First Pediatric Exercise Oncology Congress (PEOC)

On behalf of the 1st Pediatric Exercise Oncology Congress, we are pleased to present the abstracts from the 2022 Conference, the inaugural gathering of an international congress. The conference was held virtually on 7 and 8 April 2022. This conference brought together key stakeholders in pediatric exercise oncology, including multidisciplinary professionals from exercise, rehabilitation medicine, psychology, nursing, and medicine. The participants included clinicians, researchers, and community-based organizations. Twenty-four abstracts were selected for presentations (10–15-min oral presentations). In addition, there were five invited speakers with 20 min presentations and two keynotes with 45 min presentations. We congratulate all the presenters on their research work and contribution.

• Exercise interventions and physical activity recommendations • Effects of physical activity on patient-and health-related outcomes • Implementation of physical activity-strategies, models, considerations • Novel methods to improve physical activity and reduce late effects • Impacts of physical activity on cancer treatment response/tolerance • Other topics in pediatric exercise oncology (e.g.,  Website: https://www.pediatric-exercise-oncology-congress. Background: Children and adolescents should have access to exercise programs throughout cancer trajectory, including during palliative care. There is only very limited experience and data available for this phase of life. An exercise project has been conducted at the University Hospital Essen for advanced cancer patients who participated in supervised exercise programs during neoadjuvant and/or adjuvant treatment, and have bonded with these programs and their exercise professionals. Methods and Results: Inclusion criteria are diagnosis of advanced cancer, age >3 years, previous participation in the hospital's exercise program, and residence in the surrounding area of the hospital (<60 min car drive). Inclusion is discussed with the Specialized Outpatient Palliative Care Team of the clinic to consider the health status and family peculiarities. After deciding on the feasibility and gaining the acceptance of the families, the assigned exercise physiologist offered sessions once a week for 30-90 min. Sessions were usually scheduled at the patients' homes, but also in in-and out-patient clinics if patients had appointments or complications. The contents were a combination of strength, endurance, coordination, body awareness, and mobility training that were resource-oriented, related to the child's interests, and adapted to their respective daily condition. Data monitoring was conducted every four to six weeks.
Conclusions: This concept takes into account the individual possibilities, goals, and interests of those directly affected. Since the project is not yet part of standard care, it should be evaluated and expanded. Pediatric advanced cancer patients should have the opportunity to participate in exercise programs, and benefit from physical activity support. Methods: MK is an exercise program for pediatric cancer patients, to improve quality of life and overall health. We also include family participation, inspiring a healthy lifestyle for all. The main program goals are: to improve cardiac and pulmonary capacity, boost immune system, reduce fatigue, and peripheral neuropathy. Its secondary goals are to reduce psychological and cognitive problems, and to reduce second tumors and chronic diseases. Results: Maple Kids starts in January 2022, and results will soon be posted. Conclusions: Some children face debilitating physical and cognitive problems as side effects of cancer treatments. Cancer can mean not running or jumping, and feeling uncomfortable during PA. There is a lack of accessible and specialized programs, of staff prepared to support cancer patients, and a lot of misinformation from family and health professionals, which means that 62% of adult survivors have at least one chronic health condition. PA for pediatric cancer patients and survivors means better physical and psychosocial health.
Background: Following the publication of the international Pediatric Oncology Exercise Guidelines (iPOEG) in 2021, resources to support end users were developed. Collectively, these resources are referred to as the iPOEG Toolkit. To better understand the value of the iPOEG Toolkit, its dissemination, implementation, and effectiveness will be tracked and explored. Methods: A research program informed by the Knowledge to Action framework is underway. A mixed-methods approach is being used, and the RE-AIM framework is guiding the evaluation of its reach (e.g., the number of iPOEG Toolkit downloads), effectiveness (e.g., the changed physical activity levels and patient-reported outcomes among end users), adoption (e.g., the number of organizations using the Toolkit), implementation (e.g., the use of and modifications made to the iPOEG Toolkit), and maintenance (e.g., the tracking of its continued use and impact, including markers of effectiveness, over time). Data will be collected via tracking metrics (e.g., webpage views, downloads), surveys, and interviews with relevant end users. Quantitative data will be analyzed descriptively and using regression analyses as appropriate, and qualitative data will be examined using content analysis and reflective thematic analysis.

