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Acute Lymphoblastic Leukemia ALL Mizzou University of Missouri


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									                           Group 5 - Acute Lymphoblastic Leukemia (ALL)
                  By: Heather Croft, Sammy Finney, Amanda Foresman, Beth Kinser, Jenn Lammert, Lindsey Penick

    1.  Differential Diagnosis
          Disease              Signs/Symptoms                                           Diagnosis
Cancer                         Anemia, infection, easy bruising and bleeding,           CBC and peripheral smear, bone marrow
                               irritability, fatigue, bone pain, bleeding gums, HA,     examination, histochemical studies,
                               raised non-pruritic rash, WBC<10,000 or                  cytogenetics, immunopheotyping, molecular
                               > 100,0001,2                                             biology studies, lumbar puncture. 1,2
Rheumatoid Arthritis           Early morning stiffness of affected jts, general         Clinical criteria, serum rheumatoid factor
                               afternoon fatigue and malaise, anorexia, general         (RF) or anti-cyclic citrullinated peptide
                               weakness, occasional low-grade fever, jt pain,           antibody (anti-CCP), x-rays. 1
                               swelling, and stiffness, mostly simultaneous (B) jt.
Legg Calve Perthes             Pain in the hip joint and gait disturbance, thigh        Dx is based on symptoms followed by a
                               muscles may become wasted. 1                             bone scan or MRI to confirm the dx. 1
Slipped Capital Femoral        The first symptom may be hip stiffness, then a           AP and frog-leg lateral x-ray studies of both
Epiphysis                      limp may develop, then pain that radiates from hip       hips are taken. Show widening of the
                               down to anterior-medial thigh to knee. 1                 epiphyseal line or apparent posterior and
                                                                                        inferior displacement of the femoral head.
                                                                                        Ultrasonography and MRI can help
Sickle Cell Anemia              Severe pain in long bones, hands, feet and jts.         Family history is taken into consideration,
                                Severe abdominal pain develops, and vomiting            laboratory tests for hemolytic anemia. 1
                                may occur. Typically in the black population. 1
Infection                       Severe jt. pain, warmth, tenderness, effusion,          Arthrocentesis with synovial fluid
                                restricted A & PROM, and sometimes redness,             examination and culture, blood culture,
                                possible high or low-grade fever. 1                     CBC and ESR. 1

    2.    Types of Leukemia1
         Type                Incidence          Signs & Symptoms          Initial Remission                   Prognosis
                                                 tachycardia, chest
                                                    pain, irregular
                                                                                                   Median survival with rx: 1 year
Acute Lymphocytic                                 menstruation, jt.       50% (average 12
                          Median age: 20                                                           Median survival without rx: 2-4
 Leukemia (ALL)                                 pain, HA, vomiting,          months)
                                                                                                            weeks p dx
                                                irritability, seizures,
                                                                                                   Mean survival with rx: 5 yr (60-
Acute Myelogenous                                Typical s/s listed
                           Median age: 4                                          90%               70% of children); if relapse,
 Leukemia (AML)                                       above
                                                                                                       usually occurs < 3 yrs
                                                   anorexia, night
     Chronic                                      sweats, sense of                                 Median survival with rx: 3 yrs
  Myelogenous             Median age: 49        abdominal fullness                90%             Survival after 80% blast crisis: 2
 Leukemia (CML)                                        (due to                                                 months
                                                 Anorexia, DOE,
                                                sense of abdominal
      Chronic                                         fullness,
                        Median age: 60 (risk                                                       Mean survival with rx: 6 years
   Lymphocytic                                       nonspecific                  90%
                        increases with age)                                                       Primary cause of death: infection
  Leukemia (CLL)                                 symptoms due to
                                                 anemia (fatigue/

    Physical Therapy Interventions
             Evidence:
                    o PT and HEP: LE strengthening and stretching, aerobic exercise found to be beneficial for gait7
                    o 8 wk exercise training program which improved muscle strength, endurance and functional mobility8

