This is a great question we looked at with beginning our physical therapy
program with stem cell transplant patients. I agree weighing the risk vs. the
benefit is crucial and to consider holding on therapy until after the platelet
transfusion, however the truth is platelets do not always recover over 10,000
after transfusion in this population. The question is what to do then. I also
think it important in these discussions to differentiate physical activity or
mobility from exercise and explain how we define each of those categories when
talking about guidelines.
As physical therapists our role with severely thrombocytopenia is first to
ensure the patient's safety and to reduce risk of injury or falls with
mobility. Regardless of their platelet count, patients are going to be
getting up to get to the bathroom. Shouldn't we assess if they are safe to do
this given the severity of their thrombocytopenia? We want to mitigate risk of
falls/injury, if they are at risk for a fall we should recommend a bedside
commode or if they walk to/from the bathroom and their BP or HR are elevated
this increases the risk of a hemorrhage and so we again may want to consider
recommending a bedside commode. These patients are often pushing a large IV
pole to get to the bathroom and some have neuropathy, are they able to do this
without accidently kicking the pole and causing a trauma to the foot. We've had
patients who are ataxic and I've seen them to recommend things like padding for
their bed rails to mitigate risk of injury.
Now if we are talking about exercise, there are some articles which we can use
to help us consider the risks. The article from Dr. Fu at MD Anderson found
bleeding events were mostly mild in nature for patients undergoing SCT with
thrombocytopenia and the article from Shirley Ryan Ability Lab confirmed
bleeding events were mild in severity and not associated with the degree of
thrombocytopenia. Both of these articles were looking at patients with
thrombocytopenia in a rehabilitation program. The article from Rexer is a small
N of 30 patients, but reported no adverse events for patients participating in
strengthening and aerobic exercise with severe thrombocytopenia. Therapists
should take this information under consideration as we weigh the risk. I often
have objective conversations with the patient on the risk vs. benefit of
physical activity or exercise and document this discussion, allowing the
patient to make an informed decision on how to proceed.
The risk of deconditioning is so high for this population, we need to be very
thoughtful about when we hold therapy because our interventions do have a
significate effect on functional outcomes and fatigue. I think there is a place
for therapy to be involved and seeing these patients at all times throughout
their admission. That being said, the therapist should always have the right to
hold on therapy if they feel it is not safe regardless of guidelines, but
should also be able to justify their reasoning to hold. The role of PT varies
widely as the blood counts acutely change and it takes a good understanding of
what to watch for to help optimize our treatments for this patient population.
But as physical therapists we are trained to be able to synthesize all of these
considerations with the patient's response to treatment and move forward to
help these patients.
It would be a great project for the oncology section to consider developing a
resource for therapists to use in day to day practice. I have put together an
oncology specific lab values resource for our therapists to follow, which I am
happy to share over email if you are interested.
Best,
Sara Yoder, PT, DPT, CLT
Physical Therapist
Oncology Rehabilitation - Emily Couric Clinical Cancer Center
University of Virginia Health System
Smy6g@xxxxxxxxxxxx<mailto:Smy6g@xxxxxxxxxxxx>
434-465-9648
From: aptaoncology-bounce@xxxxxxxxxxxxx
[mailto:aptaoncology-bounce@xxxxxxxxxxxxx] On Behalf Of Allison Brookins
Sent: Wednesday, August 12, 2020 8:11 PM
To: aptaoncology@xxxxxxxxxxxxx
Subject: [aptaoncology] Oncology Lab Values Reference
Hi!
I'm a new member of this group.
We are developing some guidelines for our PT/OT team when treating our general
oncology patients and also for our BMT patients.
We generally use the Academy of Acute Care Physical therapy Laboratory Values
Interpretation Resource (Updated 2017) as our reference point. Lately we are
having some challenges with our RN colleagues "pushing us" to see patients who
we might feel are not physiologically ready/stable enough for certain
activities.
Does anyone have/is anyone developing an Oncology-specific lab values resource?
One of our PTs today had 2 patients whose platelets were 5,000 or below.
(diagnoses were AML and lymphoma)
In both cases, our RN colleagues were not-so-gently pushing for us to engage
these patients in activity.
Thanks for your input!
Allison Brookins, PT
Staff PT and Clinical Educator
________________________________
"This message is intended for the use of the person or entity to which it is
addressed and may contain information that is confidential or privileged, the
disclosure of which is governed by applicable law. If the reader of this
message is not the intended recipient, you are hereby notified that any
dissemination, distribution, or copying of this information is strictly
prohibited. If you have received this message by error, please notify us
immediately and destroy the related message."
Attachment:
ThrombocytoSCTExerciseFeasibility.pdf
Description: ThrombocytoSCTExerciseFeasibility.pdf
Attachment:
BleedingEventsSCTAcuteRehab.pdf
Description: BleedingEventsSCTAcuteRehab.pdf
Attachment:
BleedingRiskSCT_Fu.pdf
Description: BleedingRiskSCT_Fu.pdf
