leukemia

Introduction

Acute lymphoblastic leukemia is a malignant proliferation of white blood cells that begins in the bone marrow and spills over into the blood stream, involving other organs in the process. The leukemic cells crowd out normal blood cells, Resulting in anemia, susceptibility to infection, and bruising (Wright et al., 2005).

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy accounting for approximately 26% of all childhood cancer (San Juan et al., 2007). 

Cure rate exceeding 80 % have been achieved with the use of protocols using multiage chemotherapy and prophylactic central nervous system (CNS) interventions (Wright et al., 2005).

As survival rates have increased for children with acute lymphoblastic leukemia (ALL). There is increasing attention to short term –complication and long –term out comes from cancer itself or the antineoplastic agents. neuromuscular and musculoskeletal complications include pain , parathesias, reduced deep tendon reflexes , muscle cramps , muscle weakness , reduced ankle dorsiflexion , impaired gross and fine motor performance ,  decreased energy expenditure , learning disabilities , avascular necrosis , osteopenia , and osteoporosis   (Marchese et al ., 2003).

Fatigue is the most frequently reported symptoms by persons with cancer, the problem affects up to 96 % of patient receiving chemotherapy, 78% of patient receiving radiotherapy and up to 80% of patient with advanced malignancy (Al-Majid and McCarthy, 2001).

Physical therapy intervention for children with ALL receiving  maintenance chemo therapy  improved body function important to normal gait  , physical therapy programs initiated earlier in treatment and with greatest emphasis on endurance activities may also  improve stamina and quality  of life ( Marchese et al ., 2003 ).

The physical fitness (as reflected by VO2  peak level) of ALL surviving tend to be reduced compared to healthy children impaired physical fitness lead to early fatigue during activities and can severely deteriorate the quality of life (QOL) of all survivors which suggest the need  for these  children to engage in regular physical activities .Exercise physiologist could assist oncologists in prescribing exercise program for attenuating cancer related fatigue and help Improve the physical fitness and QOL of children surviving cancer .Furthermore there are scientific indication that exercise training improve the function of immune system component ,and can attenuate tumor development (Brussel et al.,2005).

Statement of the Problems:

The ALL is a very prevalent socially disabling problem and is the most commomn childhood malignancy that lead to early fatigue and impairment of physical fitness during daily activities and severely deteriorate the quality of life. Therefore, from the rehabilitative point of view the problem of this study was stated in a questionery form:

 Does the exercise program play a vital role in treatment of children with acute lymphoblastic leukemia?  

Purpose of the Study:

The aim of this study was to evaluate the therapeutic efficacy of exercise training as a type of physical therapy approach in improving the cardiopulmonary endurance, the muscle strength, the cancer related fatigue and quality of life (QOL) by using three methods of assessment which were exercise test, hand-held dynamometry and Iowa fatigue scale.   

Significant of the Study:

The need for the present study developed from lack of quantitative information in the published literatures related to ideal and benefits of exercise therapy in cases of acute lymphoblastic leukemia. The importance of this study arises from the severity of lymphoblastic leukemia which leads to serious problems such as neuromuscular and musculoskeletal complications include pain, fatigue, muscle weakness, impaired gross and fine movement motor reflex.

Leukemia accounts for 30% of cases in children 0 to 14 and 25% of cancer occurring before age 20. Acute lymphoblastic leukemia (ALL) is the most child hood cancer (Ladha et al., 2006).

A malignant disease or its treatment may cause long term impairment in intellectual, emotional, and physical domains that diminish function (performance limitation). Performance limitation can restrict the survivors' ability to participate fully in daily activities necessary for self care, home management, or work participation restriction, delayed consequence of therapy of physical interest in children with cancer because of the potential remaining years of life that may be affected (                Ness et al., 2005).  

This present study assists to prove that physical therapy procedures especially exercise program is very effective and important line in the treatment package of acute lymphoblastic leukemia.

Delimitation:

This study was delimited to the following respect:

Subjects:

Forty children with acute lymphoblastic leukemia participated in the study; their ages were ranged from 6 to 12 years.

Equipment and Tools:

Measurement Tools:

·        Exercise test used to measure maximum functional capacity and endurance of cardio respiratory system.

·        Hand-held dynamometry(HHD) have been used to assess the  muscle strength  of both upper and lower body.

