Group 5 - Acute Lymphoblastic Leukemia (ALL)
By: Heather Croft, Sammy Finney, Amanda Foresman, Beth Kinser, Jenn Lammert, Lindsey Penick
1.
Differential Diagnosis
Disease
Signs/Symptoms
Cancer
Anemia, infection, easy bruising and bleeding,
irritability, fatigue, bone pain, bleeding gums, HA,
raised non-pruritic rash, WBC<10,000 or
> 100,0001,2
Rheumatoid Arthritis
Early morning stiffness of affected jts, general
afternoon fatigue and malaise, anorexia, general
weakness, occasional low-grade fever, jt pain,
swelling, and stiffness, mostly simultaneous (B) jt.
involvement.1,3
Legg Calve Perthes
Pain in the hip joint and gait disturbance, thigh
muscles may become wasted. 1
Slipped Capital Femoral
The first symptom may be hip stiffness, then a
Epiphysis
limp may develop, then pain that radiates from hip
down to anterior-medial thigh to knee. 1
Sickle Cell Anemia
Infection
2.
Severe pain in long bones, hands, feet and jts.
Severe abdominal pain develops, and vomiting
may occur. Typically in the black population. 1
Severe jt. pain, warmth, tenderness, effusion,
restricted A & PROM, and sometimes redness,
possible high or low-grade fever. 1
Types of Leukemia1
Type
Incidence
Acute Lymphocytic
Leukemia (ALL)
Median age: 20
Acute Myelogenous
Leukemia (AML)
Median age: 4
Chronic
Myelogenous
Leukemia (CML)
Median age: 49
Chronic
Lymphocytic
Leukemia (CLL)
Median age: 60 (risk
increases with age)
Signs & Symptoms
tachycardia, chest
pain, irregular
menstruation, jt.
pain, HA, vomiting,
irritability, seizures,
papilledema
Typical s/s listed
above
anorexia, night
sweats, sense of
abdominal fullness
(due to
splenomegaly)
Anorexia, DOE,
sense of abdominal
fullness,
nonspecific
symptoms due to
anemia (fatigue/
malaise)
Diagnosis
CBC and peripheral smear, bone marrow
examination, histochemical studies,
cytogenetics, immunopheotyping, molecular
biology studies, lumbar puncture. 1,2
Clinical criteria, serum rheumatoid factor
(RF) or anti-cyclic citrullinated peptide
antibody (anti-CCP), x-rays. 1
Dx is based on symptoms followed by a
bone scan or MRI to confirm the dx. 1
AP and frog-leg lateral x-ray studies of both
hips are taken. Show widening of the
epiphyseal line or apparent posterior and
inferior displacement of the femoral head.
Ultrasonography and MRI can help
Family history is taken into consideration,
laboratory tests for hemolytic anemia. 1
Arthrocentesis with synovial fluid
examination and culture, blood culture,
CBC and ESR. 1
Initial Remission
Prognosis
50% (average 12
months)
Median survival with rx: 1 year
Median survival without rx: 2-4
weeks p dx
90%
Mean survival with rx: 5 yr (6070% of children); if relapse,
usually occurs < 3 yrs
90%
Median survival with rx: 3 yrs
Survival after 80% blast crisis: 2
months
90%
Mean survival with rx: 6 years
Primary cause of death: infection
Physical Therapy Interventions
 Evidence:
o PT and HEP: LE strengthening and stretching, aerobic exercise found to be beneficial for gait7
o 8 wk exercise training program which improved muscle strength, endurance and functional mobility8

Making therapy fun
o Wii Fit (aerobic capacity, balance, strength)
o Dance Dance Revolution (aerobic capacity)
o
o
o
o
o
o
o
o
o
Yoga Poses: River, down dog, gorilla, cobra, bridge, boat, tree, airplane, lying twist, dragon, cat,
triangle (flexibility, ROM)
Jungle Gym (strength, aerobic capacity)
Basketball (strength, ROM, aerobic capacity)
Scavenger Hunt (strength)
Painting/Whiteboard drawing (strength, ROM)
Aqua Therapy (aerobic capacity, strength)
Ride Bike (ROM, aerobic capacity, strength)
Simon Says (strength, ROM, flexibility, aerobic capacity)
Red Light / Green Light (aerobic capacity)
3. Our Recommended Intervention:
 3/wk for 6 wks, therapy consists of: ROM, strengthening exercises, aerobic exercises, flexibility exercises.
4. Physical Therapy Precautions
 HR may not be accurate in patients taking chemotherapy, so use MET, BP, face rating for fatigue7
 Bone metastases patients’ should avoid all contact sports7
 Adriomycin: may have cardiac side effects that impair cardiac fxn and oxygen transport which will limit
ability to participate in exercise7
 High number of REPs should be avoided due to fatigue7
 Nadir is the lowest point the white blood count reaches, usually occurs 7 - 14 days after chemo or radiation.3
o At this point the patient is extremely susceptible to infections. 3
o The importance of good handwashing and hygiene practices cannot be overemphasized when treating
these patients. 3
o Fatigue is a side effect: be aware of pt getting tired during tx so we may have to take frequent breaks.
3
5. Psychosocial Manifestations
 Depression/Sadness since he is away from family and friends
 Anxiety about being in the hospital, and side effects of treatment
 Fear of hospitals, doctors, or procedures that may take place
 Anger due to a lack of understanding
 Family dynamic issues
o The investigators of this study used the Short-Form 36 as a quality of life assessment measure.
 Compared to families with healthy children, families with children who have cancer reported
decreased physical and psychosocial quality of life in the following domains: physical role,
bodily pains, general health perceptions, energy/vitality, social function, emotional role, and
mental health. 10
 Characteristics of the child that enhanced the quality of life of family with a child who has
cancer: improve health status, decreased intensity of the treatment, and a increased time
period.10
 School: patient may have difficulty catching up in school, which may frustrate patient
 Sports: patient is very interested in sports, and may have difficulty sitting out during sports
6. Other Information
 A lot of bruising may indicate abuse; therefore it is very important to rule out abuse.
References:
The Merck Manual Online Medical Library
A Cancer Source Book for Nurses (7th ed.) Atlanta, GA: American Cancer Society;1997.
Goodman CC, & Snyder TE. Differential diagnosis for physical therapists (4 th ed.) St. Louis, MO: Saunders-Elsevier; 2007.
Basmajian JV & Wolf SL. Therapeutic Exercise (5th Ed.) Baltimore, MD: Williams & Wilkins; 1990.
www.happysoccerfeet.com
Ciccone CD. Pharmacology in Rehabilitation (4th ed.) Philadelphia, PA: E.A. Davis Company; 2007.
Marchese VG, Chiarello LA, Lange BJ. Effects of physical therapy intervention for children with acute lymphoblastic leukemia. Pediatr Blood
Cancer. 2004; 42(2): 127-33.
8. San Juan AF, Fleck SJ, Chamorro-Vina C, et al. Early-phase adaptations to intrahospital training in strength and functional mobility of children with
leukemia. J Strength Cond Res. 2007; 21(1): 173-7.
9. www.payvand.com/news/07/dec/MAHAK-Patient.jpg
10. Klassen AF, Klaassen R, Dix D, et al. Impact of caring for a child with cancer on parents’ health-related quality of life. J Clin Onc. 2008;26(36):588489.
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