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Functional evaluation indicates physical losses after hematopoietic stem cell transplantation
Rev Bras Hematol Hemoter. 2012;34(5):345-51
including patients with chronic GVHD
(20)
. Although fatigue is a
very common symptom after transplant, the Borg scale was not
significantly different before and after transplant. However, the
HR before 2MWT was higher. According to Gillis & Donovan
(34)
maintaining bed rest causes a chain of cardiac events that
increases resting HR and provokes orthostatic intolerance with
postural hypotension occurring due to the diminished blood
volume and/or changes in autonomic responses. The increased
HR before the 2 MWT found in our cohort of patients might be
explained by bed rest.
The patients in this study presented reductions in spine
mobility after HSCT. Muscle atrophy, restricted activities and
being bedridden also have consequences on the overall range
of motion. Schober’s test is commonly used to evaluate lumbar
spine mobility in patients with lumbar pain or lumbar joint
impairment
(35)
. Suesada et al.
(36)
investigated spine mobility in
patients submitted to short-term hospitalization using the Stibor
and Schober’s tests and showed a decrease in mobility (p-value
< 0.0001) which strongly suggests that only a short period of bed
confinement is likely to reduce pelvic and spine mobility. As trunk
flexion requires great joint mobility and muscle activation
(37)
this
test gives an idea of whether or not the overall mobility is affected.
There was a statistically significant loss of weight and
BMI in Phase 2 (p-value < 0.0001) and the grip test showed an
important reduction in muscles of both hands after transplant.
Chemotherapy, toxicities involved in HSCT and reduced
food intake contribute to an energy imbalance that provokes
loss of lean mass and weight
(14)
. Not only corticosteroids and
chemotherapy induce fatigue, but also the neoplasia itself and
the resulting production of inflammatory cytokines in the disease
process
(5)
. In addition, oxidative stress from chemotherapy and
radiation treatment, along with iron overload from multiple
blood transfusions may contribute to muscle dysfunction
through an excessive production of reactive species
(11)
. White
et al.
(38)
demonstrated that patients before HSCT had lower
plasma concentrations of glutathione peroxidase, an important
component of the circulating antioxidant system, compared with
controls. Hence, muscle atrophy followed by strength loss and
functional impairment are expected. Hand strength appears to be
valid measurement to assess overall strength loss with this being
confirmed by a great number of studies that investigated patients
with other diseases and clinical conditions
(20,39-42)
.
One useful and widely used instrument with cancer patients
is the QOL questionnaire. Courneya & Friedenreich, in a literature
review about exercise and cancer, observed that all authors used
some QOL instrument
(19)
to evaluate the effect of interventions.
The choice in this study was the HAP questionnaire. Created by
Daughton et al.
(43)
this instrument evaluates functioning in daily
life activities. It correlates 94 possible activities with themaximum
consumption of oxygen needed to perform each activity. In this
study there was a significant reduction in functioning as detected
by the variables assessed by the HAP questionnaire (MAS and
AAS). Herzberg et al.
(8)
observed that, within one year of HSCT,
the HAP was more sensitive to detect functional deficits resulting
from chronic GVHD manifestations and steroid myopathy than
the FACT-BMT and the SF-36 questionnaires. There was also a
strong correlation between these questionnaires.
It is well known and documented that patients with
cancer go through great physical and psychosocial stress since
diagnosis, causing a variety of signs and symptoms that may
last for some time after treatment
(3,7,44-47)
even when results of
treatment are positive
(3,28)
. Patients submitted to HSCT have an
extra dose of factors that contribute even more to disability, such
as conditioning regiments, restrictions before, during and after
treatment and complications inherent to the procedure (including
acute and chronic GVHD) that can occur in the early and late
periods after the procedure.
Physical domain functions are considered predictors of
longevity and good health and their parameters are being used
in clinical trials as primary or secondary endpoints associated
to clinical evaluation
(16,17)
. The instruments used in this study
were chosen with the main objective of using one tool for each
physical domain with simple and effective evaluations that can be
performed in clinical settings.
The results of comparing physical parameters between the
allogeneic and autologous groups in the Phase 1 evaluation were not
statistically different, showing that the functional status of allogeneic
and autologous patients are similar. Differences were observed for
clinical parameters at Phase 2. Thus, an important limitation of our
study was that our sample was not large enough to compare the Phase
2 results between the two groups. The different types of procedure
may impact on function differently, but the analyses were not
possible due to the small number of patients. Further investigations
should be considered with larger sample sizes as some of the findings
of this study may be confirmed or reinforced.
This study only verified physical impairment but it is known
that psychic conditions might influence the physical performance
and these variables should be investigated in future studies.
Conclusion
Significant differences identify decreases in aerobic
conditioning before and after physical stress, declines in functioning
and gait performance, reduction of muscle strength and spine
flexibility and diminished functioning in daily activities after HSCT.
The intensity and specificity may guide preventive measures and
conduct a better rehabilitation program in the post-HSCT period.
Acknowledgments
We deeply thank the collaboration of all our patients, the
health team of the Hematopoietic Stem Cell Transplant Unit
and the Universidade Estadual de Campinas (UNICAMP) that
allowed us to conclude this work and to whom we dedicate our
efforts. We also thank FAPESP for financial support.
References
1. Mastropietro AP, Dos Santos MA, Oliveira EA. Bone marrow
transplantation survivors: reconstruction of daily living. Rev Ter Ocup
Univ São Paulo. 2006;17(2):64-71.
2. Bevans MF, Mitchell SA, Marden S. The symptom experience in the first
100 days following allogeneic hematopoietic stem cell transplantation
(HSCT). Support Care Cancer. 2008;16(11):1243-54.