Musculoskeletal, Neurologic, and Cardiopulmonary Aspects of Physical Rehabilitation in Patients with Chronic Graft-versus-Host Disease

Chronic graft-versus-recipient disease: Systematic review of joint and fascial involvement

BACKGROUND AND OBJECTIVE

Chronic graft-versus-host disease (cGVRD) is a systemic immune-mediated complication that occurs in approximately half of the patients undergoing allogeneic haematopoietic stem cell transplantation (allo-HCT) and, although it is associated with beneficial graft versus tumour effects and lower relapse rates, it remains the leading cause of late morbidity and mortality in these patients. The aim of this systematic review of the literature is to provide a current overview on the diagnostic musculoskeletal manifestations of cGVRD, its clinical evaluation, and therapeutic possibilities.

METHODS

We ran a systematic search in PubMed, Embase, and Cochrane Library. Studies from the last 20 years were included. Priority was given to cross-sectional studies to evaluate diagnostic methods and to clinical trials in the case of articles referring to treatment. The search was limited to humans and articles published in English or Spanish.

RESULTS

We identified 6423 studies, of which we selected 86 (37 on clinical and diagnostic evaluation and 49 on treatments). Specific studies on fascial and joint complications are scarce and of low quality, including only isolated clinical cases or case series. Fasciitis is the most relevant musculoskeletal manifestation, and isolated joint involvement is low, sometimes unnoticed and underdiagnosed, if a thorough exploration of joint motion is not performed. Early detection of cGVRD with fascial and/or joint involvement requires careful and repeated evaluation.

CONCLUSIONS

The search for new biomarkers or advanced imaging techniques that allow early diagnosis is necessary. Physiotherapy is essential to improve functionality and prevent disease progression. Controlled studies are needed to establish recommendations on second lines of treatment. Because of its multisystemic nature, cGVRD requires a multidisciplinary approach.

Graft-Versus-Host Disease: an Update on Functional Implications and Rehabilitation Interventions

PURPOSE OF REVIEW

Despite advances in treatment, chronic graft-versus-host disease (cGVHD) remains a highly morbid complication of allogeneic hematopoietic stem cell transplantation. Due to direct effects of the disease on specific body sites, and its treatment, patients lose function. This review summarizes the latest evidence surrounding how cGVHD affects function, and restorative interventions.

RECENT FINDINGS

Different body sites of cGVHD carry a higher risk of functional decline, including pulmonary and sclerotic/fascial. Support should be comprehensive and individualized, with precautions taken to avoid worsening fibrosis, offloading painful joints and fractures, and utilizing function-directed skilled therapies. Inpatient rehabilitation improves function in hospitalized people with cGVHD. For people with cGVHD, rehabilitation addresses different aspects of impaired function across the spectrum of disease. Given the dynamic nature of the disease process, routine assessment may be warranted. Rehabilitation may also improve deleterious effects of anti-cGVHD medication including glucocorticoids and tyrosine kinase inhibitors.

Evaluation of a group-based exercise and relaxation rehabilitation program during hospitalization for allogeneic hematopoietic stem cell transplant

BACKGROUND

Exercise and relaxation interventions have demonstrated benefits in allogeneic hematopoietic stem cell transplant (allo-HSCT) patients; however, little is known about the implementation enablers and barriers for inpatient rehabilitation or its impact on health outcomes.

OBJECTIVE

To conduct a program evaluation of group-based rehabilitation consisting of exercise and relaxation classes for allo-HSCT inpatients.

DESIGN

Prospective program evaluation using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.

SETTING

Inpatient hospital unit at a tertiary care center.

PARTICIPANTS

Forty-five adult patients admitted for allo-HSCT.

INTERVENTIONS

Standard of care rehabilitation.

MAIN OUTCOME MEASURES

Program attendance, safety, satisfaction, and fidelity were assessed. Exploratory effectiveness analyses were conducted via the measurement of physical, psychosocial, clinical, and health resource use outcomes at hospital admission and discharge.