Results:
The iPOEG Toolkits are currently being disseminated via the Health and Wellness Lab website, emails, and social media, and data will be gathered up until 2025. Discussion: The findings from this research program will highlight if and how the iPOEG Toolkit is being used, and offer critical guidance to optimize the iPOEG Toolkit. It is hoped that this work will support the spreading of the message that it is time for children and adolescents with cancer to 'move more'. Backgound: Childhood cancer survivors (CCSs) are at elevated risk of experiencing fatigue, depression, and reduced quality of life. Low physical activity (PA) levels may worsen these. Very few randomized controlled trials have investigated the effect of PA on psychosocial health among CCSs. We investigated the effect of a one year individualized exercise intervention on fatigue, mental health, and health-related quality of life (HRQoL) in adult CCSs. Methods: We randomized 151 CCSs aged ≥16 years, <16 at diagnosis, and ≥5 years since diagnosis, identified through the Swiss Childhood Cancer Registry. The intervention participants received personalized exercise counselling to increase intense PA by ≥2.5 h/week for one year. Controls maintained usual PA levels. We assessed the severity of fatigue, psychological distress, and physical and mental HRQoL at baseline, 3, 6, and 12 months. Outcomes were transformed into T-scores (mean = 50, standard deviation (SD) = 10). We used generalized linear mixed-effects models with intention-to-treat (ITT, primary), as well as per protocol allocations with compliance based on self-reported PA or a cardiopulmonary fitness test. Results: The mean baseline outcomes ranged from T-score 49.8 to 52.2, of the 133 (88%) who completed the trial. ITT analyses found significantly lower severity of fatigue by T-score −3.56 (95% confidence interval (CI) −5.69 to −1.43, p = 0.001) in the intervention group compared to controls at 12 months. The physical component of HRQoL was significantly better than controls in the intervention group for per protocol analyses by 3.06 (95%CI 0.99 to 5.14, p = 0.004) and 3.54 (1.13 to 5.96, p = 0.004).

Conclusions: Individualized exercise interventions may improve fatigue and physical
Background: Patients with childhood cancer are confronted with exercise intolerance (EI (VO 2 peak < 85% predicted)) after treatment, with a detrimental effect on quality of life and mortality. Knowledge about the limiting factor(s) for this EI and its relation to physical activity (PA) is essential in order to prescribe individually tailored rehabilitation and to stimulate physical and social reintegration. Methods: A total of 41 patients with childhood cancer (13 ± 3 years; 71% boys), diagnosed with leukemia/lymphoma (61%), a solid tumor (32%) or brain tumor (7%), and who had recently finalized their oncology-related treatment, were included in the study. Patients performed a maximal symptom-limited cardiopulmonary exercise test on a treadmill (4.8 km/h; +2% elevation/min). PA was recorded with a 3-axial accelerometer (Dynaport MoveMonitor, McRoberts, The Hague), that patients wore for 7 consecutive days. Active time (standing and walking), sedentary time, and steps were withheld. Results: Exercise tolerance (VO 2 peak: 29.7 ± 7.8 mL/min/kg (67 ± 16% predicted)) was markedly reduced in patients with childhood cancer compared to healthy peers. The majority of patients were peripherally limited (83%). A cardiac limitation was present in 71% of patients and was predominantly due to a reduced oxygen pulse (97%). Hyperventilation (32%) and a ventilatory limitation (12%) were less prevalent. The PA data of 13 patients were available (Active time: 178 ± 67 min/day; sedentary time: 515 ± 113 min/day; steps: 6411 [4458-6838]). Conclusions: Exercise tolerance is markedly reduced in patients with childhood cancer shortly after intensive treatment and this is mainly caused by the deconditioning of peripheral muscles and a reduced oxygen pulse. Further research is necessary to study the link with physical activity. Background: Despite the physical and psychosocial benefits of exercise for children and adolescents living with and beyond cancer, few exercise oncology programs have been successfully implemented for this population. Implementation barriers herein include cost as well as a lack of qualified exercise professionals and appropriate facilities, which may be exacerbated in resource-limited countries. The purpose of this implementation project was to overcome these barriers and implement a sustainable exercise oncology program with Tumaini La Maisha (TLM) in Tanzania. Methods: Interdisciplinary stakeholder discussions were held between nurses, oncologists (PS), caregivers, TLM teachers, and the visiting exercise professional (ME) in order to provide a broad range of perspectives and agree upon a feasible