Effect of Cognitively Challenging Physical Activity on Executive Functions in Pediatric Cancer Patients

The Hearts and Flowers Task is a cognitive test designed to measure executive functions, particularly inhibitory control and cognitive flexibility. The test consists of two types of conditions: In the simple condition (hearts), participants are instructed to respond on the same side as the heart appears. In the complex condition (flowers), they are instructed to respond on the opposite side of the flower's appearance. Reaction time and accuracy are recorded.

The Hearts and Flowers Task is a cognitive test designed to measure executive functions, particularly inhibitory control and cognitive flexibility. The test consists of two types of conditions: In the simple condition (hearts), participants are instructed to respond on the same side as the heart appears. In the complex condition (flowers), they are instructed to respond on the opposite side of the flower's appearance. Reaction time and accuracy are recorded.

The Hearts and Flowers Task is a cognitive test designed to measure executive functions, particularly inhibitory control and cognitive flexibility. The test consists of two types of conditions: In the simple condition (hearts), participants are instructed to respond on the same side as the heart appears. In the complex condition (flowers), they are instructed to respond on the opposite side of the flower's appearance. Reaction time and accuracy are recorded.

The Hearts and Flowers Task is a cognitive test designed to measure executive functions, particularly inhibitory control and cognitive flexibility. The test consists of two types of conditions: In the simple condition (hearts), participants are instructed to respond on the same side as the heart appears. In the complex condition (flowers), they are instructed to respond on the opposite side of the flower's appearance. Reaction time and accuracy are recorded.

The Fish-Flanker Task is a cognitive test used to measure inhibitory control. Participants are shown a row of five fish and must respond to the direction of the central target fish while ignoring the surrounding flanker fish. In congruent trials, the flankers face the same direction as the target fish, while in incongruent trials, they face the opposite direction. Reaction time and accuracy are recorded.

The Fish-Flanker Task is a cognitive test used to measure inhibitory control. Participants are shown a row of five fish and must respond to the direction of the central target fish while ignoring the surrounding flanker fish. In congruent trials, the flankers face the same direction as the target fish, while in incongruent trials, they face the opposite direction. Reaction time and accuracy are recorded.

The Fish-Flanker Task is a cognitive test used to measure inhibitory control. Participants are shown a row of five fish and must respond to the direction of the central target fish while ignoring the surrounding flanker fish. In congruent trials, the flankers face the same direction as the target fish, while in incongruent trials, they face the opposite direction. Reaction time and accuracy are recorded.

The Fish-Flanker Task is a cognitive test used to measure inhibitory control. Participants are shown a row of five fish and must respond to the direction of the central target fish while ignoring the surrounding flanker fish. In congruent trials, the flankers face the same direction as the target fish, while in incongruent trials, they face the opposite direction. Reaction time and accuracy are recorded.

The Corsi Block Task is a cognitive test used to measure visuospatial working memory. Participants are shown a series of blocks on a screen, which light up in a specific sequence. The task requires replicating the sequence by tapping the blocks in the same order (forward condition) or in reverse order (backward condition). The length of the sequence increases after each correct attempt. The score is the longest correctly repeated sequence, ranging from 0 (no correct sequences) to 10 or more (longer sequences).

The outcome measures include the total number of correctly recalled sequences, the achieved Block Span, the z-score of the Block Span and the percentile of the Block Span. Additionally, they include a summary score calculated as the product of the Block Span and the total number of correct sequences, the z-score of this total score and the percentile of the total score.

The Corsi Block Task is a cognitive test used to measure visuospatial working memory. Participants are shown a series of blocks on a screen, which light up in a specific sequence. The task requires replicating the sequence by tapping the blocks in the same order (forward condition) or in reverse order (backward condition). The length of the sequence increases after each correct attempt. The score is the longest correctly repeated sequence, ranging from 0 (no correct sequences) to 10 or more (longer sequences).

