CASE STUDY 2 Acute Lymphoblastic Leukemia (ALL)

1. CASE STUDY 2Acute Lymphoblastic Leukemia (ALL) AHP GROUP FOR CHILDREN & YOUNG PEOPLE WITH CANCER Jenna Reid, Clinical Specialist Physiotherapist, RHSCE Natalie McLeod, Senior Occupational Therapist, RHSCE Charlotte Okoe, Generic Assistant Practitioner, RHSCE

2. SOCIAL HISTORY • Child X • Attends mainstream school • Lives in a two-storey house with mum and 1 sister • Interests: Baking, arts and crafts, dancing, bike riding

3. MEDICAL HISTORY • 2 week history of sore throat, headaches and fever. Treated with IV antibiotics at local hospital. Admitted via A & E with dizziness • Diagnosed with Acute Lymphoblastic Leukemia (ALL), following bone marrow aspirates and trephines • Birth History: Normal delivery at term • Previously fit and well. All developmental milestones achieved within normal range

4. MEDICAL INTERVENTION • Dexamethazone • Portacath insertion • Lumbar Puncture • Intrathecal methatrexate • Consent obtained for UK ALL (2003) trial • Child X commenced on Regimen B Protocol

5. MEDICAL COMPLICATIONS • Linogram. Infected portacath requiring removal in theatre • Oxygen requirement following fungal infection • New portacath inserted • Urgent endocrine review due to high potassium and ketones ? Diabetes • Ongoing issues with wound infection at primary portacath site, requiring IV antibiotics

6. PRESENTATION • Quiet, subdued but appropriate responses • Initial Physio Ax: full AROM and power (bilateral UL’s and LL’s), normal gait pattern but slight tightness in hamstring and quads • Initial OT Ax: loss of confidence and independence in ADL’s - requiring maximum assistance for carrying out daily tasks, transfers and mobilising around the house. Unable to climb stairs due to fatigue

7. MULTI-DISCIPLINARY TEAM • Haematologist • General surgeons • Endocrinologist • Nursing staff • Physiotherapist • Occupational Therapist • Generic Therapy Assistant • Dietician • Play Specialist • POONS • Social Work • Hospital Teacher

8. OCCUPATIONAL THERAPY GOALS • SHORT TERM: - To educate the patient and parents on the role of Occupational Therapy and to establish good rapport - To establish equipment needs to facilitate a safe and timely discharge home - To facilitate engagement and independence in ADL’s to increase Child X’s quality of life and minimise loss of function - To maintain functional skills necessary for return to school i.e. upper limb strength and fine motor control - To provide strategies for fatigue management - To assist Child X in maintaining a positive self-image, mood and confidence • LONG TERM: - To reintegrate Child X back into home/ school with as much independence in activities as possible

9. OCCUPATIONAL THERAPY INTERVENTION • Referral to local OT team with recommendations for provision of supportive toilet and bath equipment for home • Completion of ‘Occupational Self Assessment’ in order to identify current areas of concern and gain an understanding of what is important to Child X at present. This can assist in developing person-centered appropriate goals • Development of weekly ADL timetables with Child X to facilitate greater engagement in daily tasks, promoting independence and improving endurance • Activities involving hand function (bilateral skills, in-hand manipulation and hand strength)/ appropriate choice of leisure pursuits • Liaison with hospital teacher regarding current level of functioning and advise regarding graphic skills • Bath assessment on the ward with provision of appropriate and safe equipment for maintaining some independence

10. PHYSIOTHERAPY GOALS SHORT TERM: • To educate the patient and parents on the role of physiotherapy and the signs and symptoms of Chemotherapy Induced Peripheral Neuropathy • To establish a baseline assessment of power, range, sensation, reflexes, gait etc. • To maintain normal muscle power and prevent muscle shortening • To promote safe mobility and independent function to facilitate discharge LONG TERM: • Ongoing assessment to identify signs and symptoms of CIPN • To enable normal function and re-establish inclusion in physical activities

11. PHYSIOTHERAPY INTERVENTION • Provision/monitoring of self-propelling wheelchair • Breathing exercises to maintain clear chest • Stairs assessment and practice • Exercise programme provided to prevent muscle shortening and promote strength of upper and lower limbs • Provision of pedal-cycle on ward and home for lower limb strengthening • Liaison with MDT to promote optimal function i.e. Occupational therapy referral and school Teacher • Provided with soft cast resting splints

12. REHABILITATION PROFILE • Local Therapists • MDT • Parent/Carers

13. JOINT WORKING • Therapy Timetable • Weekly ADL timetable • Joint goal setting with the patient • Rehabilitation Profile • MDT meetings • Clinic reports • c.c into medical clinic letters • Early referral to local therapists and ongoing joint working