2.3 | |
| Rapid visual processing (mistakes) | 8.1±11.3 | |
| Rapid visual processing (median latency) | 434.1±225.7 | |
| BOT-2 | Fine motor skills, scores | 36.5±8.7 |
| Gross motor skills, scores | 33.8±10.9 | |
| Coordination, scores | 34.7±8.8 | |
| Strength and agility, scores | 37.0±11.2 | |
| General score | 32.9±8.3 |
For assessment motor functions was used Bruininks-Oseretsky Test (BOT-2). The Bruininks-Oseretsky Test of Motor Proficiency is a standardized, norm-referenced measure. It is a tool of a discriminative and evaluative measure to characterize motor performance, specifically in the areas of fine manual control, manual coordination, body coordination, and strength and agility (Table II). The test includes the following subtests: gross motor skills, fine motor skills, body coordination, strength and agility, and general score.31 The test was conducted by a qualified doctor of physical therapy.
For assessment visual-motor integration was used Beery VMI. The Beery VMI consists of three subtests: motor coordination, visual perception, and visual-motor integration of children of age 6-18. The VMI method allows you to assess fine motor skills — hand and eye movements (Table II).32 The test was carried out by a psychologist in paper form.
For assessment of saccadic eye movements we used the Arrington eye tracker (Arrington Research, Inc., Scottsdale, AZ, USA) with a sample rate of 60 Hz. Two oculomotor tests were performed: gaze holding at a static stimulus and visual search for counting 10 black dots. Detailed description of the procedure is given in the article.33 In the gaze holding test ellipse squares covered the gaze fixation were estimated. In visual search test execution time, number of fixations, scan path (sum of all performed saccades amplitudes), mean fixation duration and mean saccade amplitude were estimated (Table II). The assessment was conducted by a neurophysiologist in quiet conditions.
Intervention
The subgroup allocated to the intervention condition received sessions of CMT during 11 days. Sessions were conducted by psychologists trained to work on appropriate equipment. CMT included 6-8 sessions using the following training devices:
Dynavision D2® (Cincinnati, OH, USA) presents a panel with 64 lamps which take the form of five circles. The task of a participant is to press a lighted up lamp as quick as possible. In the trial, eight modes are used; they have different instructions which are aimed at visual-motor co-ordination, processing speed, inhibition, and shifting. DynaVisionD2 is highly reliable for estimating motor and visual response times;34 DynaVisionD2 is effective for training reaction speed and visual attention in healthy subjects and for correcting visual and motor disorders and patients with organic lesions of the brain and spinal cord, as well as in the clinic of stroke;35-37
Fitlight Trainer® (Aurora, ON, Canada) is a simulator for improving and rehabilitating motor coordination qualities, as well as sensorimotor response, control, monitoring and switching functions.25, 38-40 Fitlight has seven sensors and a central controller. The sensors are located far enough from each other, including on the floor, which makes it possible to develop hand-eye interaction not only between the eyes and hands, but also between the eyes and legs. Depending on the selected mode, the sensors light up, the subject has to press on them with his hand or foot as soon as possible;
NeuroTrackerX® (CogniSens, Montreal, Canada) a system consisting of a screen with the possibility of realizing a three-dimensional image and a control computer on which the original software is installed. The test subject is invited to track with his eyes the movement of dynamically moving stimuli (colored balls), some of which are relevant (the number of stimuli can be varied, depending on the characteristics of a particular subject). The speed of the balls on the screen automatically varies depending on the success of a particular subject.41 This device is widely used in foreign practice to develop the functions of working memory and long-held attention in children.42, 43
One training session took from 30 to 45 minutes. The child could go through the procedures in a row, but if he was tired, he could take a break. Almost all children studied without a break, as the tasks for them were interesting.