The outcome measures include the total number of correctly recalled sequences, the achieved Block Span, the z-score of the Block Span and the percentile of the Block Span. Additionally, they include a summary score calculated as the product of the Block Span and the total number of correct sequences, the z-score of this total score and the percentile of the total score.

The Corsi Block Task is a cognitive test used to measure visuospatial working memory. Participants are shown a series of blocks on a screen, which light up in a specific sequence. The task requires replicating the sequence by tapping the blocks in the same order (forward condition) or in reverse order (backward condition). The length of the sequence increases after each correct attempt. The score is the longest correctly repeated sequence, ranging from 0 (no correct sequences) to 10 or more (longer sequences).

The outcome measures include the total number of correctly recalled sequences, the achieved Block Span, the z-score of the Block Span and the percentile of the Block Span. Additionally, they include a summary score calculated as the product of the Block Span and the total number of correct sequences, the z-score of this total score and the percentile of the total score.

The Corsi Block Task is a cognitive test used to measure visuospatial working memory. Participants are shown a series of blocks on a screen, which light up in a specific sequence. The task requires replicating the sequence by tapping the blocks in the same order (forward condition) or in reverse order (backward condition). The length of the sequence increases after each correct attempt. The score is the longest correctly repeated sequence, ranging from 0 (no correct sequences) to 10 or more (longer sequences).

The outcome measures include the total number of correctly recalled sequences, the achieved Block Span, the z-score of the Block Span and the percentile of the Block Span. Additionally, they include a summary score calculated as the product of the Block Span and the total number of correct sequences, the z-score of this total score and the percentile of the total score.

Self-regulation will be assessed using the Head-Toes-Knees-Shoulders task (HTKS). This task measures self-regulation by requiring participants to follow specific instructions that conflict with automatic responses.

The task involves a series of instructions where participants are asked to perform actions that oppose their natural impulses. For example, they may be asked to touch their head when instructed to touch their toes or to touch their knees when told to touch their shoulders.

For a wrong movement the participant gets 0, for a corrected movement 1 and for a correct movement 2 points.

The score ranges from 0-60.

The frailty score is calculated to assess an individual's vulnerability and considering 5 different aspects.

Weakness, slowness, shrinkage, exhaustion and diminished physical activity. These are defined by the following corresponding parameters, the hand strength measurement from the Moon Test, the 6 MWT, the triceps skinfold thickness, the PedsQL fatigue scale, as well as the PedsQL core and the BSA as well as the Godin-Shephard Leisure-Time Physical Activity Questionnaire (GSLTPAQ). All tests are already listed and described in the outcomes.

The frailty score is the composite endpoint of the named tests. The score ranges from 0 to 10, with a higher value indicating greater frailty (meaning higher Frailty worse clinical outcome).

Heart rate variability (HRV) will be assessed using an ECG 4 activity sensor. HRV provides insights into how the heart responds to stress and relaxation. A high HRV is typically associated with better cardiovascular fitness, a more adaptable autonomic nervous system, and greater resilience to stress. Conversely, low HRV is often linked to poor health outcomes, such as higher stress levels, cardiovascular issues, and an increased risk of chronic diseases. Monitoring HRV can help assess an individual's overall well-being and autonomic nervous system functioning, as well as their response to various stressors.

Aortic Stiffness will be measured with the Mobil-O-Graph. This test helps to understand how flexible or stiff the aorta is, which is important for blood flow and blood pressure. Aortic stiffness is a key indicator of cardiovascular health, as it reflects the ability of the aorta to expand and contract with each heartbeat. Increased stiffness of the aorta can lead to higher systolic blood pressure and can be a risk factor for cardiovascular diseases.