RESULTS

Forty-seven of the 63 patients receiving allo-HSCT between November 2019 and March 2020 were consented. Data presented in this publication are from the 33 participants who completed study assessments (high attrition due to cancellation of research during the COVID-19 pandemic). Eighty-two percent of participants attended at least one class; however, 55% of the participants invited to the classes on a daily basis were not able to attend. Barriers to participation included transplant complications, isolation for infection prevention, and fatigue. There were no adverse events associated with the intervention and 82% of participants adhered to the prescribed activities. Participants reported satisfaction with the program and enjoyed the motivational support and social interaction. Between hospital admission and discharge, anxiety scores improved; however, fatigue, depression, grip strength, functional mobility, and quality of life scores declined. Physical activity volume and lower body strength were maintained.

CONCLUSIONS

Group-based exercise and relaxation classes seem to be feasible and safe during hospitalization for allo-HSCT; however, there are pragmatic barriers to be considered for optimal program implementation. Further research examining program effectiveness and adoption is warranted.

Musculoskeletal Chronic Graft versus Host Disease-A Rare Complication to Allogeneic Hematopoietic Stem Cell Transplant: A Case-Based Report and Review of the Literature

Musculoskeletal graft versus host disease (GVHD) is a rare manifestation of chronic GVHD (cGVHD) following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Left untreated, the disease can cause extensive damage to muscle tissue and joints. We describe a 62-year-old male with musculoskeletal GVHD and generalized muscle pain and stiffness. In addition, we performed a systemic literature review based on published cases of musculoskeletal GVHD between 1983 and 2019. We identified 85 cases, 62% male and 38% female with an age of 4-69 years and median age of 39 years at diagnosis. The majority of patients (72%) also had manifestations of cGVHD in at least one other organ system, most frequently the skin (52%), followed by oropharyngeal mucosa (37%), and pulmonary and gastrointestinal tract (GI tract) (21%). We conclude that, while musculoskeletal cGVHD is a rare complication of allo-HSCT, it remains a serious and debilitating risk that must be considered in patients with muscle pain, muscle weakness, joint stiffness, and tissue inflammation. Early intervention is critical for the patient's prognosis.

Exercise training and NR supplementation to improve muscle mass and fitness in adolescent and young adult hematopoietic cell transplant survivors: a randomized controlled trial {1}

Background

Advances in hematopoietic cell transplantation (HCT) have led to marked improvements in survival. However, adolescents and young adults (AYAs) who undergo HCT are at high risk of developing sarcopenia (loss of skeletal muscle mass) due to the impact of HCT-related exposures on the developing musculoskeletal system. HCT survivors who have sarcopenia also have excess lifetime risk of non-relapse mortality. Therefore, interventions that increase skeletal muscle mass, metabolism, strength, and function are needed to improve health in AYA HCT survivors. Skeletal muscle is highly reliant on mitochondrial energy production, as reflected by oxidative phosphorylation (OXPHOS) capacity. Exercise is one approach to target skeletal muscle mitochondrial OXPHOS, and in turn improve muscle function and strength. Another approach is to use “exercise enhancers”, such as nicotinamide riboside (NR), a safe and well-tolerated precursor of nicotinamide adenine dinucleotide (NAD⁺), a cofactor that in turn impacts muscle energy production. Interventions combining exercise with exercise enhancers like NR hold promise, but have not yet been rigorously tested in AYA HCT survivors.

Methods/design

We will perform a randomized controlled trial testing 16 weeks of in-home aerobic and resistance exercise and NR in AYA HCT survivors, with a primary outcome of muscle strength via dynamometry and a key secondary outcome of cardiovascular fitness via cardiopulmonary exercise testing. We will also test the effects of these interventions on i) muscle mass via dual energy x-ray absorptiometry; ii) muscle mitochondrial OXPHOS via an innovative non-invasive MRI-based technique, and iii) circulating correlates of NAD⁺ metabolism via metabolomics. Eighty AYAs (ages 15-30y) will be recruited 6–24 months post-HCT and randomized to 1 of 4 arms: exercise + NR, exercise alone, NR alone, or control. Outcomes will be collected at baseline and after the 16-week intervention.

Discussion

We expect that exercise with NR will produce larger changes than exercise alone in key outcomes, and that changes will be mediated by increases in muscle OXPHOS. We will apply the insights gained from this trial to develop individualized, evidence-supported precision initiatives that will reduce chronic disease burden in high-risk cancer survivors.

