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Bone marrow transplantation is a procedure that replaces cancerous or diseased tissue inside a patient’s bones with healthier marrow. A form of stem cell transplantation, BMT transfers stem cells harvested from a donor’s blood stream, bone marrow, or umbilical cord blood into the recipient through an intravenous line.

BMT can help children battling leukemia, lymphoma, plasma cell disorders, severe anemia, sickle cell disease, and other blood and marrow disorders. It also can aid patients with cancer whose marrow has been damaged by high doses of chemotherapy or radiation therapy. Children undergoing BMT are hospitalized for approximately one month and, during that time, can benefit from physical therapy to restore their strength and mobility.

“This therapy can be quite arduous. This is a life-threatening treatment for life-threatening diseases,” says Willis Navarro, MD, medical director of transplant services at the National Marrow Donor Program, based in Minneapolis. “For children that are deconditioned, physical therapy can help them maintain musculoskeletal function. PT also plays a significant role in maintaining mobility and improving flexibility for patients affected by complications. Adults get these complications more frequently than children, but children are also subject to them.”

Road Less Traveled

To prepare a child for BMT, doctors administer a conditioning regimen of chemotherapy and/or radiation therapy that destroys diseased cells and prevents the immune system from attacking new donor cells. This conditioning process can take from four to 10 days and may begin before the child is admitted to the hospital. Once conditioning is complete, the new stem cells can be administered. At this time, the child’s immune system will be compromised, and he or she may need transfusions of blood, platelets, and growth factors. As donated stem cells begin to take hold and restore marrow function during the following weeks, through a process called engraftment, the patient’s strength slowly returns.

Because each patient’s response to treatment is so variable, it’s impossible to give blanket survival numbers for BMT. “Prognosis could be terrific to really dismal,” Navarro says.

Early in the process, the child will experience nausea and soft tissue inflammation, usually around the nose or mouth. Two weeks following the actual transplant, risk of fungal infection, pneumonias, and veno-occlusive diseases increases. At three weeks out, the child could develop graft-versus-host disease, a serious condition in which donor cells react against the recipient’s body. Opportunistic infections from herpes simplex viruses are a risk throughout the process.

“Some of the complications manifest similar to autoimmune disorders, where patients can get inflammation of joints and symptoms similar to scleroderma, where the skin gets tight,” Navarro says. “PT has a significant role in maintaining mobility and improving flexibility for patients whose connective tissues are affected.”

Preventing Breakdowns

Richard Gee, MPT, is lead physical therapist at the Lucile Packard Children’s Hospital at Stanford University Medical Center, in Palo Alto, Calif. “When children first come in, we do a full PT evaluation,” he says. “We screen any bony or soft tissue abnormality, muscle weakness, and any problem with function affecting range, flexibility, or endurance. If the child is 5 years old or younger, we look at their developmental milestones. If they’re missing any skills, we establish a program for them.”

Gee starts by addressing pre-existing conditions, such as tightness in the lower extremities from earlier hospitalizations, and works to get patients as strong as possible before they face weakness and other side effects that accompany the transplant.

In addition to causing nausea, which can lead to nutritional problems, BMT causes pain, emotional difficulties, and sleep disturbances. Gee says it helps to establish a schedule right from the start, developing the habit of getting the youngster out of bed. A typical day includes waking, having morning care, and participating in schooling and other out-of-bed activities.

Because the children are immunosuppressed, PT equipment must be kept very clean, but the days of keeping children with BMT behind glass with a glove box setup for interaction are mostly gone at pediatric hospitals. “It’s isolating and extremely emotionally traumatic for the children, and not all that beneficial,” Navarro says.

Flexible Schedules

Every patient’s course of PT is adjusted as needed. “We focus on preventing problems, as well as restoring and supporting functioning,” Gee says. “We get them active while accommodating their level of fatigue, pain, and weakness.” PTs who work with children post-BMT should consider blood platelet levels, white blood cell counts, how much time has elapsed since the child’s transplant, and any side effects the child is experiencing before deciding on a day’s activities. Low blood platelets increase the risk of bleeding, so rigorous activities must be curtailed accordingly.

“We have to be mindful of bleeding, pain, nausea, their ability to move, and their inability to lift heavy things,” Gee says. He’ll focus on light, resistance-oriented play when the child is up to it. “We catch and kick balls, but use a light blow-up ball. When they can’t stand or walk, we do tabletop activities that could be as simple as a game where they’re reaching up and down and getting things,” he says.

The idea is to get children active and upright, instead of just lying in bed. If pain or nausea becomes too intense, the child participates in bedside activities, including active and passive range of motion, such as stretching. “How the child responds will guide us as to what to do,” Gee says.

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Wendy Lyons Sunshine is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.

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