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leukaemia.ppt
1. Christie Hospital
NHS Foundation Trust
NHS
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.
Leukaemia
2. Christie Hospital
NHS Foundation Trust
NHS
Acute myeloid leukaemia AML
Acute lymphoblastic leukaemia ALL
Chronic myeloid leukaemia CML
Chronic lymphoblastic leukaemia CLL
Four main types:-
3. Christie Hospital
NHS Foundation Trust
NHS
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
Treatment of Acute Leukaemia
4. Christie Hospital
NHS Foundation Trust
NHS
• diagnosis
• therapy received
• age
• treatment course
Physiotherapy Intervention
depends on:-
5. Christie Hospital
NHS Foundation Trust
NHS
In hospital 4 - 6 weeks
ill
bored
isolated
They spend a lot of time in bed
Hospitalisation
6. Christie Hospital
NHS Foundation Trust
NHS
Exercise programme to:-
- prevent loss of strength and endurance
- maintain mobility
- maintain lung function
Preventative
7. Christie Hospital
NHS Foundation Trust
NHS
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
Implement a plan of
Physiotherapy treatment
8. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
Respiratory and cardiac function
Chest Infections
bacterial staphylococcus
streptococcus
fungal aspergillus
candida
Mucocitis
ARDS
Respiratory failure - no ICU
Cardiac toxicity
10. Christie Hospital
NHS Foundation Trust
NHS
The Side-Effects Of Chemotherapy
• Bone marrow depression
• Gastro-intestinal symptoms
• Specific drug-related problems
• Psychological issues
12. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
Gastro-Intestinal Side Effects
• Nausea
• Vomiting
• Diarrhoea
• Oesophagitis
• Mucocitis
17. Christie Hospital
NHS Foundation Trust
NHS
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
19. Christie Hospital
NHS Foundation Trust
NHS
Septic Shock
• Increasing metabolic and respiratory demand.
• No response of blood pressure.
20. Christie Hospital
NHS Foundation Trust
NHS
Severe Sepsis
• Multi-organ involvement.
• Global cellular damage.
• Global organ damage.
• Critical Care for respiratory, cardiac and renal
support
21. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
Acute Bleed
• Lungs, Brain, Gastro-intestinal
• At risk
• Low platelets
• No increment on platelets
• Altered clotting
• DIC
23. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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. Christie Hospital
NHS Foundation Trust
NHS
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.