Trial registration

ClinicalTrials.gov, NCT05194397. Registered January 18, 2022, https://clinicaltrials.gov/ct2/show/NCT05194397 {2a}.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09845-1.

Risk Factors of Graft-Versus-Host Disease in the Iranian Allogeneic Hematopoietic Stem Cell Transplantation: A 10-Year Experience

Background: Graft-versus-host disease (GVHD) is a serious complication associated with allogeneic hematopoietic stem cell transplantation (allo-HSCT). Thus, it is necessary to evaluate the risk factors of GVHD in allo-HSCT. Herein, we studied the effects of some risk factors on GVHD incidence in patients with allo-HSCT. Methods: We retrospectively evaluated the GVHD incidences and risk factors in 199 patients diagnosed with hematological disorders who underwent allo-HSCT in Taleghani hospital, Tehran, Iran, between 2007 and 2017. The univariable and multivariable analyses of time to event data were performed using the Logistic regression model. Computations were performed using SAS, and the level of statistical significance for univariable and multivariable analyses was set at 20% and 10%, respectively. Results: Acute GVHD (aGVHD) was seen in 59 (29.6%) patients, and 18 (9%) patients developed chronic GVHD (cGVHD). The odds of GVHD incidence in male to female transplants was 3.49 times greater than the male-to-male transplantations (CI, 1.16, 11.5; p<0.001). The patients with body mass index (BMI) below 18.5 had 96% lower odds of GVHD incidence compared with those with BMI above 30 (CI, 0.007-0.27; p=0.013). The odds of GVHD incidence in patients who were negative for cytomegalovirus (CMV) antigen was 76% lower than patients with positive CMV antigen (CI, 0.06-0.93; p=0.081). Conclusion: In a nutshell, our results indicated that the donor-recipient gender disparity, the recipient's BMI, and CMV infection/reactivation status might be pivotal risk factors, which should be taken into account for prevention and management of GVHD.

Rehabilitation after Allogeneic Haematopoietic Stem Cell Transplantation: A Special Challenge

Simple Summary

After undergoing an allogeneic haematopoietic stem cell transplantation (alloHCT), patients need intensive physiological and psychological rehabilitation. This should start immediately after discharge from the transplant ward as in- or outpatient rehabilitation. The rehabilitation centres should be qualified and experienced because this patient group exhibits problems that differ from those of patients who have undergone oncological therapies or autologous HCT. An experienced multidisciplinary team in close consultation with the primary transplantation centre should perform the rehabilitation therapy. This review will show the special challenges of these patients according to different timepoints after HCT. Because there is so little data available, personal experience and general guidelines on patient care after alloHCT are presented.

Abstract

The general population is getting older and suffer more haematological malignancies despite being physically fit. These malignancies are mainly only curable via an alloHCT, and they are now carried out more frequently. Patients benefit from intensive rehabilitation earlier and may need it repeatedly in cases of severe side effects (e.g., graft-versus-host disease). They can suffer many problems that other cancer patients do not experience, such as severe infections, continued immunosuppression, nutritional restrictions, acute or chronic GvHD, or organ impairments (e.g., lung, eyes). They may also encounter various associated psychological problems, e.g., feeling like a chimera. Rehabilitation centres willing to care for patients after alloHCT should have an experienced multidisciplinary team and should work in close co-operation with the primary transplant centre.

Clinical characterization and cytokine profile of fatigue in hematologic malignancy patients with chronic graft-versus-host disease

Limited information is available regarding clinical and biological properties of fatigue in patients with chronic graft-versus-host disease (cGvHD). Patients with moderate-to-severe cGvHD per NIH criteria were enrolled on a cross-sectional study and categorized as "fatigued" if SF-36 vitality score was <40. Clinical and laboratory parameters of fatigued (n = 109) and nonfatigued patients (n = 72) were compared. In univariate analysis, walk velocity, NIH joint-fascia score, human activity profile, and SF-36 physical and mental health self-report scales were correlates of fatigue. No cGvHD biomarkers were associated with fatigue. NIH joint score, Lee sleep and depression questions, and PG-SGA activities and function score jointly predicted fatigue. Though higher rates of depression and insomnia were reported in the fatigued group, antidepressant or sleep aid use did not differ between groups. Survival ratio was not significantly different by fatigue status. Pathophysiology of fatigue in patients with cGvHD is complex and may involve mechanisms unrelated to disease activity. Patients with cGvHD experiencing fatigue had higher rates of untreated depression and insomnia, highlighting the need to focus clinical management of these conditions to improve health-related quality of life.