The cardiopulmonary function will be evaluated with the 6-Minute Walk Test (6MWT). This test measures overall endurance and heart-lung efficiency by walking as fast as possible for 6 minutes. A longer distance walked in 6 minutes generally indicates better cardiovascular and pulmonary health, while shorter distances may signal reduced endurance or impaired heart-lung function. The test is particularly useful for evaluating patients with cardiovascular and respiratory conditions, as it provides an objective measure of physical capability and helps track changes in health status over time.

Triceps skin-fold thickness will be measured with calipers to estimate body fat percentage based on the thickness of the skinfold at the triceps. This will be needed to calculate the frailty score.

Health-related Quality of Life (HrQoL) will be assessed with the Pediatric Quality of Life Inventory (PedsQL 4.0 Generic Core Scales), which measures overall well-being and quality of life.

The score ranges from 0-100. Higher scores signifying better HrQoL.

Cancer-related fatigue will be assessed with the PedsQL Fatigue Module. This questionnaire is designed to evaluate fatigue in pediatric populations, including its impact on physical, emotional, and cognitive functioning. Scores are reversed and linearly transformed to a scale of 0 to 100, where higher scores indicate less fatigue and better functioning. Subscale scores and a total fatigue score can be calculated by averaging the item responses, providing a comprehensive assessment of fatigue levels.

Physical Self-Concept will be measured with the Physical Self-Description Questionnaire - short version (PSDQ-S), focusing on how participants view their physical abilities.

The questionnaire contains 22 questions. The score reaches from 22-132. The higher the score the greater the clinical outcome and physical self-concept.

Physical activity enjoyment will be assessed with Physical Activity Enjoyment Scale - short version (PACES-S) to examine enjoyment levels related to physical activity.

The questionnaire contains 4 questions. The score reaches from 0-16. The higher the score the greater the physical activity enjoyment.

Functional Appreciation will be evaluated through the Functionality Appreciation Scale (FAS), which measures appreciation for the body's functional abilities.

The score reaches from 7-35. The higher the score the greater the functional appreciation.

Motor abilities will be assessed with the Moon Test, which measures across several key areas:

Strength, speed, coordination, and flexibility will be evaluated with the Moon Test, which provides a comprehensive assessment of various motor skills in paediatric cancer patients. The Moon Test includes the following items: inserting pins, static stand, reaction test, stand and reach, medicine ball shot, sit to stand and hand grip strength.

There is no overall score provided for the Moon Test.

As a part of the motor abilities the postural balance will be assessed using a force plate to analyse body stability and balance control in bipedal, tandem, monopedal and a semi-tandem stand.

The measurement variables are path length (cm) and the ellipse area (cm2). The higher the values the worse is the postural balance.

Physical activity will be evaluated through the BSA (Measurement of physical and sports activity) to understand participants' activity levels. The BSA is a self-report questionnaire that assesses the frequency, intensity, and duration of physical and sports activities over a period of one month. Participants are asked to report their engagement in various activities, focused on structured sports, allowing for a comprehensive evaluation of their activity profile.

The score ranges from 0 to 15 hours per week, with higher values indicating greater levels of physical activity. This measure captures both the intensity and time commitment to physical activities, providing insights into the participants' physical activity patterns.

Physical activity will be evaluated using the GSLTPAQ (Godin-Shephard Leisure-Time Physical Activity Questionnaire) to assess participants' typical activity levels during their leisure time. This questionnaire asks participants to report the frequency of mild, moderate, and vigorous physical activities they engage in over a typical week. Each category is weighted by its intensity to calculate a total Leisure Score Index (LSI), which provides an overall measure of physical activity.

The theoretical score range for the Leisure Score Index (LSI) in the GSLTPAQ starts at 0 and typically extends up to 100, as most participants report values within this range. However, the scale is open-ended, allowing for higher scores depending on the frequency and intensity of reported physical activities. Higher scores indicate greater physical activity in leisure time.

At T1(6 Weeks after baseline measurement) accelerometers and e-diaries will be used to quantify physical activity (PA) levels objectively (over a period of seven days) and to investigate children's affective experiences after sedentary behaviour and PA with a Ecological Momentary Assessment (EMA).

