An Exploratory Study on Physical Function in Stem Cell Transplant Patients Undergoing Corticosteroid Treatment for Acute Graft-Versus-Host-Disease

Glucocorticoid-Induced Myopathy: Typology, Pathogenesis, Diagnosis, and Treatment

Glucocorticoid-induced myopathy is a non-inflammatory toxic myopathy typified by proximal muscle weakness, muscle atrophy, fatigue, and easy fatigability. These vague symptoms coupled with underlying disorders may mask the signs of glucocorticoid-induced myopathy, leading to an underestimation of the disease's impact. This review briefly summarizes the classification, pathogenesis, and treatment options for glucocorticoid-induced muscle wasting. Additionally, we discuss current diagnostic measures in clinical research and routine care used for diagnosing and monitoring glucocorticoid-induced myopathy, which includes gait speed tests, muscle strength tests, hematologic tests, bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA), computed tomography (CT), magnetic resonance imaging (MRI), electromyography, quantitative muscle ultrasound, histological examination, and genetic analysis. Continuous monitoring of patients receiving glucocorticoid therapy plays an important role in enabling early detection of glucocorticoid-induced myopathy, allowing physicians to modify treatment plans before significant clinical weakness arises.

IMPROVE-BMT: A Pilot Randomized Controlled Trial of Prehabilitation Exercise for Adult Hematopoietic Stem Cell Transplant Recipients

Background: There is limited evidence on the effects of aerobic and resistance training exercise interventions to improve physical function and patient-reported outcomes prior to autologous and allogeneic hematopoietic stem cell transplant (HSCT). IMPROVE-BMT was a single-site, pilot randomized controlled trial investigating the feasibility, acceptability, and safety of a pragmatic resistance training exercise program prior to HSCT compared to usual HSCT care. Secondary aims included differences in physical function between the exercise group (EX) and usual care control group (UC). Methods: Outcome measurements were assessed: prior to HSCT, on/around day of HSCT admission, +30 days post-HSCT, and +100 days post-HSCT. The exercise intervention was a home-based exercise program that incorporated resistance-band and bodyweight exercises. Results: Acceptability among participants was 83%; exercise adherence averaged at 92%; and there were zero exercise-related adverse or serious adverse events. The average pre-transplant exercise phase was 6.28 weeks (2.71-18.29 weeks). EX (n = 36) demonstrated larger increases in the six-minute walk test distance, short physical performance battery scores, and 30-s chair stands compared to UC (n = 38) and demonstrated significant within-group improvements for the six-minute walk test, the short physical performance battery, the 30-s chair stands, and the timed up-and-go test. Conclusions: IMPROVE-BMT demonstrates that pragmatic exercise is highly feasible for HSCT recipients and can potentially lead to enhanced recovery that may not be achievable in non-exercisers.

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.

Impact of Resistance Exercise and Nutritional Endorsement on physical performance in patients with GvHD (IRENE-G study) - design and rational of a randomized controlled trial

BACKGROUND

Graft-versus-host disease (GvHD) remains a major complication and limitation to successful allogeneic hematopoietic stem cell transplantation. Treatment of GvHD is challenging due to its heterogeneous nature of presentation, with steroids remaining the established first-line treatment. Long-term doses of systemic corticosteroids have many well-known side-effects including muscle atrophy. Despite the fact that reports in non-cancer clinical populations treated with glucocorticoids demonstrated that resistance training can reverse atrophy and weakness, no RCT has evaluated the potential of resistance training on preventing the disease- and treatment-induced loss of skeletal muscle mass and function in GvHD patients yet. In this context, ensuring adequate nutrition is important as protein deprivation may accelerate the wasting process. As GvHD patients are commonly found to be malnourished, nutritional medical care should be considered when investigating the effect of exercise in GvHD patients. Therefore, the aim of the present "Impact of Resistance Exercise and Nutritional Endorsement on physical performance in patients with GvHD" - Study (IRENE-G) is to evaluate the effects of resistance exercise in combination with nutritional endorsement on physical, nutritional and patient-reported outcomes in GvHD patients.

METHODS

IRENE-G is a 24-week prospective interventional RCT. One hundred twelve participants will be randomly allocated (1:1) to one of two arms: resistance exercise and nutritional optimization (experimental) vs. nutritional optimization only (control). Participants in the experimental group will engage in a supervised, progressive moderate-to-high intensity resistance training that is consistent with exercise guidelines for cancer patients, while additionally receiving nutritional support/therapy. Subjects of the control group solely receive nutritional support/therapy based on individual needs. Participants will be assessed at baseline, at 8, 16, 24 weeks for physical performance and various physiological, nutritional and patient-reported outcomes. Follow-up will be 6 months after intervention completion.

DISCUSSION

To our knowledge, this will be the first RCT to assess and compare the effects of a resistance intervention supplemented by nutritional support/therapy against nutritional support only on various health-related outcomes in GvHD patients. The study will contribute to our understanding of the value of exercise and nutritional endorsement in counteracting the negative consequences of GvHD and its treatment.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT05111834 . Registered 8 November 2021 - Retrospectively registered.

Rehabilitation Needs for Patients Undergoing CAR T-Cell Therapy

PURPOSE OF REVIEW

Chimeric antigen receptor (CAR) T-cell therapy is a relatively new, innovative treatment strategy to manage refractory hematological cancers, including some types of leukemia, lymphoma, and multiple myeloma. This article outlines the CAR T-cell therapy process, toxicity, and complications, along with an overview of the currently known short- and long-term physical and functional sequelae that will be helpful for general or oncology rehabilitation specialists caring for these patients.

RECENT FINDINGS

There is a dearth of literature on the topic of rehabilitation of patients receiving CAR T-cell therapy. Rehabilitation practices can be extrapolated from the limited functional information on patients who have completed treatment for lymphoma and multiple myeloma. Patients present with cognitive impairment, muscle weakness, reduced exercise capacity, neuropathy, and cancer-related fatigue. Physical activity and rehabilitation programs may be beneficial to address fatigue, psychological symptoms, and quality of life. There is limited rehabilitation research in patients receiving CAR T-cell therapy. These patients may present with general deconditioning and neurological complications which translate to neuromuscular and cognitive impairment that benefit from multidisciplinary rehabilitation intervention prior to, during, and after treatment. Studies measuring the impairments at baseline and evaluation of the impact of rehabilitation practices are much needed to support this.

What else do I need to worry about when treating graft-versus-host disease?

Graft-versus-host disease (GVHD) is the main cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant survivors. Patients with acute and chronic GVHD often endure substantial symptom burden and quality of life (QOL) and functional impairments. Living with GVHD affects multiple domains of patient-reported QOL, physical functioning, and psychological well-being. Patients describe living with GVHD as a life-altering "full-time job" requiring unique knowledge, personal growth, and resilient coping strategies. Managing the supportive care needs of patients living with GVHD must include (1) monitoring of patient-reported QOL and symptom burden; (2) routine screening for psychological distress and implementing therapeutic strategies to treat depression, anxiety, and posttraumatic stress symptoms; (3) a systematic review of care needs by a multidisciplinary team experienced in managing transplant-related complications and organ-specific GVHD symptoms; and (4) ensuring optimal prevention and management of infection complications in this highly immunocompromised population. Improving the QOL in patients with GVHD requires a multidisciplinary approach with emphasis on aggressive symptom management, psychological coping, and promoting physical activity and rehabilitation in this population living with immense prognostic uncertainty and struggling to adapt to this difficult and unpredictable illness.