Understanding the Process and Challenges for Return-to-Work Post-Hematopoietic Cell Transplantation from a Musculoskeletal Perspective: A Narrative Review

The current paper seeks to inform healthcare professionals on how adapting various components of return to work (RTW) programs that are already in use by other musculoskeletal rehabilitation settings can help optimize return to work process for patients with or without musculoskeletal manifestations, posthematopoietic cell transplantation. Since there is no universally agreed RTW structure for hematopoietic cell transplant patients, a narrative approach has been taken utilizing evidence from the existing musculoskeletal return to work assessment publications to help draw parallel for the hematopoietic cell transplant patients. Databases were searched including PUBMED, CINHAL, AMED, SCOPUS, and Cochrane using keywords RTW, functional restoration program, hematopoietic cell transplant, bone marrow transplant, stem cell transplant, and musculoskeletal functional assessment. The authors have managed to outline and propose a structured RTW assessment and monitoring program which can aid in getting patients back to employment by utilizing the functional capacity and job evaluation to help hematopoietic cell transplantation patients reintegrate socially. Patients undergoing hematopoietic cell transplant require additional support and a robust assessment system to allow safe RTW. The proposed model of RTW assessment can prove to be beneficial in helping patients return to work safely. Clinical Significance. To acknowledge the individuality in functional limitation is important in determining not only the rehab needs but also the RTW capabilities. The proposed RTW plan not only promotes an individualized approach to patients but also provides a structure for return to work assessments for hematopoietic cell transplantation patients, thus, eliminating the need for guess work by healthcare professionals. In line with the International Classification of Functioning, Disability, and Health (ICF) recommendations, a RTW assessment combined with a job evaluation helps healthcare professionals and stakeholders to understand the unique challenges and strengths of a patient and thereby design an individualized therapy approach.

Should healthcare organisations offer ongoing rehabilitation services for patients undergoing haematopoietic cell transplant? A narrative review

Purpose

Hematopoietic stem cell transplant (HSCT) patients can suffer from long-term transplant-related complications that affect their quality of life and daily activities. This study, a narrative review, aims to report the impact of HCT complications, the benefits of rehabilitation intervention, the need for long-term care and highlights the research gap in clinical trials involving rehabilitation.

Design/methodology/approach

A comprehensive search strategy was performed on several databases to look for relevant articles published from 1998 to 2018. Articles published in English with the following terms were used: hematopoietic stem cell transplant, chronic graft-versus-host disease, rehabilitation, exercise, physical therapy, occupational therapy. A patient/population, intervention, comparison, and outcomes (PICO) framework was employed to ensure that the search strategies were structured and precise. Study year, design, outcome, intervention, sample demographics, setting and study results were extracted.

Findings

Of the 1,411 records identified, 51 studies underwent title/abstract screening for appropriateness, 30 were reviewed in full, and 19 studies were included in the review. The review found that, for the majority of patients who underwent HSCT and developed treatment-related complications, rehabilitation exercises had a positive impact on their overall quality of life. However, exercise prescription in this patient group has not always reflected the scientific approach; there is a lack of high-quality clinical trials in general. The review also highlights the need to educate healthcare policymakers and insurance companies responsible for rationing services to recognise the importance of offering long-term follow-up care for this patient group, including rehabilitation services.

Practical implications

A large number of HSCT patients require long-term follow-up from a multidisciplinary team, including rehabilitation specialists. It is important for healthcare policymakers and insurance companies to recognise this need and take the necessary steps to ensure that HSCT patients receive adequate long-term care. This paper also highlights the urgent need for high-quality rehabilitation trials to demonstrate the feasibility and importance of rehabilitation teams.

Originality/value

Healthcare policymakers and insurance companies need to recognise that transplant patients need ongoing physiotherapy for early identification of any functional impairments and appropriate timely intervention.