·        Iowa fatigue scale has been used to assess the fatigue.

Therapeutic Equipment and Tools:

·        Strength training include exercise engaging the major muscle groups (bench press , shoulder press , leg press, leg press, abdominal crunch , low back extension , arm curl , elbow extension).

·        Stretching exercises of the muscle involved in the previous exercises was performed.

·        Aerobic exercise consisted of pedaling a cyclic ergometer, running and walking on treadmill.

Limitations:

 This study was limited by the following factors:

·        The effect of environmental variable during treatment time such as unmentioned diseased or infection.

·        Psychological status of the patients at the times of measurement and treatment might affect the results.

·        Individual difference in patients and their influence on treatment program.

·        Possible human error in measurement.

·        Co-operation of child with therapist was a vital factor of level of understanding and the degree of awareness of the treatment.

·        Cancer pain might affect the performance of the child.

Hypothesis:

It was hypothesized that exercise training as a physical therapy intervention are not effective treatment approach in

·        improving the  cardiopulmonary endurance and physical fitness ,

·        improving the muscle strength ,

·        Improving the cancer related fatigue and quality of life (QOL).

Basic Assumptions:

It was assumed that

·        All information that has been taken from the patients was correct.

·        All patients received the same routine of medical treatment and equivalent care.

·        The patient of the study group received equal time of treatment.

·        All patients followed the instructions and advices during treatment.

·        All patients were under the same psychological and mental conditions and situations.

·        Both evaluative and therapeutic tools were valid.

Definition of Terms:

The following terms are defined for a clear understanding of the terminology used in the present study:

Acute Lymphoblastic Leukemia:

Acute lymphoblastic leukemia is a malignant proliferation of white blood cells that begins in the bone marrow and spills over into the blood stream, involving other organs in the process. The leukemic cells crowd out normal blood cells .resulting in anemia, susceptibility to infection, and bruising (Wright et al., 2005).

Aerobic Exercise:

Defined as the rhythmical contraction and relaxation of large masses over an extended time (Dimeo et al., 1997).

Cancer -Related Fatigue:

Cancer –related fatigue (CRF) has been operationally defined by the national comprehensive cancer network (NCCN) as a persistence, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning (Mock et al., 2001).

Muscular Strength:

          Muscular strength is a force or torque produced by muscle during a maximal voluntary contraction (Deusen and Brunt, 1997).

Quality of Life:

          The term ''quality of life and more specifically-related quality of life ''refer to the physical and social domains of health that are influenced by disease process (Testa and Simonson, 1999).

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Chilblains(erythema pernio)

Chilblains can also be referred to as Pernio or Perniosis. They most commonly present as itchy red bumps on the toes, fingers, ears or nose. They might appear after they have been subjected to extremely cold temperatures. A possible reason why people get Chilblains is due to poor circulation of the affected area. This might include the way in which the body adapts when subjected to cold weather. The small blood vessels underneath the skin of the extremities (i.e. the fingers) will naturally begin to narrow when the temperature is colder and in order to allow less blood to flow through and reach the skin. When you suddenly come in from the cold weather to warm up, your blood vessels will want to increase in size in order to increase the amount of blood that reaches the skin. When the blood vessels do this very quickly, small amounts of blood might leak through the blood vessels and sit underneath your skin of your fingers and toes, and, this will appear swollen and will possibly be painful. These swollen and inflamed bumps on the skin are Chilblains
Chilblains are common and may occur in people from a variety of ages and backgrounds.

Aetiology:
1-Atherosclerosis,buergers s disease,raynaud s phenomenon and arteries.
2-disorder of calciun metabolism.
3-deficiency of some substance in the blood.
Medical:
1-vasodilators drugs, and correction of blood calcium content.
2-aviodance of exposure to cold.
3-penicillin ointment is often used in a broken skin.


Physical Therapy:
1-galvanic or sinusoidal bathes
2-calcium ionization by iontophoresis
3-ultraviolet light.
4-zinc ionization by iontophoresis in skin lesions and small ulcers.
5-exercises .
6-reflex heating.
carbachol ionization.

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Varicose veins

Definition; they are dilated, twisted,elongated superficial veins that look blue In the lower limb

They are produced by incompetent valves and increased intraluminal pressure

Varicose veins affect 1 out of 2 people over age 50. They are more common in women than men.

