Disclosures. Role of Therapy in Acute Care. Objectives. Rehabilitating Pre- and Post-liver transplant Patients

Transcription

1 Rehabilitating Pre- and Post-liver transplant Patients Michelle Oberst, PT, DPT, GCS, CEEAA Alicia Rivas MS, OTR/L Disclosures I have nothing to disclose Objectives Understand the role of physical therapy with pre- and post-liver transplant patients Understand the role of occupational therapy with pre-and post-liver transplant patients Understand common physical therapy interventions Understand common occupational therapy interventions Identify when to consult therapy services Role of Therapy in Acute Care Physical Therapists (PT) and Occupational Therapists (OT) are trained in the medical model to provide detail assessments and interventions (activity modifications, strengthening, neuromuscular re-education, trunk stabilization, balance activities) after illness and injury. 1

2 Physical Therapists are Biomechanical experts Assess and promote proper movement strategies and safety with bed mobility, transfers, gait and stairs. Provide Interventions that will maximize performance of the oxygen transport system, musculoskeletal and neuromuscular systems; titration of activity in response to changes in physiological status Occupational Therapist are Experts in assessing and promoting independence with activities of daily living (ADLs) and daily life roles Experts in assessing cognition and perception as it relates to safety in ADLs and mobility Interventions focus on adapting the environment, modifying the task, and educating the client/family Goal: to increase participation in and performance of ADLs and iadls (instrumental activities of daily living) Model of Human Occupation (MOHO) explains how human occupation is motivated (VOLITION), organized (HABITUATION), performed (PERFORMANCE) and influenced by the environment Areas of Occupation ADLs IADLs Work Leisure Social Participation Metabolic Gastrointestinal Musculoskeletal Bowel & bladder mangement Safety procedures/emer gency response Employment seeking Leisure participation Community Bathing, showering Dressing Care of others/pets Community mobility Employment Leisure interest/prusui exploration ts Job performance Leisure participation Family Peer, friend Hematologic Complications of immobility Psychological Feeding Financial management Cardiovascular Integumentary Functional mobility Health maintenance Hygiene and Grooming Home management Respiratory Inflammation Sleep/rest Sexual activity Meal prep Shopping Winkelman C, Higgins PA, Chen YJ, Levine AD. Cytokines in chronically critically ill patients after activity and rest. Biol Res Nurs. Apr 2007;8(4): Bloomfield, S. A. (1997) Changes in musculoskeletal structure and function with prolonged bed rest. Medicine and Science in Sports and Exercise. 29 (2),

3 Impairments Deconditioning Hepatic encephalopathy Pain/discomfort Ascites Balance Sleep deficiency Depression/apathy Frailty Ascites and Edema Makes sitting up uncomfortable Difficulty getting center of gravity over base of support to achieve standing With extra weight and fluid status will see fluctuation in activity tolerance Lower extremity edema makes legs heavier to move, rub together, and patients more uncomfortable Malnutrition, Cachexia and Sarcopenia Sarcopenia- loss of muscle mass Cachexia- loss of both fat and muscle mass Sarcopenic obesity- disproportionate loss of muscle mass in the presence of increased adipose tissue mass Adversely affects survival and quality of life Dasarathy S. Consilience in sarcopenia of cirrhosis. J Cachexia Sarcopenia Muscle. 2012;3(4): Fried s Frailty Index Unintentional weight loss Self-reported exhaustion Low physical activity Weakness (grip strength) Atrophy, overall physical activity 3/5 = frail Each 1 unit increase associated with 50% increased risk of waitlist mortality Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:M146-M156. Lai, J.C.., et al. (2014). Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14:

4 Impact of Frailty Decreased physiologic reserve and resistance to stressors Increased risk of post-surgical complications and the need for extended care. More than doubles the risk of morbidity and mortality from surgery and cardiovascular conditions. Strongly predicts waitlist mortality in liver transplant candidates Short Physical Performance Battery Balance Test Feet Side by Side Semi-Tandem Stand Tandem Stand Gait Speed Test Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA5, Popma JJ, Ferrucci L, Forman DE (2014). "Frailty assessment in the cardiovascular care of older adults". Journal of the American College of Cardiology 63 (8): Makary MA, Segev DL, Pronovost PJ, et al. (June 2010). "Frailty as a predictor of surgical outcomes in older patients". J. Am. Coll. Surg. 210 (6): Lai, J.C.., et al. (2014). Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: Chair Stand Test 5 x sit to stand with arms across chest Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994; 49: M85-M94. Image of test available from Google image search for SPPB. Physical Therapy Objectives in Pre- Transplant Patients Daily functional assessments, activity tolerance information correlated to vitals, lab values, medications Providing psycho-social orientation, motivation, self-efficacy Family education Environment management Identify and minimize barriers to mobility Preventative medicine- Carefully monitored activity Sleep disorders Steroids osteopenia, hyperglycemia, and muscle wasting Pneumonia Delirium, mood affect Endurance, fatigue Balance Treating Patients with ESLD Assessment Questions: Patient physiologic reserve- past and present Ambulatory enough to be listed? patient s MELD score does not always correlate with function Family able to realistically continue care for the patient? Is patient already listed and will stay admitted until organ available? What is the patient s hemodynamic and 02 response to activity? Motivation Discharge Options 4

5 Interventions Bed mobility Transfer training Gait training Stair training Balance exercises Therapeutic exercises Education re: energy conservation and safety Caregiver training Equipment recommendations Exercise Can increase skeletal muscle volume and strength Increase physical activity Increase exercise capacity Improve insulin resistance Can prevent or minimize sarcopenia Toshikuni N et al, Nutrition and exercise in the management of liver cirrhosis. World J Gastroenterol 2014 June 21; 20(23): Lai, J.C.., et al. (2014). Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: Equipment Occupational Therapy Pre-transplant Ascites and Edema Impaired lower body dressing/bathing Impaired bed mobility Impaired toileting Back pain Shortness of breath Skin breakdown Frailty and weakness Impaired balance Impaired functional mobility Poor endurance/activity tolerance Falls and injuries Loss of independence in ADLs Loss of independence in iadls Loss of meaningfull roles Encephalopathy Attention deficits Hypereflexia/impaired motor planning Impaired sleep patterns Inability to manage medications Inability to manage finances Unable to work Unable to drive Lactulose Frequent bathroom trips Accidents Skin breakdown Loss of freedom to leave home Brown, J., Sorrell, J H., McClaren., & Crewel,J.W. (2006). Waiting for a liver transplant. Qualitative Health Research, 16(1),

6 Impact of Liver Disease on ADLs and Participation Treating Patients with ESLD Assessment questions: Baseline and current level of ADL/iADL function Baseline and current cognitive functioning Home environment setup/barriers Access to durable medical and adaptive equipment Motivation Meaningful roles, routines, hobbies Discharge options Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational Therapy in Health Care, 25:4, Occupational Therapy Objectives in Pretransplant Patients individuals in the prolonged transplant pipeline must learn either independently or with assistance, to cope with the serious limitations and restrictions to performance of ADLs and participation in valued occupations So you had a liver transplant Education about changes in role performance Adapting ADL/iADLs tasks Conserving energy Durable medical equipment Adaptive equipment Medication management Caregiver education Education and preparation for later stage disease and potential transplant Recommendations for home and out patient services Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational Therapy in Health Care, 25:4,