                 Making therapy fun
                     o Wii Fit (aerobic capacity, balance, strength)
                     o Dance Dance Revolution (aerobic capacity)
                    o     Yoga Poses: River, down dog, gorilla, cobra, bridge, boat, tree, airplane, lying twist, dragon, cat,
                          triangle (flexibility, ROM)
                    o     Jungle Gym (strength, aerobic capacity)
                    o     Basketball (strength, ROM, aerobic capacity)
                    o     Scavenger Hunt (strength)
                    o      Painting/Whiteboard drawing (strength, ROM)
                    o      Aqua Therapy (aerobic capacity, strength)
                    o      Ride Bike (ROM, aerobic capacity, strength)
                    o      Simon Says (strength, ROM, flexibility, aerobic capacity)
                    o      Red Light / Green Light (aerobic capacity)

3. Our Recommended Intervention:
        3/wk for 6 wks, therapy consists of: ROM, strengthening exercises, aerobic exercises, flexibility exercises.

4. Physical Therapy Precautions
       HR may not be accurate in patients taking chemotherapy, so use MET, BP, face rating for fatigue7
       Bone metastases patients’ should avoid all contact sports7
       Adriomycin: may have cardiac side effects that impair cardiac fxn and oxygen transport which will limit
           ability to participate in exercise7
       High number of REPs should be avoided due to fatigue7
       Nadir is the lowest point the white blood count reaches, usually occurs 7 - 14 days after chemo or radiation.3
                o At this point the patient is extremely susceptible to infections. 3
                o The importance of good handwashing and hygiene practices cannot be overemphasized when treating
                     these patients. 3
                o Fatigue is a side effect: be aware of pt getting tired during tx so we may have to take frequent breaks.

5. Psychosocial Manifestations
        Depression/Sadness since he is away from family and friends
        Anxiety about being in the hospital, and side effects of treatment
        Fear of hospitals, doctors, or procedures that may take place
        Anger due to a lack of understanding
        Family dynamic issues
               o The investigators of this study used the Short-Form 36 as a quality of life assessment measure.
                        Compared to families with healthy children, families with children who have cancer reported
                            decreased physical and psychosocial quality of life in the following domains: physical role,
                            bodily pains, general health perceptions, energy/vitality, social function, emotional role, and
                            mental health. 10
                        Characteristics of the child that enhanced the quality of life of family with a child who has
                            cancer: improve health status, decreased intensity of the treatment, and a increased time
        School: patient may have difficulty catching up in school, which may frustrate patient
        Sports: patient is very interested in sports, and may have difficulty sitting out during sports

6. Other Information
       A lot of bruising may indicate abuse; therefore it is very important to rule out abuse.

    1.  The Merck Manual Online Medical Library
    2.  A Cancer Source Book for Nurses (7th ed.) Atlanta, GA: American Cancer Society;1997.
    3.  Goodman CC, & Snyder TE. Differential diagnosis for physical therapists (4 th ed.) St. Louis, MO: Saunders-Elsevier; 2007.
    4.  Basmajian JV & Wolf SL. Therapeutic Exercise (5th Ed.) Baltimore, MD: Williams & Wilkins; 1990.
    6.  Ciccone CD. Pharmacology in Rehabilitation (4th ed.) Philadelphia, PA: E.A. Davis Company; 2007.
    7.  Marchese VG, Chiarello LA, Lange BJ. Effects of physical therapy intervention for children with acute lymphoblastic leukemia. Pediatr Blood
        Cancer. 2004; 42(2): 127-33.
    8. San Juan AF, Fleck SJ, Chamorro-Vina C, et al. Early-phase adaptations to intrahospital training in strength and functional mobility of children with
        leukemia. J Strength Cond Res. 2007; 21(1): 173-7.
    10. Klassen AF, Klaassen R, Dix D, et al. Impact of caring for a child with cancer on parents’ health-related quality of life. J Clin Onc. 2008;26(36):5884-

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