Gait Analysis of Patients After Allogeneic Hematopoietic Cell Transplantation Reveals Impairments of Functional Performance

Background: After allogeneic hematopoietic cell transplantation (alloHCT), patients often report functional impairments like reduced gait speed and muscle weakness. These impairments can increase the risk of adverse health events similar to elderly populations. However, they have not been quantified in patients after alloHCT (PATs). Methods: We compared fear of falling (Falls Efficacy Scale–International) and temporal gait parameters recorded on a 10-m walkway at preferred and maximum gait speed and under dual-task walking of 16 PATs (aged 31-73 years) with 15 age-matched control participants (CONs) and 17 seniors (SENs, aged >73 years). Results: Groups’ gait parameters especially differed during the maximum speed condition: PATs walked slower and required more steps/10 m than CONs. PATs exhibited greater stride, stance, and swing times than CONs. PATs’ swing time was even longer than SENs’. The PATs’ ability to accelerate their gait speed from preferred to fast was smaller compared with CONs’. PATs reported a greater fear of falling than CONs and SENs. Conclusion: Gait analysis of alloHCT patients has revealed impairments of functional performance. Patients presented a diminished ability to accelerate gait and extending steps possibly related to a notable strength deficit that impairs power-generation abilities from lower extremities. Furthermore, patients reported a greater fear of falling than control participants and even seniors. Slowing locomotion could be a risk-preventive safety strategy. Since functional disadvantages may put alloHCT patients at a higher risk of frailty, reinforcing appropriate physical exercises already during and after alloHCT could prevent adverse health events and reduce the risk of premature functional aging.

Proceedings From the Global Cardio-Oncology Summit: The Top 10 Priorities to Actualize for CardioOncology

The discipline of cardio-oncology has expanded at a remarkable pace. Recent developments and challenges to clinicians who practice cardio-oncology were presented at the Global Cardio-Oncology Summit on October 3 to 4, 2019, in São Paulo, Brazil. Here, we present the top 10 priorities for our field that were discussed at the meeting, and also detail a potential path forward to address these challenges. Defining robust predictors of cardiotoxicity, clarifying the role of cardioprotection, managing and preventing thromboembolism, improving hematopoietic stem cell transplant outcomes, personalizing cardiac interventions, building the cardio-oncology community, detecting and treating cardiovascular events associated with immunotherapy, understanding tyrosine kinase inhibitor cardiotoxicity, and enhancing survivorship care are all priorities for the field. The path forward requires a commitment to research, education, and excellence in clinical care to improve our patients' lives.

The Association of Performance Status and Disease Severity in Patients With Chronic Graft-vs-Host Disease

OBJECTIVE

Determine the relationship between functional status and degree of specific organ involvement, physical performance, and subjective well-being chronic graft-vs-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation.

DESIGN

Observational cohort.

SETTING

Outpatient clinic.

PARTICIPANTS

Adult patients (N=121) with cGVHD with 634 assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Karnofsky Performance Status (KPS). Skin, fascia/joints, lungs, upper and lower extremity range of motion, liver, eye, mucosal, and gastrointestinal involvement were measured using the National Institutes of Health GVHD scale. Physical performance was assessed with the 2-minute walk test (2MWT) and hand grip strength. Subjective measures were the Patient Health Questionnaire 9 (PHQ-9) and Lee Symptom Burden (LSB) scale.

RESULTS

Myofascial (P<.001) and lung (P=.001) involvement, 2MWT (P<.001), LSB (P<.001), and PHQ-9 (P=.03) had the largest associations with KPS with liver (P=.05) and hand grip strength (P<.001) more modest associations with KPS.

CONCLUSIONS

Patients with cGVHD experience multifactorial impairment in function associated with potentially modifiable symptoms physiatrists have the expertise to address to enhance function. More research is needed to determine rehabilitation interventions to mitigate the impact of cGVHD on function.

Rehabilitation in Chronic Graft-Versus-Host Disease

Chronic graft-versus-host disease is a potentially debilitating complication of allogeneic hematopoietic stem cell transplantation. Due to the direct inflammatory effects of the disease on tissue, and the impact on muscle and bone of the high-dose glucocorticoid immunosuppression used to treat the disease, patients are at risk of developing multifactorial functional impairment. This review outlines the clinical assessment and rehabilitation interventions to manage aspects of the disease that cause the most impairment: involvement of the skin/fascial and cardiopulmonary organ systems, as well as steroid-induced myopathy and bone and joint destruction.