On the devices, children performed various exercises. When working with the Dynavision, several modes were used:
“the time of a simple sensorimotor reaction”: the lamps light up randomly over the entire working surface of the device. The patient needs to turn off the light bulbs as quickly as possible. This module is aimed at diagnosing and correcting the sensory-motor reaction time, and correcting the «eye-hand» interaction;
“sensorimotor reaction with rhythmic stimulation”: this is an analogue of “The time of a simple sensorimotor reaction,” but during the exercise the child hears the sound of the metronome beats;
“inhibition”: Inhibition, red and green lights are activated. The patient is asked to extinguish only the green ones, ignoring the red bulbs. This exercise promotes the development of braking and self-control skills;
“differentiated Inhibition”: the patient is given the task of turning off the green lights with his left hand, and red with his right hand. The task contributes to the correction and development of switching skills, braking, self-control, also affecting motor coordination;
“shifting”: the patient is asked to turn off the red lights, ignoring the green ones; every 20 seconds, the psychologist gives a “vice versa” command, according to which the research participant must change his work strategy and start turning off only green stimuli, etc. In this mode of correction, the functions of switching, inhibition and attention are exposed;
“visual attention”: the patient is given the task of extinguishing only the red lights, letting the green ones pass; periodically on the LED-display appear numbers (from 1 to 9), which the child should call out loud. This protocol is primarily aimed at developing visual attention. Also involved are the functions of braking and self-control;
“midline 1”: in the process, the patient must extinguish light bulbs in the left half of the working field with his left hand, and in the right half with his right hand;
“midline 2”: the patient is instructed: to extinguish the bulbs with the right hand in the left half of the field, with the left hand — in the right half of the field. The protocol is a sophisticated version of the Midline 1 mode.
When working with the Fitlight Trainer, several modes were used in three subtests:
simple sensorimotor reaction: extinguish sensors as quickly as possible;
inhibition: click on sensors that turn green, ignoring red;
color-hand: press the yellow sensors with the left hand or foot, the blue sensors with the right hand or foot.
These subtests allow you to diagnose and correct the functions of hand-eye integration (eye-arm and eye-leg interactions) and executive functions such as inhibition, encryption and programming and control.
When working with NeuroTrackerX®, several modes were used in one subtest:
“core”: the patient is asked to follow three stimuli of the same color. The task is to keep all stimuli in the field of attention, correctly naming them at the end of the process of their dynamic movement in three-dimensional space. According to the literature, it is known that the skills to keep dynamic stimuli in the field of attention are largely associated with cognitive functions, the ability to concentrate attention and the work of the visual working memory.
At the same time, another subgroup was allocated to the ‘empty’ period. During the ‘empty’ period, the participants did not receive any cognitive training. At this time, they visited the pool, massages, drank oxygen cocktails and took a lot of walks in the fresh air.
Statistical analysis
Statistical analysis was carried in STATISTICA v. 13.3 (TIBCO Software Inc., Palo Alto, CA, USA). Impact of parameters connected with the disease, age group on cognitive and motor functions state in PFT survivors was estimated using ANOVA and MANOVA.
Results
Difference in dynamics between intervention and control weeks
When comparing the data obtained before and after CMT, it was found that the overall motor score for the BOT-2 test (P=0.006), the visual-motor integration in the VMI test (P=0.000), and the RVP indicator (Rapid visual processing) in CANTAB (P=0.02) increased. In the control group (those who did not receive training), these indicators did not significantly change (Table III). Other outcomes did not demonstrate significant changes after intervention weeks.
Table III. —Intervention condition: mean scores at BOT-2, VMI and CANTAB before and after intervention.
| Test | Parameter | Timepoint | P value | 95% CI Lower bound |
95% CI Upper bound |
|---|---|---|---|---|---|
| BOT-2 | General score | After intervention | 0.006 | -3.4 | -0.5 |
| After control weeks | 0.673 | -1.49 | 0.97 | ||
| VMI | VMI visual-motor integration | After intervention | 0.000 | -6.04 | -2.1 |
| After control weeks | 0.88 | -1.9 | 1.7 | ||
| VP visual perception | After intervention | 0.05 | -5.00 | 0.07 | |
| After control weeks | 0.02 | -5.6 | -0.3 | ||
| MC motor coordination | After intervention | 0.01 | -5.7 | -0.73 | |
| After control weeks | 0.06 | -3.4 | 2.15 | ||
| CANTAB | Rapid visual processing | After intervention | 0.02 | 0.38 | 5.06 |
| After control weeks | 0.16 | -2.1 | 0.37 |
Impact of parameters connected with the age on baseline assessment scores
The age of the child during the onset of the disease is very important. We used one-way ANOVA to analyze the influence of separate factors on cognitive and motor scores.
The data obtained demonstrate the influence of age on the cognitive, motor and visual-motor functions of a child, which does not contradict the laws of development. With increasing of the age, children show better indicators in all performed measures (Table IV). In eye movement domain the outcome most affected by age is ellipse square that indicates the stability of gaze holding. Also characteristics of visual search show tendency to improve with the age. Measurements collected from training devices as well as from CANTAB show strong age-related dynamic in visual motor coordination, visual attention and various executive functions.
