Acute Myeloid Leukemia Case Study

Author/s

Chelsea Bentley, Aubrey Jacobi, Lauren Jones, Gina Pottkotter, and MegAnne Punt from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Patient Characteristics

• 66 year old male, named Bert 
• Retired Navy Seal and school bus driver
• Current Volunteer at Veteran’s Affairs Hospital in Louisville, KY
• Lives with wife of 45 years
• Type II diabetic, controlled
• Left Transtibial Amputation secondary to diabetic ulcer
• Previous physical therapy in acute, rehabilitation, and outpatient settings following surgery
  

Examination

SUBJECTIVE:

• Chief Complaint: Patient presents to outpatient physical therapy clinic (2 months post discharge), with desire for further prosthetic training. Patient’s prior outpatient PT included gait training and stair training with use of cane. Now, patient desires more independence without assistive device and further training to accommodate his increased activity level in the community with his volunteer work. Patient notes that he feels increasingly tired after a day of volunteering, therefore he wants more endurance training with his prosthetic.
  
• Medical History:
  • Previous history of smoking, 30 pack years
  • Quit smoking at age 48, when he was diagnosed with Type II diabetes
  • Diabetic ulcer on L heel, led to transtibial amputation approximately 1 year ago
  • Patient reports history of anemia while in hospital post-op
• Recent onset of headaches, 3 out of 10 on pain scale
• Patient reports shortness of breath with increased activity
• 1 year post-operation from amputation
  
  • Discharged from outpatient physical therapy 2 months prior to current visit

Self Report Outcome Measures:

• Pain Scale:
  • Headaches reported 3 out of 10 on Visual Analog Scale
  • Otherwise, patient complains of no pain
• Short Form 36 Questionnaire (Quality of Life Measure)
  • Physical Functioning Score (PF) of 45 (significant decrease in physical functioning )
  • Role limitations due to physical health (RP) score of 25 (significant limitations)
  • Vitality Score of 20 (significant decrease in quality of life)
  • Physical Health overall largely impacted, score of 31
  • Mental Health, stable with score of 59
  • Scores under 50 represent significant impact

Physical Performance Measures:

• Amputee Mobility Predictor
  • Score of 37/47
  • Indicates Functional Level 3/K3
• 5 Time Sit Stand Test (endurance)
  • 12.5 seconds (average for age group 11.4 secs, fall risk over 12 seconds)
  

OBJECTIVE:

• Vital Signs:
  • Blood Pressure 110/75 mmHg
  • Heart Rate 64bpm
  • Respiratory Rate 18bpm(at rest)
  • Temperature 99.4°F
• 'Patient presents with cough. Auscultation reveals adventitious lung sounds.
  
  
  '
• Petechaie and bruising noted on patients R lower leg and ankle, also minor spots noted on residual limb
• Due to fever, palpation of abdomen revealed enlarged spleen and tenderness
  
  
• Upper and lower quarter screen ROM WNL.
• All deep tendon reflexes present and symmetrical
• Sensation diminished over L residual limb and R foot
• Hip flexion 4-/5 bilaterally, Shoulder abduction 4-/5 bilaterally, shoulder flexion 4-/5 bilaterally. All other manual muscle tests within normal limits.
  

Summarization of Examination/Clinical Impression

Following evaluation, the patient presents with signs and symptoms consistent with proximal muscle weakness. Patient demonstrates diminished sensation in bilateral lower extremities. The patient presents with increased fatigue, headaches, and adventitious breath sounds consistent with possible infection. The patient’s outcome measure scores indicate decreased ability to perform ADLs due to fatigue. Additionally, Mr. Bert’s AMP score indicates the ability to perform most activities, but the patient’s self-report demonstrates limitation due to restricted endurance. Due to the patient’s risk factors of diabetes and age coupled with enlarged spleen upon palpation and tenderness, physical therapy recommends referral back to the primary care physician for further evaluation and blood work.

The clinical impression of this patient is that the proximal muscle weakness and increased fatigue are consistent with presentation of acute myeloid leukemia. Other risk factors to consider with this patient include being male, age, history of smoking. Mr. Bert also has comorbidities to consider with diabetes.The patient will be referred back to his primary care physician. The patient would benefit from physical therapy to strengthen proximal muscles and increase cardiovascular endurance.

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Interventions

Since the patient will be undergoing concurrent cancer treatments, the main focus of the interventions will be aerobic and strength training along with pain management, when necessary. Physical therapy treatment sessions will be symptom dependent and it will be vital to monitor the patient for signs of excessive fatigue. The patient should also be monitored for chemo-induced neuropathies, which could put them at a greater risk for falls.

•Aerobic training – Current literature shows that walking for at least 12 minutes, five times per week for 3 weeks at a pace that would get them a heart rate of RHR+30bpm. This prescription is sufficient to maintain the cardiovascular system and alleviate symptoms of fatigue, anxiety and depression.1

•Strength training- Strength training twice a day, 3 times per week, for 10-30 minutes at 40-50% of HRR has been shown to decrease fatigue and depression in patients undergoing chemotherapy. Upper and lower extremity resistance exercises should be used.2

•Combination of strength and aerobic training – It is important to include both types of exercise into a patient's regimen. A combination helps to combat the effects of bed rest and deconditioning, which are common with patients undergoing chemotherapy.3

•Pain Management –Hot/cold packs, TENS, and massage are all modalities that can be used to decrease pain in patients.

Expected Outcomes

After completing 6 weeks of aerobic and resistance training, the patient showed improvements in physical endurance as evident in 6MWT, as well as aerobic fitness with improvements in peak VO2. The patient also had statistically significant increases in muscle strength for both upper extremities, and lower extremities with improvements in 1 rep max test.

At the end of the 6 weeks our patient also had an increase in body weight, with a decrease in body fat. This is a crucial finding as most AML patients lose weight throughout the disease process and chemo sessions. It is important for the patient to not only gain weight, but to gain lean muscle mass instead of fat.

At the end of the exercise protocol, our patient also showed significant improvements in global quality of life, fatigue, anxiety, and emotional function. There were no statistically significant changes in depression however, even though there were improvements in depression. The patient also reported a decrease in pain (using a VAS pain scale), through the use of heat/cold packs as well as pharmaceutics.

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

Related Pages

http://www.physio-pedia.com/Acute_Myeloid_Leukemia

References

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