Palliative care during and following allogeneic hematopoietic stem cell transplantation

PURPOSE OF REVIEW

The purpose of this review is to synthesize recent literature regarding the provision of palliative care to patients during and following allogeneic hematopoietic stem cell transplantation (HSCT), highlighting factors which mediate impairments in health-related quality of life in this patient population, and the intervention approaches and models of care delivery that clinicians can consider to address unmet needs for palliative care and to strengthen patient and family resiliency.

RECENT FINDINGS

Provision of palliative care simultaneous with the delivery of treatment directed at the underlying malignancy has emerged as a recommended practice for patients with advanced cancer and high-symptom burden, and a recent randomized trial demonstrates the effectiveness of early palliative care in reducing some of the symptom burden and mood disturbances associated with HSCT. Although more research is needed, there is an expanding body of research-tested interventions to ameliorate the physical and psychological morbidity of HSCT across the transplant trajectory.

SUMMARY

Palliative care interventions delivered by an interdisciplinary team that includes transplant clinicians and palliative care across the HSCT trajectory can alleviate physical and psychological morbidity, thereby improving the patient and family experience of HSCT.

Functional Outcomes of Acute Inpatient Rehabilitation in Patients With Chronic Graft-Versus-Host Disease

BACKGROUND

Growing numbers of allogeneic stem cell transplants and improved posttransplant care have led to an increase of individuals with chronic graft-versus-host disease (cGVHD). Although cGVHD leads to functional impairment for many, there is limited literature regarding the benefits of acute inpatient rehabilitation for patients with cGVHD.

OBJECTIVE

To assess Functional Independence Measure (FIM) outcomes of patients with cGVHD during acute inpatient rehabilitation and to compare inpatient rehabilitation outcomes with patients with burn injuries, a rehabilitation patient population with similar comorbidities.

DESIGN

Retrospective chart review.

SETTING

Acute rehabilitation center at a large academic medical center.

PATIENTS (OR PARTICIPANTS)

A total of 37 adult patients with cGVHD and 30 with burn injuries admitted to inpatient rehabilitation from 2010 to 2015.

METHODS OR INTERVENTIONS

Linear regression analysis to evaluate group (cGVHD versus burn) differences in functional gains. Effect size and minimal detectable change at the 90% confidence level (MDC90) were used to evaluate change in FIM outcomes.

MAIN OUTCOME MEASUREMENTS

Total FIM gain, motor FIM gain, and FIM efficiency.

RESULTS

Patients with cGVHD had statistically significant lower functional gains than patients with burn injuries, with an average of 11.66 fewer total FIM points (P ≤ .001), 10.54 fewer motor FIM points (P = .01), and 2.45 units less of FIM efficiency (P = .01). At the time of discharge, 7 (18%) patients with cGVHD exceeded the MDC90 values for total FIM gain versus 9 (30%) patients with burn injuries (P = .26). Eight (21%) patients with cGVHD exceeded the MDC90 for motor FIM gain versus 13 (43%) patients with burn injuries (P = .048). Effect sizes for patients with cGVHD and with burn injury were moderate to large, respectively, with patients with burn injuries having nearly twice the magnitude of gains as patients with cGVHD.

CONCLUSIONS

Despite achieving more modest functional gains than patients with burn injuries, patients with cGVHD improved in function after acute inpatient rehabilitation. If replicated in larger studies, patients with functional impairment from cGVHD can be considered for inpatient rehabilitation. Future work should also determine minimal clinically important differences in function gain from inpatient rehabilitation for patients with cGVHD.

LEVEL OF EVIDENCE

II.

Joint and fascial chronic graft-vs-host disease: correlations with clinical and laboratory parameters

Aim

To determine if there are correlations between joint and fascial chronic graft-vs-host disease (cGVHD) with clinical findings, laboratory parameters, and measures of functional capacity.

Methods

29 patients were diagnosed with cGVHD based on National Institutes of Health (NIH) Consensus Criteria at the University Hospital Centre Zagreb from October 2013 to October 2015. Physical examination, including functional measures such as 2-minute walk test and hand grip strength, as well as laboratory tests were performed. The relationship between these evaluations and the severity of joint and fascial cGVHD was tested by logistical regression analysis.