exercise program for implementation at Muhimbili National Hospital. Cost barriers were addressed by using volunteers and paid TLM staff for program delivery, with the exercise professional educating staff on exercise principles. To address facility barriers, a public sports field served as the exercise space. Results: Discussions led to the development and implementation of a 30 min teacher-led, group-and family-focused, play-based exercise program. The program was delivered daily for 3 months, with high attendance and satisfaction from parents and children. Three TLM teachers were trained for long-term program delivery. Newly identified barriers included sun exposure risks (addressed via indoor exercise) and a lack of cultural relevancy (addressed by integrating traditional dance within the program). Conclusions: The involvement of stakeholders in the implementation planning and consideration of resource limitations led to the successful implementation and maintenance of an exercise oncology program in a resource-limited setting. Background: Cancer and the acute and late effects of its treatment are associated with a decline of physical activity behavior in childhood cancer patients and survivors. Children have a legal right to exercise as well as to the active participation in physical activities, and to the positive effects of exercise-related benefits. Methods: Network ActiveOncoKids (NAOK) is a Germany-wide initiative with the main goal of enabling children, adolescents, and young adults with exercise opportunities during and after cancer treatment. The network uses and bundles the knowledge, expertise, and experience of decentralized clinical sites and working groups on the topic of "Exercise and Sport in Pediatric Oncology". For this purpose, NAOK was founded in 2012, striving for networking and structuring. It is managed and accompanied by an overarching coordination, a steering group, and an advisory board. Its main aims are (A) physical activity support for patients and families, (B) policy change to establish structures and guidelines, and (C) the generating of evidence through scientific projects. Results: NAOK brings together 33 pediatric oncology treatment centers that offer exercise interventions either during acute treatment and/or in follow-up care. The main focus of the last 2.5 years was to support children, adolescents, and young adults through individualized counselling, to help in implementing exercise programs at pediatric oncology centers, and to adapt and change medical and care structures (e.g., via guidelines and educational lessons). Conclusions: NAOK is an interdisciplinary network that supports the implementation of pediatric exercise oncology in usual care. In the past few years, great progress has been achieved in the areas of exercise implementation, structural organization, and communication, which might serve as a model for other countries. Background: With the onset of the COVID-19 pandemic in Italy and its related restrictions, the National Orders Federation of Technical, Rehabilitation and Prevention Health Professions, recommended remote rehabilitation interventions. Therefore, in April 2020, the rehabilitation working group of the Italian Hematology and Oncology Association (AIEOP) created a website for telerehabilitation within the "#IoMiMuovoACasa" (#IDoHomeTraining) pilot project. According to the preliminary safety and efficacy results, and users' opinions, the need for a more structured website arose. The Reh-PLAY project aims to create a new website to support remote individualized rehabilitation interventions, in addition to the direct treatment, for the prevention/rehabilitation of motor difficulties related to the disease and/or to treatment side effects. Methods: The website contents are written according to the AIEOP Consensus Conference on Rehabilitation in Pediatric Oncohematology. Exercise videos created by physiotherapists are based on their expertise and are smartly accessible by the professionals who can create personalized exercise programs, available in a patient's personal area. Results: In one month, twenty patients used the website. The Reh-PLAY website is smartly accessible for families, patients, and physiotherapists from the AIEOP website. Professionals can select texts/infographics about prevention and rehabilitation, and access 250 exercise videos, divided by type, age, and intensity. Patients can download information brochures, adhesion diaries, patients reporting outcome measures, and a questionnaire to improve the service. Conclusions: Growing evidence in Pediatric Oncohematology identifies rehabilitation as a fundamental aspect of treatment. The Reh-PLAY website improves continuity in rehabilitation management, supporting families and patients with telerehabilitation, and facilitating the dissemination of knowledge between professionals.

