Leukaemia

1. Leukaemia Leukaemia represents a group of diseases characterised by “ unregulated proliferation and incomplete maturation of the precursors to white cells and lymphocytes” – Lichtman MA, Segel GB.

2. Four main types:- Acute myeloid leukaemia AML Acute lymphoblastic leukaemia ALL Chronic myeloid leukaemia CML Chronic lymphoblastic leukaemia CLL

3. Treatment of Acute Leukaemia 1 Remission Induction therapy - in hospital about 4weeks 2 Consolidation therapy - when WCC drops, back in hospital, usually about 10 days 3 Maintenance therapy 4 Intensification therapy 5 CNS therapy

4. Physiotherapy Interventiondepends on:- • diagnosis • therapy received • age • treatment course

5. Hospitalisation In hospital 4 - 6 weeks ill bored isolated They spend a lot of time in bed

6. Preventative Exercise programme to:- - prevent loss of strength and endurance - maintain mobility - maintain lung function

7. Implement a plan of Physiotherapy treatment Exercise regime designed to maintain and improve:- 1 Muscle strength 2 Respiratory and cardiac function 3 Joint ROM 4 Body’s protein reserve 5 To help with the long tern psychological considerations associated with long term hospitalisation

8. Muscle strength Need to include:- weight bearing exercises, including upper limbs trunk exercises ambulation muscle strengthening Considerations Myelosupression - anaemia - thrombocytopenia - leucopenia N & V - restricts activity Neurotoxicity Myopathies CNS involvement TBI - Somnolence syndrome

9. Respiratory and cardiac function Chest Infections bacterial staphylococcus streptococcus fungal aspergillus candida Mucocitis ARDS Respiratory failure - no ICU Cardiac toxicity

10. The Side-Effects Of Chemotherapy • Bone marrow depression • Gastro-intestinal symptoms • Specific drug-related problems • Psychological issues

11. Bone Marrow Depression • Anaemia • Neutropenia • Thrombocytopaenia

12. Anaemia • Occurs when the Haemoglobin is <11g/dl • Normal for Males = 13.5 – 17.5g/dl • Normal for Females = 11.5 – 15.5g/dl Symptoms:- • Lethargy • Dyspnoea • Weakness • Peripheral shutdown • Hypotension

13. Neutropaenia • Occurs when the neutrophil count is <0.5 x 109/l • Normal count is 2.5 – 7.5 x 109/l or 40-75% of WBC • Patients are prone to infection • Opportunistic/Atypical infection common • Oncological Emergency = Septic Shock

14. Thrombocytopaenia • Occurs when the platelet count is <50 x 109/l, normal values are 150 – 400 x 109/l. Symptoms:- • Bruising (peticheae) • Nosebleeds (epistaxis) • Blood in urine (haematuria) • Vomiting blood (haematemesis) • Blood in sputum (haemoptysis)

15. Gastro-Intestinal Side Effects • Nausea • Vomiting • Diarrhoea • Oesophagitis • Mucocitis

16. Oncological Emergencies • Tumour Lysis Syndrome • Sepsis • Acute Bleed • Disseminated Intra-Vascular Coagulation (DIC)

17. Sepsis • At risk – neutropenic patients any patient on chemotherapy • Occur at any stage during treatment phase • Haemato-oncology patients experience profound neutropenia therefore more at risk • Three phases

18. Sepsis – Systemic InflammatoryResponse Syndrome • Pyrexia   Cardiac Output • Tachycardia  Vasoconstriction • Low blood pressure • Low urine pressure  Oliguria •  metabolic demand •  respiratory rate  Poor Perfusion

19. Septic Shock • Increasing metabolic and respiratory demand. • No response of blood pressure.

20. Severe Sepsis • Multi-organ involvement. • Global cellular damage. • Global organ damage. • Critical Care for respiratory, cardiac and renal support