The normal veins are taut, however if the blood flow is too sluggish, the veins slowly get dilated and tortuous in order to accommodate more blood in the lumen. Another possible reason is that the valves in the vein do not function properly and the blood leaks down with gravity and collects in the veins of the legs.

classification

 1-primary varicose vein

Primary varicose veins from result hereditary weekness of the vein wall and vakves

2-secondry varicose veins

They are sequel to deep venous thrombosis

Coditions lead to varicose veins

·  standing for long periods of time

    being overweight

    age – they appear more often as people grow older

sex – they are more common in women

going through a pregnancy

    Signs and Symptoms: • May be asymptomatic • Pain in leg • Leg fatigue

    • Leg heaviness

     • Visible dilated veins

     • Feeling of heat in the leg

     • Edema

     • Itching over affected area

    • Stasis ulcers

Evaluation

trendelenburg test

aim

this test is used to determine valves incompetence of great saphenous, deep and communicating veins

Procedure

The patient lies supine and the leg is elevated 15 second to empty all varocasities

Asoft rubber tourniquet is applied to the leg just below the knee and the patient stand

Interpertation

Normally

The saphenous vien should fill slowly from below in 30 second , with the tourniquet in the place

Abnormally

Filling from above indicate retrograde flow

After 30 seconds the tourniquet is removed , any sudden filling indicates incompetence of great saphenous vein valves

Immediate filling of varicosities despite atourniquet above them, indicates incompetent deep and communicating veins

    Doppler test is an ultrasound technique that uses sound waves to produce an image of the inside of your leg. This gives your doctor information about the direction of blood flow in your vein and whether your valves are working properly.

    Colour duplex ultrasound scanning is used to look for any abnormalities in the structure of your vein, and to look at the bloodflow through it.

Complication

    Thrombophlebitis – your superficial veins can become painful and reddened due to inflammation or blockage of your veins.

    Bleeding – your varicose veins can bleed if you cut or bump your leg. You should raise your leg above the level of your heart and apply pressure to the bleeding area to help stop the bleeding.

    Varicose eczema – this is brown or purple discolouration of the skin that often becomes permanent.

    Venous ulcers – you can get ulcers when fluid leaks out of the varicose vein into the surrounding tis

Treatment

Non surgical treatment

Sclerotherapy

Include injection of chemical into your varicose veins which damages the veins, causing them to close. Liquid sclerotherapy is often used to treat smaller varicose veins. For larger veins, foam sclerotherapy is sometimes used.

Laser therapy

continuous stream of high-intensity light to cut or destroy tissue. However, the usefulness of this therapy has not yet been determined. Intense pulsed light therapy can be used to treat small spider veins. This therapy is similar to laser therapy except that the light is applied in short bursts.

Surgical treatment

    Ligation and stripping – the vein is cut and tied off (ligation). Stripping the vein involves inserting a slender instrument into the vein through a small incision. The vein is then pulled out through a second incision.

    Phlebectomy – small incisions are made, and the veins removed with a special hook.

Physiotherapy

Positioning

The patient lies on bed with the legs vertical supported by the wall

He practice this method for 20 minutes at least twice daily

The effect of this position is to reduce edema by removing gravitational effect and reduce venous hypertention

Pandaging

Augment the muscle pump mechanism and support distended veins

Elastic stocking

Compression stockings are elastic stockings that squeeze your veins and stop excess blood from flowing backward. In this way, compression stockings also can help heal skin sores and prevent them from returning. You may be required to wear compression stockings daily for the rest of your life. For many patients, compression stockings effectively treat varicose veins and may be all that are needed to relieve pain and swelling and prevent future problem.

Massage

It is effective in reducing edema though time consuming

Slow ,firm effleurage massage start from proximal to distal to edema

We can use slow kneading and squeeze kneading to soften the edema

Care must be taken to avoid ulcer

How to prevent varicose veins?

    Avoiding crossing the legs when sitting.

    Maintaining a healthy body weight.

    Avoiding tight clothing that constricts the legs, groin or waist eg: knee high pantyhose.

    Avoiding constipation.

    When standing for long periods, shifting weight from one leg to the other every few minutes.

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