Transcript physical therapy for bone marrow transplant patients

Bill Tatu, DPT
BENEFITS OF EXERCISE
 Almost
all BMT patients will benefit
 Physical performance improves
 Decreased fatigue
 Reduce severity of treatment related side
effects
 Minimize fall risk
 Improved QOL
EXERCISE TOLERANCE FOR
CANCER PATIENTS
 11
million cancer survivors
 Meta analysis shows that most patients
tolerate exercise during and after
treatment
 82 unique studies
 Evidence has been slow coming but is
starting to accumulate
 Quality of Life concerns draw much more
attention than prior to 2005 (ACS first
mentions QOL)
QUALITY OF LIFE STUDIES
 Physical,
Emotional, Social & Role
Functioning
 Function prior to transplant
 ADL’s
 Time in Bed/ small room
 Activity (able to ambulate indep?)
 Functional Nadir 30 to 100 days post
transplant
 “Lack of energy”
PHYSICAL THERAPY EVALUATION
 Comorbidities
/Age
 Premorbid function
 Treatment effects
 Strength with ADL’s (trunk and
extremeties)
 Pulse oximetry while moving
 Motor planning
 Fall risk (balance vs weakness)
Contraindications







DVT/PE
Oxygen sats below 90% (at rest vs moving)
Orthostasis
Unstable Bone
During Transfusion
Plts below 20k
Hgb below 8
CONTRAINDICATIONS
 AMS
 Low
platelets (<10)
 Hgb <7
 ACSM guidelines for more vigorous
exercise




Just published in 2010
Plts > 50 for more strenuous exercise
Normal wbc’s
Hgb >10+5+
DALLAS STUDY
 1966-
5 20 YO students put in bed for 18
days
 Same 5 men evaluated 30 years later
showed more deterioration after bedrest
as 20 year olds than after 30 yrs of aging
 Another study of older adults showed
decrease in voluntary activity after bed
rest
 Lose strength, aerobic capacity
EFFECTS OF IMMOBILITY
Orthostasis
 Thrombus formation
 Secretion accumulation
 Decreased strength/loss of independence
 Increased muscle wasting

Reduced muscle protein synthesis
 Increased muscle protein breakdown

POST-ICU PATIENTS
 Approx
5-15% of HSCT patients
 Respiratory difficulties
 More ICU patients than in the past (no
longer futile)
 Length of stay?
 How long on vent (especially sedated)
 Some impaired function is highly likely
 Age of patient (sarcopenia)
CRITICAL ILLNESS
MYOPATHY
 Post
ICU stay
 Complex etiology may be
metabolic/inflammatory
 Initially masked by sedation, AMS
 Global profound weakness
 Patient has difficulty with seemingly simple
tasks such as rolling over, maintaining
sitting balance
STEROID MYOPATHY
 Proximal
Muscle Weakness
 Weak Hips (trouble standing)/shoulders
 Can develop dyspnea
 Important to communicate to MD
 Improvement or Resolution in 3 months
 Mechanism unclear



Decreased protein synthesis
Increased protein degradation
Mitochondrial Alterations
STEROID MYOPATHY
MANIFESTATIONS
 May
occur weeks to years after
administration
 Acute (less common) 5-7 days after
starting
 Difficulty standing
 Unable to do controlled descent to sit
 Stair climbing much more difficult than
level surface walking
 Toileting difficult
IDENTIFY FRAILTY
 Nurses
are often the first to identify
problems
 Older isn’t better
 GVH
 Cancer Fatigue
 Pancytopenia
CANCER FATIGUE
 NCCN
definition: “A persistent, subjective
sense of tiredness related to cancer or
cancer treatment that interferes with usual
functioning”
 NCCN
Category I Level Evidence that
exercise helps with cancer fatigue
FALL PREVENTION
 Motor
planning problems?
 Trunk control
 Therapist positioning during transfer
 Equipment positioning
 Bail out plan!
 When do you take patient off fall
precautions?


Controlled descent
perturbation
PERIPHERAL NEUROPATHY
 Exercise
will not help nerve heal
 Assess how much disability
 Work on accessory muscles
 Enhance function of denervated muscle
 Educate patient ( no exertional activity,
healing time, what to expect)
TESTING FUNCTION in BMT
PATIENTS
 Assess
all adult patients pre transplant
 6 minute walk test(for endurance and
cardiovascular assessment )
 Get up and Go test (Identify fall potential)
GET UP AND GO TEST
 Total
time taken to complete task
 Rise from chair walk 3 meters and return
 Has been well correlated with fall risk
6 Minute Walk Test
 Easy
to administer
 No assistance needed
 Better reflects ADL’s than other walk tests
 Objective measurement better than
subjective
 400-700 ft norm for healthy subjects