21. Sepsis Physiotherapy Management • Most valuable tool = ASSESSMENT • Often non-productive cough  positioning and relaxation • Be aware that respiratory techniques place further demand on tiring patient • Treat what find • Critical Illness Myopathy

22. Acute Bleed • Lungs, Brain, Gastro-intestinal • At risk • Low platelets • No increment on platelets • Altered clotting • DIC

23. JOHN • Diagnosed with ALL 06/08/01 • 12/08/01 Rt.arm is red and oedematous from fingers to the axilla. The lymphatic vessels tracking from hand to axilla are bright red • Decreased ROM shoulder and elbow

26. John • 22/08/01 Arm less painful. ROM increased in shoulder and elbow but still has cording of vessels in the cubital fossa and axilla • Arm normal colour now but vessels remain tight but improving slowly • 01/10/01 platelets too low to do stretching –John not feeling well.

27. John • Blood counts increasing but John concerned about decreased strength • Discharged home with community physiotherapy • Saw as O.P. – pain ++both feet ?CT induced. Morphine, Amitryptiline & TNS

28. John • 26/01/02 allogeneic PSCT • 26/01/02 reasonably well, asymptomatic from low Hb. • Has developed acute GVHD skin of the hands, trunk & limbs – steroids Went on to develop chronic GVHD skin, mouth, eyes

29. John • 19/04/07 In complete remission. Generally well in himself • Continues to be troubled with long term effects of his sclerodermatous chronic GVHD • He developed contractures of both shoulders, elbows, wrists and hands. • He underwent contractive release surgeries for Rt. Shoulder and elbow – for further surgery to Lt. elbow, both hands and Rt, foot.

30. John • Has developed pain and instability in both hips – MRI scan suggests avascular necrosis. • Has been seen by an orthopaedic surgeon and has had some procedures performed on the left hip as a holding measure. • He has been told that he will need bi-lateral hip replacements in the future

31. John • He also has early bi-lateral cataract formation which is progressive . • He will need cataract surgery in the future. • His most troubling symptom is persistent, widespread and frequently occurring cramps in his hands, arms and legs.

32. N 05/92 18 year old student. Presented with flu-like symptoms, had had recurrent sore throats. Diagnosed Myelodysplastic Syndrome (MDS). Supported with blood transfusion, ciproxin and ketoconazole over the next few months. 24/08/92 Transformed to Acute Myeloid Leukaemia. 31/08/92 1st Clarkson’s. 17/09/92 21st birthday 30/09/92 2nd Clarkson’s. 25/12/92 Admitted prior to allogeneic bone marrow transplant. 30/12/92 BMT. 15/01/93 GVHD 02/04/93 E.A - ? GVHD or CMV Chest infection - sputum specimen required.

33. 19/04/93 Re - referred - anorexic - decreased strength - Grade 3-4 all muscle groups. 10/05/93 Developed a dry irritating cough Sputum specimen sent -Aspergillus. 15/06/93 Number of problems :- - febrile -aspergillus infection - extensive mucosal thickening of sinuses - becoming depressed 17/06/93 Increased activities 21/06/93 Continues to improve, days spent at home. 23/06/93 Discharged from ALU

34. 25/08/93 Admitted with - N & V - anorexia - still ? GVHD or CMV 10/09/93 Pharyngeal candidasis. 17/09/93 Another birthday 27/09/93 Transferred to Hope Hospital. 13/10/93 Re - admitted from Hope with chest infection and Lt. sided pleuritc pain 27/10/93 Developed pain in Lt, shoulder - line leakage. 14/11/93 Improving - home for WEL. 14/01/94 Emergency admission - rapid deterioration of liver function tests and increasing jaundice and somnolence. 17/01/94 Liver biopsy. 21/01/94 Sudden dramatic deterioration - bleed - probably from liver - transfused - stabilised - further bleed, BP and CVP both fell rapidly - more transfusions but unable to maintain BP or CVP - intinsive support carried out for further 5 hours but to no avail 22/01/94 N. died.