Therefore, the Movisens Move4 accelerometers and study smartphones will be used.

The Move 4 accelerometer, is a small three-axis sensor (movisens GmbH, Karlsruhe, Germany), which will be attached to the right hip, that captures body position and movement acceleration intensity.

At T1(6 Weeks after baseline measurement) accelerometers and e-diaries will be used to quantify physical activity (PA) levels objectively (over a period of seven days) and to investigate children's affective experiences after sedentary behaviour and PA with a Ecological Momentary Assessment (EMA). Therefore, the Movisens Move4 accelerometers and study smartphones will be used.

For the e-diaries the investigators will hand out smartphones and instruct the children to take them with them throughout seven days. Participants will be prompted to fill in the e-diary between 8am and 8pm, using a mixed sampling strategy.

The Self-Assessment Manikin (SAM) will be used to measure the affective experience over the 7 days throughout the day on a Visual Analogue Scale (VAS).

At T1(6 Weeks after baseline measurement) accelerometers and e-diaries will be used to quantify physical activity (PA) levels objectively (over a period of seven days) and to investigate children's affective experiences after sedentary behaviour and PA with a Ecological Momentary Assessment (EMA).

Therefore, the Movisens Move4 accelerometers and study smartphones will be used.

For the e-diaries the investigators will hand out smartphones and instruct the children to take them with them throughout seven days. Participants will be prompted to fill in the e-diary between 8am and 8pm, using a mixed sampling strategy.

The Present Functioning Visual Analogue Scales (PEDSQL VAS) will be used to measure the affective experience and cancer related side effects over the 7 days throughout the day.

At T1(6 Weeks after baseline measurement) accelerometers and e-diaries will be used to quantify physical activity (PA) levels objectively (over a period of seven days) and to investigate children's affective experiences after sedentary behaviour and PA with a Ecological Momentary Assessment (EMA).

Therefore, the Movisens Move4 accelerometers and study smartphones will be used.

For the e-diaries the investigators will hand out smartphones and instruct the children to take them with them throughout seven days. Participants will be prompted to fill in the e-diary between 8am and 8pm, using a mixed sampling strategy to get information about the current activity.

Body composition will be assessed to understand the physical changes of the body. This includes the muscle mass measured by using a Bioelectrical impedance analysis.

Body composition will be assessed to understand the physical changes of the body. This includes the fat-free mass measured by using a Bioelectrical impedance analysis.

Body composition will be assessed to understand the physical changes of the body. This includes the fat mass measured by using a Bioelectrical impedance analysis.

Feasibility of the intervention will be assessed to ensure it is practical, safe, and well-received by participants. This includes:

A self-developed questionnaire and semi-structured interviews to evaluate whether the cognitively challenging physical activity intervention is feasible and motivating for the target group. The aim is to understand how manageable and engaging participants find the program.

Feasibility of the intervention will be assessed to ensure it is practical, safe, and well-received by participants. This includes exercise adherence. Exercise adherence will be tracked through an exercise diary to monitor participants' commitment to the program.

Feasibility of the intervention will be assessed to ensure it is practical, safe, and well-received by participants. This includes adverse events. Adverse events will be tracked within the exercise diary to monitor any physical or medical problems during intervention program.

The investigators will collect data on demographic and clinical characteristics to understand the background of each participant. This includes the age of the participant.

This information is needed for the overall information about the participant.

The investigators will collect data on demographic and clinical characteristics to understand the background of each participant. This includes the sex of the participant.

This information is needed for the overall information about the participant.

The investigators will collect data on demographic and clinical characteristics to understand the background of each participant. This includes the diagnosis o the participant.

This information is needed for the overall information about the participant.

The investigators will collect data on demographic and clinical characteristics to understand the background of each participant. This includes the medical treatment.

This information is needed for the overall information about the participant.