Hodgkin's Lymphoma Case Study

Author/s

A.J. Costin, Callie Eaves, Dan Purdy, and Lauren Willis from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

100 word limit, non-structured description

Patient Characteristics

• Demographic Information: Mr. Hodgkin's is a 61 year old caucasian male. He has worked as an electrical engineer for 30 years.   
• Medical diagnosis: Referred from primary care physician to therapy for low back pain (LBP) due to history of disc herniation. No recent imaging. MRI from 5 years ago. 
• Co-morbidities: HTN, BMI = 27, hyperlipidemia
• Previous Physical Therapy: Mr. Hodgkin's has received prior physical therapy for disc herniation at L4-L5 five years ago.

Examination

Subjective:  

Mr. Hodgkins reports a four month history of pain in his low back and recently the pain has moved into his left hip. He states this pain is different from his previous low back pain; it is lower and this is the first time that he has experienced hip pain. His chief complain is that when he comes home from work he is just too tired to go fishing or work in his wood shop. He states his doctor instructed him on dieting and exercise to lose weight and decrease HTN and cholesterol, but he states he just hasn't had the energy to exercise or perform his usual hobbies. However, he has lost some weight even though he's not sure how much. Pt reports the pain wakes him up at night and can't seem to get comfortable and sitting for long periods of time at work bothers him. He says he recently started doing some of the stretches and light exercises that were given to him by his last therapist; they helped a little at first but doesn't seem to be making much of a difference. 

• Patient's Past Medical History:  Patient reports HTN and high cholesteral both managed medically.  He  Patient was hospitalized 10 years ago for infectious mononucelosis, and he reports his mother passing away from breast CA 10 years ago. Patient reports no other significant past medical history (liver, lungs, DM, kidneys), and he does not smoke and rarely drinks alcohol socially because he notices that drinking makes his pain worse. 
• Medications:  Prinivil, Crestor, and Aleve (prn)
• Patient Goals: His primary goal is to decrease his pain and increase his stamina so that he can return to fishing and working in his woodshop. 
• Self Report Outcome Measures: Numeric Pain Rating is 4 at best and 5 at worst and the pain is constant; Oswestry Disability Index (46%)
• Physical Performance Measure: 2 minute walk test, RPE: 16 (distance 125 meters; cardiovascular response WNL, decreased distance likely due to fatigue and need for rest breaks)
  

Objective :

• ROM: Lumbar ROM decrease 75% of normal, no increase in pain with movement; Hip ROM 75% of normal, no increase in pain with movement. All other ROM measurements within functional limits, no pain. 
• Reflexes: +2 for L3/4, L5, and S1
• Sensation: Normal
• MMT: 4+/5 on LE general exam
• Palpation: Hip pain not reproduced with palpation, pain over center of sacrum present with palpation, positive costell's percussion
• Special Tests: + Slump Test, SLR negative bilaterally, FABER decrease motion, pain negative bilaterally

Clinical Impressions

Mr. Hodgkin's presents to physical therapy with LBP and left hip pain. He has a history of LBP and has responded well to prior physical therapy. The symptoms that he presents with now are inconsistent with her former symptoms and inconsistent with pain of musculoskeletal causes. The following symptoms warrant the need for further systemic screening by his primary care physician: pain is constant and not reproduced with movement, fatigue present with low intensity activity, general malaise, history of cancer in primary family member, history of infectious mononucleosis, non-intended weight loss, and positive lumbar percussion test. 

Summarization of Examination Findings

1. Cancer - Metastasis to the Lumbar/Sacral Area

2. Lumbar radiculopathy referring pain to hip area

3. Reoccurence of Epstein Barr Virus/mononucleosis

Intervention

Mr. Hodgkin's returned to his PCP. After further medical screening and testing, he was diagnosed as having Hodgkin's lymphoma with metastasis to lumbar spine area (L5-S1). Patient began chemotherapy and radiation treatment after having surgery to remove pelvic malignant lymph nodes. He continued physical therapy per PCP order to increase cardiovascular/pulmonary health, improve strength and flexibility, improve lymphedema and reduce fatigue and symptoms produced from the cancer and treatments.

Phases of Interventions 

• Phase I - primary goal decrease fatigue, decrease risk of falling, and promote endurace. Intervention include patient education of fatigue managment, falls risk assessment, general aerobic exercise including cycle ergometer, ambulation, cycling (monitoring cardiovascular/pulmonary response), and stretching to promote flexibility. Begin lymph edema treatment and educate patient on lymph edema managment at home.Include balance training and address falls risk due to any vestibular issues or other balance issues caused by cancer treatment.
• Phase 2 - Continue stretching, general aerobic exercise program, and lymph edema management at home; begin progressive resistance exercise (PRE) to improve strength and promote function with ADLs and all community invovlement. Include interventions to improve functional movement and promote correct movement patterns (gait training, squat training, posture, ADLs)
• Phase 3: Promote independence with ADLs, IADLs and all strength training and aerobic exercises. Reintegration into community living. Address patient goals; promote patient's abiility to fish and continue wood working.

Dosage and Parameters:

• Aerobic training: Begin with low impact aerobic traning (cycle ergometer, bycycle) progressing to ambulation over ground. Begin at 10 minutes per day and progress to 30 minutes, 3-4 times/week.
• Strength and Resistance Training: Functional close chain exercises (mini-squats, lunge matrix, stair training, etc.) for LE, resistance band/weight training for posture stabilizers and UE, increase core strength). Perform 8-12 reps of each exercise, 2-3 sets, to point of fatigue but not beyond that point. 20-30 minutes, 2-3 times per week and progress as tolerated

Rationale for Progression

• Progress patients to maintain/improve level of fitness during treatment and promote overall better quality of life. Progress patient as he can tolerate, being aware of affects of medical treatment.Coordinate with PCP and oncologist.

Co-interventions:

• Chemotherapy, radiation, proper diet, and psychological counseling

Outcomes

Findings Over time

Discussion

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

Related Pages

Hodgkin's Lymphoma - Physiopedia

References

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