Lessons Learned from Innovating the Pediatric Cancer Patients and Survivors Engaging in Exercise for Recovery (PEER) Program to an Online Modality Due to COVID-19
Methods: After 12 months of running the program, which was attended regularly by 17 families (16 kids and 9 teens), we sought participant feedback through anonymous surveys. A total of 12 parent and 10 participant responses were collected outlining information about motivators for and barriers to online programming, safety, and satisfaction. Results: The families participated in the program mainly to (1) improve fitness and (2) increase peer connections. Of these, 100% felt safe, 95% agreed that sport kits increased engagement, and most agreed that sport kits also helped kids increase their activity level after participation in the PEER sessions. Furthermore, 86% felt that 45-60 min was a good session duration and that participation in the program increased their child's fitness level. Conclusions: This program was (i) engaging, (ii) safe, and (iii) accessible for children affected by cancer who are medically vulnerable and/or remotely located. We suggest a program length of 45-60 min based on the age group. Exercises should have a greater focus on physical literacy and fundamental actions for younger age groups and should be more fitness-based for teens. Fun and the inclusion of socialization are key elements in increasing enjoyment, adherence, and community belongingness. The provision of a sport kit is recommended. Individualized adaptations are necessary for program success. Background: Supporting children/adolescents with cancer to be more physically active has the potential to improve short-and long-term outcomes. The objective of this study was to assess the feasibility of CanMOVE, a complex, theoretically informed, behaviour change intervention to promote participation in physical activity for children/adolescents undergoing acute cancer treatment. Method: A feasibility study utilising single-group, repeated measures, and a mixed methods design was completed. Participants completed the 10 week CanMOVE intervention, which involved structured support from a physiotherapist and the provision of a Fitbit (child and parent). Feasibility domains of demand, acceptability, implementation, practicality, limited efficacy, and integration were evaluated. Objective assessments of physical activity, physical function, and health-related quality of life were completed. Qualitative data were collected via semi-structured interviews with participants (parents and children/adolescents) and focus groups with clinical staff. Results: Twenty families completed CanMOVE, including children/adolescents (median age 12 years, range 5-16) with a mix of cancer diagnoses. There was a high demand for CanMOVE with a 95% enrolment rate. CanMOVE was acceptable from both participant and staff perspectives. All feasibility thresholds set for implementation were met. There were no serious adverse events. Under limited efficacy, data indicate that CanMOVE shows promise in influencing child/adolescent physical activity behaviour. Positive impacts were also seen in parent and staff behaviour towards physical activity promotion. The pre/post physical function and HRQOL assessments showed positive trends. Conclusions: CanMOVE is feasible and safe to implement in the paediatric oncology setting. CanMOVE shows potential in influencing the behaviour of children/adolescents and of the people in their social and professional support networks. These findings can be used to inform services in the paediatric cancer setting to ensure physical activity promotion is a considered and prioritised aspect of clinical care.
Abstract Poster Presentations International studies and organizations, such as the World Health Organisation, have identified the health risks across lifespan that are associated with physical inactivity. Childhood cancer and its treatment have considerable impact on a child's physical and mental wellbeing and often lead to reduced physical activity levels and sedentary behaviour. The combination of long-term chemotherapy, surgery and/or radiotherapy as administered in children with cancer especially impairs physical activity and fitness, both during and after therapy. Physical activities are important for the development of children and increasing evidence suggests the beneficial effects of physical activity promotion during cancer treatment as well. Therefore, ways to promote physical activity and exercise are becoming an important part of children's cancer treatment. By means of our "Maximal Activity" program in the Princess Máxima Center for Pediatric Oncology, we want to encourage our patients to get out of bed and be as active as possible, both during and after treatment. Methods: A qualitative survey of 30 individuals (children, families and health care professionals) was used to ask about the experiences of the developmentally appropriate care program, of which 'Maximal Activity' is a part. Results: An important point that emerged was that the facilities and environment invite physical activity. The program was named by many as valuable. Trust and confidence in physical activity increased during hospitalization. Other results still need to be analysed and will be presented at the congress. Conclusions: Maximal Activity is a health program that contributes to a stimulating environment for physical activity and is appreciated by all stakeholders.

