Bleeding frequency during physiotherapy in thrombocytopenic patients undergoing hematopoietic stem cell transplantation

Abstract

Background During hematopoietic stem cell transplantation (HSCT) the patients perform activities of low and moderate intensity because have reduced hematological lineages, leaving them susceptible to hemorrhagic events. The objective of this study was to describe the frequency of bleeding events, severity, and possible association with physical exercise in thrombocytopenic patients. Methods A retrospective study with seventy-seven HSCT patients hospitalised, that had a platelet count ≤ 50,000 /μL and received physical exercise during physiotherapy intervention. Results Regarding bleeding events, only six were related to physical exercise, and bleeding events occurred more frequently at platelet levels ≤ 10,000 /μL. The most frequent bleeding event was epistaxis, considered of low severity, and with the moderate possibility of being related to physical exercise; followed by extremity hematoma, considered of medium severity and highly related to physical exercise. In this study, there was no occurrence of bleeding events considered of high severity. Conclusion Bleeding frequency in supervised physical exercise during physiotherapy in adults with thrombocytopenia undergoing HSCT is minor and relatively rare but occurs more frequently in patients with platelet count ≤10,000 /μL. These results encourage the maintenance of physical activity in this population who is at high risk of developing immobility-related complications.

Health care professionals’ understanding of contraindications for physical activity advice in the setting of stem cell transplantation

“…Excluding these patients is mainly explained with thrombocytopenia potentially leading to hemorrhages [ 33 ]. However, recent studies have shown that most HSCT patients are able to tolerate and benefit from PA despite low platelet counts (< 10,000/μl) [ 34 , 35 ]. A retrospective study by Fu et al adapted the inpatient rehabilitation protocol with regard to platelet counts and designed therapy sessions addressing each patient’s individual impairments and rehabilitation goals [ 36 ].…”

Inpatient Rehabilitation of Hematopoietic Stem Cell Transplant Patients

“…37,38 In a study of 77 patients on the acute care stem cell transplant unit with a platelet count less than 50,000/μl undergoing physical therapy, there was only two instances of moderate severity complications (leg hematoma) that was highly related to physical exercise (and no high severity bleeding episodes reported). 39 In a study, evaluating 135 acute rehabilitation hematologic malignancy inpatients with an admission platelet count less than 20,000/μl (37% of which were post-HSCT), only one patient suffered a high severity event highly attributable to physical activity using institutional guidelines (MD Anderson Cancer Center). 37 These guidelines are used for all patients including outpatients, acute care, and acute inpatient rehabilitation:…”

“…There is concern regarding the possibility of bleeding events such as intramuscular hematomas, intracranial hemorrhages, and bleeding related to trauma or falls 37,38 . In a study of 77 patients on the acute care stem cell transplant unit with a platelet count less than 50,000/μl undergoing physical therapy, there was only two instances of moderate severity complications (leg hematoma) that was highly related to physical exercise (and no high severity bleeding episodes reported) 39 …”

Medical and Cardiac Risk Stratification and Exercise Prescription in Persons With Cancer

“…24 Bleeding events are most likely to occur with exercise when platelets are less than 10,000/μl. 25 There have been a number of retrospective reviews investigating the relationship of platelet levels to bleeding risk, and currently there is no evidence to suggest that physical exercise is related to bleeding in patients with thrombocytopenia from hematologic malignancy. 26 Anemia physiologically results in reduced oxygen and nutrient delivery to the muscles, lungs, and heart during exercise by reduced numbers of red blood cells.…”

“…In a closely monitored rehabilitation inpatient setting, bleeding events due to severe thrombocytopenia (<20,000/μl) are rare—occurring approximately 4% in one study 24 . Bleeding events are most likely to occur with exercise when platelets are less than 10,000/μl 25 . There have been a number of retrospective reviews investigating the relationship of platelet levels to bleeding risk, and currently there is no evidence to suggest that physical exercise is related to bleeding in patients with thrombocytopenia from hematologic malignancy 26 …”