Table IV. —The impact of the factor ‘Group age’ on the scores of diagnostic tests.
| Method | Parameter | Group 1 (6-12 years) |
Group 1 (13-18 years) |
F | P value |
|---|---|---|---|---|---|
| Eye tracking | Execution time | 10.01±1.22 N.=17 |
7.24±1.03 N.=24 |
F(1, 39)=3 | 0.091 |
| Number of fixations | 26.71±2.88 N.=17 |
20.04±2.42 N.=24 |
F(1, 39)=3.13 | 0.084 | |
| Scan path | 248.83±31.02 N.=17 |
171.55±26.1 N.=24 |
F(1, 39)=3.63 | 0.063 | |
| Ellipse square | 16.93±3.74 N.=17 |
5.85±3.29 N.=22 |
F(1, 37)=4.96 | 0.032 | |
| Dynavision | Reaction time | 1.74±0.09 N.=31 |
1.33±0.1 N.=26 |
F(1, 55)=8.26 | 0.006 |
| Fitlight | Reaction time | 1.69±0.09 N.=29 |
1.25±0.1 N.=26 |
F(1, 53)=11.26 | 0.001 |
| NeuroTrackerX | Score | 0.53±0.09 N.=29 |
1.05±0.09 N.=26 |
F(1, 53)=16.36 | 0.000 |
| CANTAB | Pattern recognition Memory immediate | 75.19±2.49 N.=32 |
85.7±2.82 N.=25 |
F(1, 55)=7.82 | 0.007 |
| Pattern recognition Memory delayed | 71.61±3.06 N.=32 |
85.77±3.53 N.=24 |
F(1, 54)=9.17 | 0.004 | |
| Spatial recognition memory | 4.06±0.25 N.=32 |
5.8±0.29 N.=25 |
F(1, 55)=20.83 | 0.000 | |
| Rapid visual processing (mistakes) | 6.9±1.28 N.=31 |
3.56±1.43 N.=25 |
F(1, 54)=3.02 | 0.008 | |
| Rapid visual processing (median latency) | 551.38±30.32 N.=32 |
313.56±33.76 N.=24 |
F(1, 54)=27.47 | 0.000 |
Impact of parameters connected with the disease on baseline assessment scores
Various cerebellar lesions may have different effects on cognitive and motor function decline. This can be affected by both the degree of damage and the method of treatment and the child’s own rehabilitation potential. We discriminated the following factors and their levels connected with the disease (Table I).
As the next step, we evaluated the cognitive motor and visual-motor functions in children with different diagnoses. Due to the small size of samples of ependymoma and ganglioglioma groups, we compared only medulloblastoma and astrocytoma groups (Table V). The factor of diagnosis has been found to influence significantly only the parameter ‘gross motor skills’ in Bruininks-Oseretsky test (P=0.042). The tendency to the impact of the factor was observed in the parameter ‘reaction time’ at Fitlight Trainer (P=0.05). Thus, medulloblastoma group shows worse gross motor coordination performance.
Table V. —The impact of the factor ‘Diagnosis’ on the scores of diagnostic tests.
| Method | Parameter | Group 1 (medulloblastoma) |
Group 2 (astrocytoma) |
F | P value |
|---|---|---|---|---|---|
| Fitlight | Reaction time | 1.62±0.1 N.=29 |
1.3±0.12 N.=18 |
F(1, 45)=3.88 | 0.055 |
| BOT-2 | Gross motor skills | 32.74±1.97 N.=31 |
34.65±2.66 N.=17 |
F(1, 46)=4.36 | 0.042 |
For the next step, we observed three levels of the factor ‘Tumor localization’: cerebellar hemispheres, IV ventricle, and vermis + IV ventricle. As a result, it was found that various tumor localization has significant effects on oculomotor activity (execution time, mean duration of fixations), several motor parameters in tests BOT-2 (fine motor skills, gross motor skills, coordination), Visual-Motor Integration (visual-motor integration, visual perception), as well as on cognitive functions (mistakes and strategy in Spatial Working Memory test in CANTAB) (Table VI). Thus, group with lesion of IV ventricle, has the poorest visual search characteristics, visual-motor coordination and perception and spatial working memory, while the group with lesion of cerebellar hemispheres has the lightest impairments between three groups.