Carolin Ohnmacht and Alexander Puzik
Department of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Mathildenstraße 1, D-79106 Freiburg, Germany Background: Regular physical activity (PA) is essential for biopsychosocial health, while reduced PA during childhood cancer treatment leads to increased late effects in affected children. Moreover, cancer and its treatment determine the everyday lives of families and parents who spend plenty of time with their children in hospital. Thus, it can be assumed that the parents' PA is significantly affected during cancer treatment. Meanwhile, parents' PA-behaviour has a pronounced influence on their children's behaviour. The aim of this project is to investigate the parents' PA-behaviour before and during their children's cancer treatment. Methods: The PA and sedentary behaviour of the parents were assessed before and during their children's intensive oncological therapy in a cross-sectional design using the International Physical Activity Questionnaire (IPAQ-SF). Results: A total of 40 parents of children with cancer took part in this survey. They were interviewed no earlier than their children's second inpatient stay. The parents' PA levels before diagnosis were in line with the reference values for healthy adults in Germany. During the children's treatment, all dimensions of the parents' daily PA, and the number of minutes of PA per week, decreased significantly (p < 0.001). The greatest reduction in PA was identified during inpatient stays, with a significant increase in sitting time (p < 0.001). Conclusions: This is the first study to show that the PA of parents whose children have cancer decreases significantly during cancer treatment. As parents' PA behaviour significantly affects that of their children, even after completion of cancer treatment, future exercise programs in pediatric oncology should include parents in order to reduce inactivity-related late effects. Background: Cancer is the leading cause of death by non-communicable diseases in children in Europe. During cancer treatment, patients' morbidity is increased due to physical inactivity and cancer-related fatigue. Precision-based exercise training programs in children and adolescents attending the intensive phases of cancer treatment is an increasingly promising therapy. However, strong evidence for exercise efficiency is lacking in paediatric oncology and, thus, precision exercise training is not part of standard care and does not reach the majority of patients.

Methods:
The FORTEe project is structured in seven work packages and intends to evaluate a personalised and standardised exercise intervention in 450 children, adolescents and young adults undergoing cancer treatment in 9 centres across Europe. The randomised, controlled FORTEe trial aims to generate high evidence for an innovative, patient-centred exercise treatment. Supervised exercise training intends to impact the efficiency of systems involved in the oxidative metabolism chain, including the skeletal muscle. The tailored training is also focused on strength in order to counteract muscular atrophy. Within the project, digital and innovative technologies (a FORTEe app, an augmented reality program and an interactive digital training) will be developed and applied to make the exercise training more attractive, age-adapted and inspirational. FORTEe will stimulate multidisciplinary research by involving paediatricians and exercise scientist in order to provide more inclusive access to paediatric exercise oncology. Conclusions: Progressing beyond the current state-of-the-art standard, FORTEe has the ambition of implementing paediatric exercise oncology as an evidence-based standard in clinical care for all childhood cancer patients worldwide.