Results

12 of 29 patients (41.3%) had joint and fascial cGVHD diagnosed according to NIH Consensus Criteria. There was a significant positive correlation of joint and fascial cGVHD and skin cGVHD (P < 0.001), serum C3 complement level (P = 0.045), and leukocytes (P = 0.032). There was a significant negative correlation between 2-minute walk test (P = 0.016), percentage of cytotoxic T cells CD3+/CD8+ (P = 0.022), serum albumin (P = 0.047), and Karnofsky score (P < 0.001). Binary logistic regression model found that a significant predictor for joint and fascial cGVHD was cGVHD skin involvement (odds ratio, 7.79; 95 confidence interval 1.87-32.56; P = 0.005).

Conclusion

Joint and fascial cGVHD manifestations correlated with multiple laboratory measurements, clinical features, and cGVHD skin involvement, which was a significant predictor for joint and fascial cGVHD.

Developing High-Quality Cancer Rehabilitation Programs: A Timely Need

The number of survivors of cancer in the United States, already 14.5 million, is growing with improved cancer treatment and aging of the population. Two-thirds of cancer survivors will be older than age 65 and are likely to enter cancer treatment already deconditioned and with multiple comorbidities. Survivors of cancer face numerous adverse consequences of cancer treatment that add to or exacerbate the effects of existing comorbidities and increase risk of functional decline. Many of these problems are amenable to rehabilitation interventions, but referral to cancer rehabilitation professionals is not a standard part of care. We present an expanded prospective model of surveillance, cancer rehabilitation assessment, and referral efforts using a multidisciplinary team approach. In this model, cancer rehabilitation begins at the time of cancer diagnosis and continues through and beyond cancer treatment. Physical impairments and psychosocial symptoms are assessed and treated, and lifestyle and exercise interventions are provided to optimize functioning, health, and quality of life. We present a stepped-care framework to guide decisions on when, how, and where to refer survivors to cancer rehabilitation specialists depending on safety requirements and needs. This model has the potential to result in early identification of symptoms and impairments, appropriate referral and timely treatment, and, in turn, will better address and minimize both acute and long-term cancer morbidity.

Rehabilitative intervention during and after pediatric hematopoietic stem cell transplantation: An analysis of the existing literature

Hematopoietic stem cell transplantation is a therapeutic strategy for several oncohematological diseases. It increases survival rates but leads to a high incidence of related effects. The objective of this paper was to examine the existing literature on physical exercise interventions among pediatric HSCT recipients to explore the most often utilized rehabilitative assessment and treatment tools. Studies published from 2002 to April 1, 2015 were selected: 10 studies were included. A previous literary review has shown that rehabilitation programs have a positive impact on quality of life. Our analysis identified some significant outcome variables and shared intervention areas.

Distress prior to undergoing hematopoietic stem cell transplantation: demographic and symptom correlations and establishing a baseline

BACKGROUND

Distress can arise from physical and/or psychosocial impairments and has been documented in patients after hematopoietic stem cell transplantation in the outpatient setting. It has not been evaluated in inpatients admitted to undergo the transplant, nor has potential correlations with length of hospital stay, physical function, and pain after receiving the transplant.

OBJECTIVES

To measure distress in patients admitted to the hospital to undergo hematopoietic stem cell transplantation, and to evaluate potential correlations with length of hospital stay, physical function, pain, and depression/anxiety.

METHODS

Eighty patients were given a questionnaire to report levels of distress and physical and psychosocial functioning. Hierarchical multiple regression analysis was used to test the relationship of demographic and transplant factors with length of stay (LOS), distress, presence of pain, and depression/anxiety.

RESULTS

Patients reported pretransplant distress with an average score of 2.2 out of 10, and 16 out of 80 patients reported clinically relevant distress. Pain was reported by 42.5% of patients, and 28.8% reported depression/anxiety. Physical functioning was generally high. Distress was correlated with depression/anxiety (P-value <0.01) and pain (0.04) but not with LOS, physical function, patient age, or transplant type.

CONCLUSION

LOS after receiving stem cell transplant was not related to pretransplant distress. Distress exists pretransplant but is generally low. Pain and the presence of depression/anxiety may be risk factors for distress. Measuring distress prior to transplant gives a baseline from which to measure changes, potentially leading to earlier intervention.