Table VI. —The impact of the factor ‘tumor localization’ on the scores of diagnostic tests.
| Method | Parameter | Group 1 (cerebellar hemispheres) |
Group 2 (IV ventricle) |
Group 3 (vermis + IV ventricle) |
F | P value |
|---|---|---|---|---|---|---|
| Eye tracking | Execution time | 6.07±1.66 N.=9 |
12.02±2.03 N.=6 |
8.09±1.11 N.=20 |
F(2, 32)=2.59 | 0.091 |
| Mean duration of fixations | 212.7±22.13 N.=9 |
327.46±27.1 N.=6 |
278.06±14.84 N.=20 |
F(2, 32)=5.75 | 0.007 | |
| VMI | Visual-motor integration | 97.33±3.8 N.=12 |
79.25±4.65 N.=8 |
92.36±2.49 N.=28 |
F(2, 45)=4.71 | 0.013 |
| Visual perception | 91.33±4.41 N.=12 |
74.37±5.4 N.=8 |
86.85±2.89 N.=28 |
F(2, 45)=3.09 | 0.055 | |
| CANTAB | Spatial working memory (mistakes) | 30.83±1.68 N.=12 |
38.37±2.06 N.=8 |
37.18±1.1 N.=28 |
F(2, 45)=5.94 | 0.005 |
| Spatial working memory (strategy) | 28.08±7.09 N.=12 |
58±8.68 N.=8 |
46.43±4.64 N.=28 |
F(2, 45)=3.95 | 0.026 |
Discussion
The aim of this study was to evaluate the possibility of CMT based on developing sensorimotor automated reactions using various devices in children who survived PFT. The results demonstrate the efficacy of short-term training. Positive changes were found in the overall motor score, visual-motor integration and visual processing. However, in the control group, the results also increased statistically significantly, so that the result obtained may simply be the effect of retesting and not the effect of the training performed. Since the stay in the rehabilitation center is limited in time, the rehabilitation program should not only improve the function, but also do it in the shortest possible time. Therefore, in this study, children received from six to eight trainings. As a result, it was shown that even such a short program has a positive effect, as well as on motor and visual-motor functions and processing.
This is an important result identified that it is possible to improve executive functions when training more “basic” functions, such as hand-eye coordination.44 This makes sense, especially in the case of PFT survivors, because a common symptom of PFT is spatiotemporal dysmetry. It manifests itself in the form of ataxia, rhythmic dyspraxia, adiadochokinesis, intentional tremor.45 As a result, sensorimotor coordination is disrupted. For example, with an excessive number of hypermetric eye saccades and limb dysmetry, eye-hand coordination is always impaired. Thus, the rapid recovery of basic executive functions (such as processing and hand-eye coordination) by automating basic hand-eye and foot coordination seems to imply cerebellar feedforward mechanisms and leads to an increase in overall motor score.
Executive functions, including working memory and processing, are closely related to academic performance and quality of life in pediatric survivors.46 The rehabilitation of such functions seems to be successful in the case of a combination of effective rehabilitation programs and the plasticity of the child’s brain.47
In addition, we found out the impacts of parameters connected with the age and disease on baseline level of examined patients. The indicators of motor and cognitive functions improve with the age onset. The most vulnerable group of patients can be considered patients with medulloblastoma and tumor localized in IV ventricle.
Rehabilitation measures should take into account various parameters that affect various functions. The pathology of the cerebellum is a conglomerate of diagnoses, each of which carries its own characteristics. The results of this study showed significant differences in motor functions in children with a diagnosis of medulloblastoma and astrocytoma.48 Not only the cancerous growth, but also its localization affects cognitive, motor and visual-motor functions.
Recovery from cancer is an important, interdisciplinary problem, in the solution of which doctors, psychologists, teachers, social workers, the patient’s family are involved. The development of this field is one of the key problems of modern neuro-oncology.
Limitations of the study
Our study has some limitations that should be considered for further investigations. Firstly, the small size of the sample, which includes children with different tumor localizations, tumor malignancy and remission time. In addition, it is necessary to assess whether this effect persists for a long time and whether it is transferred, for example, to the academic performance of the child. This lack of follow-up up assessment provides a field for future studies to obtain more convincing results for our implemented training.
Conclusions
This study showed the effectiveness of a short-term training program for children who survived tumors of the posterior fossa. The training was aimed at improving hand-eye and hand-foot coordination. As a result of the assessment, children who attended the training received statistically significant improvements in processing, visual-motor coordination, and overall motor score. The study also found that visual-motor and executive functions are affected by the localization of the tumor, diagnosis, and the child’s age at the time of onset. In further studies, with an increase in the sample, it is necessary to take into account these differences for differentiated rehabilitation of children.
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