Background: Modern therapy improved survival for children with cancer. However, the treatment has unintended consequences. Depending on neurotoxic agents, 52-100% of children develop a chemotherapy-induced peripheral neuropathy (CIPN). The severe symptoms such as loss of sensation, numbness, pain, absent reflexes and loss of balance control, not only delay motor development milestones such as walking, running, jumping, or climbing, diminishing children's quality of life and affecting their social reintegration, but are also of high clinical relevance. Streckmann et al. confirmed in their meta-analysis that recovery is poor, but there is a clear benefit for adults in favor of sensorimotor training (SMT) to target the symptoms of CIPN. Methods: In our RCT, we will recruit N = 131 children from 6 centers (Switzerland and Germany). Immediately after being scheduled to receive neurotoxic chemotherapy, the intervention group will perform a standardized, age-adjusted, specific playful SMT program twice a week for the duration of their medical therapy, while the control group will receive treatment as usual. Results: For the intervention, we created a training manual which will finally lead to a simple therapy option for children suffering from CIPN. The manual provides a basis for playful SMT based on a modular system, which leaves the therapists and the children room for scope and still respects all the training modalities within the background of "specific exercise is medicine". Conclusions: We hypothesize that children in the intervention group will develop fewer symptoms of CIPN and will be able to maintain their motor and sensory functions for an age-appropriate motor development.

Impact of the COVID-19 Pandemic on the Availability of Exercise Programs in Pediatric Oncology: A Survey of Providers in Germany
Background: An increasing amount of in-hospital and out-patient physical activity offers facilitate access to professional exercise programs for children and adolescents during acute anticancer treatment and surveillance. The COVID-19 pandemic has presented major challenges to hospitals and rehabilitation facilities. An online survey among providers in Germany investigates the impact of the pandemic on individual sectors of exercise programs in pediatric oncology. Methods: From 19 January until 9 February 2022, all German clinics and institutions with an exercise program for pediatric cancer patients and/or survivors are invited to participate in an online survey. Methodology and recruitment is conducted in cooperation with Network ActiveOncoKids. Limitations, challenges and measures for adapting offers in the context of the individual pandemic waves, are collected. In addition, challenges for the implementation of scientific studies are analyzed. Results: Thirty-three sites have been requested to participate in the survey. We assume that exercise professionals and scientists have used the pandemic-related challenges to modify the existing concepts of exercise promotion and adapt them to the specific local conditions. Conclusions: We expect new ideas and approaches for the realization of exercise programs under pandemic conditions. The extension of digital offers may improve the access for children and adolescents to exercise programs in pediatric oncology in the long term and, therefore, could potentially be adopted into standard exercise care.
Background: A sensorimotor training (SMT), mostly applied as balance training on different surfaces and in different positions, has the potential to contribute to the nervous system's plasticity and to improve lower extremity impairments. In recent years, SMT has not only been conducted in rehabilitation, injury and fall prevention, but has also been successfully applied in adult oncology. In this context, studies showed improvements in common lower extremity impairments, such as impaired balance control, sensory and motor symptoms. While SMT or associated training modalities have been investigated in different pediatric patient collectives, they have rarely been conducted in pediatric oncology, though the outlined effects are promising for these patients. Methods: In order to identify therapeutic potentials of SMT for pediatric oncology, current data on SMT in different pediatric patient collectives are reviewed. Furthermore, to gather preliminary insights on a playful and child-specific SMT in pediatric oncology, first pilot studies during and after inpatient medical treatment in this field are conducted. Results: SMT resp.-related training modalities with various pediatric patients demonstrate potential effects on lower extremity parameters. The preliminary results in pediatric oncology indicate that a child-specific and playful SMT for children after cancer treatment is feasible. Motivating sensorimotor exercises are identified. Further study results on SMT performed during acute pediatric oncological therapy will be available and presented at the congress. Conclusions: The reviewed interventions in pediatric collectives, and preliminary study results in pediatric oncology in particular, suggest that SMT might be a promising and targeted training modality supplementing exercise therapy for children with cancer. Background: The "Tuesday Boogie" is a quality improvement initiative which was developed to promote physical activity and enhance psychosocial wellbeing amongst in-patients, parents and staff on an in-patient paediatric cancer ward. It involves children, parents