7 Physical Therapy Considerations Specific to Liver Transplant OLT Delayed cognitive recovery, malnutrition, delayed liver function Complications from cardiopulmonary impact of disease and prolonged surgery Central nervous system complications, seizures Large abdominal incision Balance, coordination Endurance Expectations- patient, family, clinicians Considerations Abdominal guidelines Logroll for bed mobility Splinting for cough/laughing to assist with pain control Post-op orthostasis Steroids Immunosuppression Side Effects Corticosteroids, prednisone Muscle wasting, steroid myopathy Osteopenia Weight gain Delayed wound healing Mood swings Hyperglycemia HTN Peptic ulcer Transplant Recovery Support for exercise training post-transplant Fitness and strength 40 to 50% less than age related normal pre-transplant Exercise capacity still low 1 year post-transplant Active recipients have higher HRQOL Most symptoms relate to weakness, fatigue, joint discomfort Painter P, Krasnoff J, Paul SM, Ascher NL. Physical activity and health-related quality of life in liver transplant recipients. Liver Transpl. 2001;7(3):

8 Occupational Therapy Post Transplant Abdominal incision Abdominal guidelines Bed mobility Pain management Returning to Independence in ADLs Lower body dressing Bathing Toileting Grooming and hygiene Frailty and Weakness Activity modification Pacing Energy conservation Safe progression of activity Post-op confusion Prevention/ management of delirium Cognitive testing Family and caregiver training Post op medications Education on side effects Strategies for management Family caregiver education Returning to work Cognition, endurance, pacing Returning to meaningful roles and routines Leisure and hobbies, family, social Occupational Therapy Post Transplant Discharge planning Caregiver education Medication management Activity Progression Post transplant adjustment Durable medical equipment Adaptive equipment Barriers? NONE other than if the patient is not stable CVVH- standing orders to disconnect CVVH for up to 2 hrs for therapy Mobilize patients who are intubated Our patients will not get transplanted if they do not demonstrate that they are able to mobilize out of bed When to Consult Consult PT Anytime Mobility impairment Frailty Home exercise program Patient family education Consult OT Anytime ADL deficits Medication management Cognitive deficits Patient and family education 8

9 Summary Physical therapist are the biomechanical and exercise experts Occupational therapist are the ADL/iADLs/cognition and participation in meaningful tasks experts Both PT and OT asses and treat the patients physiological state Both PT and OT asses for proper minimal lift equipment Frailty is a major factor in pre- and post op exercise and ADL performance PT and OT work with patients both pre- and post op to maximize function, participation and outcomes References Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA5, Popma JJ, Ferrucci L, Forman DE (2014). "Frailty assessment in the cardiovascular care of older adults". Journal of the American College of Cardiology 63 (8): Bloomfield, S. A. (1997) Changes in musculoskeletal structure and function with prolonged bed rest. Medicine and Science in Sports and Exercise. 29 (2), Brown, J., Sorrell, J H., McClaren., & Crewel,J.W. (2006). Waiting for a liver transplant. Qualitative Health Research, 16(1), Derck, J. E., et al. (2015). "Quality of life in liver transplant candidates: frailty is a better indicator than severity of liver disease." Transplantation 99(2): Dasarathy S. Consilience in sarcopenia of cirrhosis. J Cachexia Sarcopenia Muscle. 2012;3(4): Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:M146-M156. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994; 49: M85-M94. Image of test available from Google image search for SPPB. References Lai, J.C.., et al. (2014). Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: Makary MA, Segev DL, Pronovost PJ, et al. (June 2010). "Frailty as a predictor of surgical outcomes in older patients". J. Am. Coll. Surg. 210 (6): Painter P, Krasnoff J, Paul SM, Ascher NL. Physical activity and health-related quality of life in liver transplant recipients. Liver Transpl. 2001;7(3): Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational Therapy in Health Care, 25:4, Toshikuni N et al, Nutrition and exercise in the management of liver cirrhosis. World J Gastroenterol 2014 June 21; 20(23): Thank you Young Na Lee OT Jamie Krueger PT Cate McDonough OT Heidi Engel PT DPT Shin Tatabe PT Winkelman C, Higgins PA, Chen YJ, Levine AD. Cytokines in chronically critically ill patients after activity and rest. Biol Res Nurs. Apr 2007;8(4):