Leukaemia

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.
Christie Hospital NHS

NHS Foundation Trust
Four main types:-
Acute myeloid leukaemia AML

Acute lymphoblastic leukaemia ALL
Chronic myeloid leukaemia CML
Chronic lymphoblastic leukaemia CLL

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
Physiotherapy Intervention
depends on:-
• diagnosis
• therapy received
• age
• treatment course

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

Preventative
Exercise programme to:-

- prevent loss of strength and endurance
- maintain mobility
- maintain lung function

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
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
Respiratory and cardiac function
Chest Infections
bacterial staphylococcus
streptococcus
fungal aspergillus
candida
Mucocitis
ARDS
Respiratory failure - no ICU
Cardiac toxicity
The Side-Effects Of Chemotherapy
• Bone marrow depression

• Gastro-intestinal symptoms
• Specific drug-related problems
• Psychological issues

Bone Marrow Depression
• Anaemia
• Neutropenia
• Thrombocytopaenia

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

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

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)

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

Oncological Emergencies
• Tumour Lysis Syndrome

• Sepsis
• Acute Bleed
• Disseminated Intra-Vascular Coagulation (DIC)

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

Sepsis – Systemic Inflammatory
Response Syndrome
• Pyrexia   Cardiac Output

• Tachycardia  Vasoconstriction
• Low blood pressure
• Low urine pressure  Oliguria
  metabolic demand
  respiratory rate  Poor Perfusion

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

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

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

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

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

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.

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

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

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.

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

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.

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.

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

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. Christie Hospital NHS

Leukaemia

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Leukaemia

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Leukaemia

Leukaemia represents a group of diseases characterised by

Christie Hospital NHS

Acute myeloid leukaemia AML

Christie Hospital NHS

Christie Hospital NHS

Christie Hospital NHS

Exercise programme to:-

Christie Hospital NHS

Exercise regime designed to maintain and improve:-

• Bone marrow depression

Christie Hospital NHS

Christie Hospital NHS

• Occurs when the Haemoglobin is <11g/dl

Christie Hospital NHS

• Occurs when the neutrophil count is <0.5 x 109/l

Christie Hospital NHS

• Occurs when the platelet count is <50 x 109/l, normal

Christie Hospital NHS

Christie Hospital NHS

• Tumour Lysis Syndrome

Christie Hospital NHS

• At risk – neutropenic patients

• Occur at any stage during treatment phase

Christie Hospital NHS

• Pyrexia   Cardiac Output

Christie Hospital NHS

• Increasing metabolic and respiratory demand.

• No response of blood pressure.

Christie Hospital NHS

Christie Hospital NHS

• Most valuable tool = ASSESSMENT

Christie Hospital NHS

• Lungs, Brain, Gastro-intestinal

Christie Hospital NHS

• Diagnosed with ALL 06/08/01

• 12/08/01 Rt.arm is red and oedematous from

• Decreased ROM shoulder and elbow

Christie Hospital NHS

• 22/08/01 Arm less painful. ROM increased in

Christie Hospital NHS

• Blood counts increasing but John concerned

Christie Hospital NHS

• 26/01/02 allogeneic PSCT

Went on to develop chronic GVHD skin, mouth, eyes

Christie Hospital NHS

• 19/04/07 In complete remission. Generally well in

Christie Hospital NHS

• Has developed pain and instability in both

Christie Hospital NHS

• He also has early bi-lateral cataract formation

Christie Hospital NHS

Christie Hospital NHS

Christie Hospital NHS

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