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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. involvement.1,3 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, papilledema 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 splenomegaly) 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/ malaise) 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. 3 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 period.10 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. References: 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. 5. www.happysoccerfeet.com 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. 9. www.payvand.com/news/07/dec/MAHAK-Patient.jpg 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- 89.
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