PHYSICAL THERAPY FOR BONE MARROW TRANSPLANT PATIENTS

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 Huge benefit with higher bed/ toilet/chair Avoid high intensity exercise

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