physical therapy for bone marrow transplant patients
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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