and staff engaging in a 15 min group dancing session and runs on a weekly basis. We conducted a service evaluation to assess the feasibility of the dance-based intervention and whether it influenced the psychosocial wellbeing of participants. Methods: Child, parent and staff questionnaires were designed by the research team to evaluate the intervention. Both quantitative (Likert, multiple choice, dichotomous) and qualitative open format questions were included. Data were collected on a voluntary, anonymous basis from June to July 2021. Results: In total, 39 questionnaires were completed (n = 4 child, n = 9 parent, n = 26 staff). A total of 97% of respondents had taken part in the intervention with 100% reporting the intervention was worthwhile. Of the respondents, 95% felt taking part improved their mood and 92% reported it helped them to cope with being in hospital. Furthermore, 77% of respondents felt less worry or stress during the intervention. The following qualitative data were collected: C1 "It is nice to be happy and dance instead of worrying", P3 "Changes the energy . . . real mood shifter and connector", P9 "M gets a chance to have fun and to interact with other kids which is so rare these days", S22 "Shows patients that not everything that happens in hospital is scary". Conclusions: A dance-based intervention for children, parents and staff on an in-patient paediatric cancer ward is feasible and has numerous psychosocial benefits. 6 Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany Background: The growing population of childhood cancer survivors is at risk of developing late chronic conditions and premature mortality. Physical activity (PA) can mitigate physical and psychological late effects, but only if engaged in regularly over sustained time periods. PA sustainment, however, remains challenging due to daily and within-daily fluctuations in how survivors feel, with whom they interact and in which environments they live. Thus far, exercise psychology has mainly focused on macro-temporal processes unfolding over weeks and months. To promote sustainable PA engagement, micro-temporal processes (e.g., unfolding over minutes, hours, days) need to be studied. Therefore, this review introduces ambulatory assessment as a method to gain insights into dynamic behavioural processes as they unfold in survivors' everyday lives. Methods: Ambulatory assessment (AA) describes a group of computer-or smartphoneassisted methods to study behavioural, biological, and psychological processes in survivors' everyday lives near real time. In this review, we discuss the characteristics of AA and expand on its promise for researching micro-temporal behavioural processes and on its potential for exercise oncology, such as the prediction of critical phases of PA relapse. This is exemplified in ongoing projects, and we expand on future avenues where ambulatory interventions might benefit survivors' tailored care. Conclusions: Insights into dynamic behavioural processes as they unfold in everyday life may critically add to our understanding of sustainable PA and the development of individualised treatment where and when it is needed. Avenues for research, prevention and treatment will be discussed as well as the acceptability, compliance and ethical issues of AA. Background: Children and adolescents with cancer receive rehabilitation interventions for the functional impacts of the disease and its corresponding treatment. Adherence to these interventions varies greatly. The purpose of this review was to identify the factors related to adherence in rehabilitation. Methods: A systematic review was conducted using Ovid Medline and CINAHL databases with search terms related to pediatric cancer, rehabilitation, and adherence. Study eligibility criteria included the following: English language, participants receiving a physical therapy, occupational therapy, speech-language pathology, cognitive or exercise intervention or service, mean age of ≤18 years old, and measurement of factors related to adherence. The PRISMA 2020 statement for reporting systematic reviews guided data synthesis. The study quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools. Results: The review included 13 studies providing rehabilitation interventions (exercise, yoga, walking, cognitive training, and vibration plate) to 283 children aged 3-19 years with adherence levels of 61-91% measured by session attendance. The majority (85%) of the studies comprised exercise interventions with 69% of the interventions being multifaceted in nature including aerobic, strengthening, and flexibility components. The factors related to adherence fell into three categories: (1) organizational; (2) condition-related; and (3) personal. Common barriers included fatigue, illness, time, family scheduling, and motivation. Facilitators included peer or caregiver support and supervision. Conclusions: The existing literature on rehabilitation adherence focuses mostly on exercise interventions delivered by a multitude of health care professionals. More research is needed to improve understanding of the factors related to adherence to rehabilitation interventions and services in survivors of childhood cancer.

Factors Related to Rehabilitation Adherence in Childhood Cancer: A Review
Funding: The 1st annual PEOC was financially supported by Universitätsmedizin Essen. Additional support was provided by the Health and Wellness Lab, Faculty of Kinesiology, University of Calgary;