Abstract
This Evidence Connection describes a case report of a man with non-Hodgkin’s lymphoma who underwent an allogenic stem cell transplant. The occupational therapy assessment and treatment processes for an outpatient rehabilitation setting are described. Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project.
Occupational therapy practitioners have the education, skills, and knowledge to provide occupational therapy interventions for adults with cancer. Because of the increasing number of cancer survivors, there has been a more intense focus on evidence-based rehabilitation for people of all ages who have cancer and undergo treatment. Findings from a systematic review of occupational therapy with adults with cancer were published in the March/April 2017 issue of the American Journal of Occupational Therapy (AJOT; Hunter, Gibson, Arbesman, & D’Amico, 2017a, 2017b) and in the American Occupational Therapy Association’s (AOTA’s) Occupational Therapy Practice Guidelines for Cancer Rehabilitation With Adults (Braveman & Hunter, 2017). Each article in this series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making.
Clinical Case
Randall is a 38-yr-old man who was diagnosed with non-Hodgkin’s lymphoma and underwent an allogenic stem cell transplant (SCT), meaning that he received stem cells from a matching donor, during a 26-day inpatient hospitalization. He was recently discharged and referred to outpatient occupational therapy and physical therapy while he undergoes 90 days of outpatient follow-up for his SCT. Isabella, an occupational therapist, was assigned to work with Randall. Isabella reviewed Randall’s electronic medical record, which indicated that before his cancer diagnosis he had been experiencing symptoms such as painless swellings in the neck and groin, night sweats, and weight loss. After a lymph node biopsy, Randall was diagnosed with non-Hodgkin’s lymphoma. After undergoing chemotherapy and biologic therapy (i.e., using substances from living organisms to treat disease), which were unsuccessful in halting the disease, he was admitted to the hospital to undergo the allogenic SCT. Allogenic SCTs are high risk and can lead to complications such as graft versus host disease (GVHD), which occurs when donor immune cells attack the recipient’s normal cells (Leukemia and Lymphoma Society, 2017).
Occupational Therapy
Assessment, Education, and Goal Setting
Isabella started the assessment process by administering the Model of Human Occupation Screening Tool (Parkinson, Forsyth, & Kielhofner, 2006) to Randall to identify possible occupational dysfunction. The Canadian Occupational Performance Measure (Law et al., 2014) was used to complete Randall’s occupational profile. Isabella learned that Randall’s roles include spouse, father, worker, and religious participant. He lives with his spouse of 8 yr and their two children ages 5 and 2 yr in a three-bedroom one-level home. He is employed as a crew supervisor and manager in a landscape design and maintenance business. He oversees eight crews (40 workers) and describes himself as a hands-on boss who often performs heavy physical labor and has responsibilities for ordering materials and doing the payroll. Randall’s spouse is a Hindu from India, and both Randall and his spouse have a strong orientation toward health interventions that include biological, psychological, and spiritual elements.
To gain additional information about Randall’s functional status, Isabella used several assessments, including the Brief Fatigue Inventory (Mendoza et al., 1999), a pain assessment scale, the Rivermead Behavioural Memory Test (Clare et al., 2008), and the Activity Measure for Post-Acute Care (Jette, Haley, Coster, & Ni, 2015). Isabella also explored Randall’s concerns about returning to work with the Worker Role Interview (Braveman et al., 2005) and completed a general assessment of his basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) function. Additionally, Isabella completed a general assessment for depression and administered the Functional Assessment of Cancer Therapy (Cella et al., 1993). A brief summary of assessment results is presented in Table 1.
Assessment Results
Note. ADLs = activities of daily living; GMI = General Memory Index; IADLs = instrumental activities of daily living.
Isabella knew that patients who have undergone SCT can experience several serious medical problems and that it was important to monitor critical lab values and vital signs on an ongoing basis. Therefore, at the start of each visit, she checked Randall’s platelets, white blood cells, hemoglobin, hematocrit, blood pressure, and pulse. In addition, because Isabella was aware of Randall’s risk for GVHD, she educated him about symptoms to watch for, including rash or reddened areas of the skin, yellow discoloration of the skin or eyes, nausea, vomiting, diarrhea or abdominal cramping, and increased dryness and irritation of the eyes. Patients with GVHD can also have sclerotic and fascial changes, resulting in impaired upper-extremity range of motion, lymphedema, myopathies secondary to the long-term use of high doses of steroids, and chronic fatigue.
Randall reported that he was able to complete ADLs independently and needed assistance with IADLs at home. During his first therapy session, he reported that his cancer-related fatigue (CRF) level was a 4 out of 10 and that his pain level was a 2 out of a 10 (10 being the highest level for both). No physical impairments were noted. Randall reported mild cognitive dysfunction such as forgetting the next step of familiar tasks and confusion during problem solving.
Based on Randall’s interests and goals, the assessment results, and the agreed-upon discharge plan of Randall remaining independent in all ADLs and preparing to return to work, Isabella developed treatment goals. The goals focused on educating Randall on managing his fatigue and cognitive impairment, maintaining upper-extremity range of motion, and monitoring for GVHD; promoting his involvement in stress-relieving occupations; and supporting his interest in complementary and integrative health interventions in addition to traditional health strategies. Isabella reviewed the evidence from the March/April 2017 issue of AJOT (Hunter et al., 2017a, 2017b) and AOTA’s Occupational Therapy Practice Guidelines for Cancer Rehabilitation With Adults (Braveman & Hunter, 2017) and incorporated that evidence into Randall’s occupational therapy interventions.
Interventions
Isabella provided two occupational therapy sessions per week over the first 8 wk of Randall’s 12-wk follow-up for his SCT. During this time, Isabella checked Randall’s lab values before every session. Because Randall did not experience symptoms of lymphedema or GVHD and was effectively using fatigue, pain management, and exercise programs at home, Isabella decreased his therapy sessions to once a week for the last month of follow-up. Over the course of treatment, the sessions included
Energy conservation strategies (Zhao & Yates, 2008);
Problem solving to aid with task analysis;
Monitoring for signs and symptoms of lymphedema and GVHD;
Education and problem solving as Randall began to experience increased pain (Ling, Lui, & So, 2012; Oldenmenger, Sillevis Smitt, van Montfort, de Raaf, & van der Rijt, 2011; Oliver, Kravitz, Kaplan, & Meyers, 2001);
Strategies for reducing anxiety and depression over the loss of roles (Chien, Liu, Chien, & Liu, 2014), including mindfulness-based interventions (Cramer, Lauche, Paul, & Dobos, 2012; Piet, Würtzen, & Zachariae, 2012);
Strategies to explore sleep quality (Sprod et al., 2010; Tang, Liou, & Lin, 2010);
Yoga and expressive writing to decrease stress and improve quality of life (Carlson et al., 2013; Harder, Parlour, & Jenkins, 2012; Mustian et al., 2013; Shneerson, Taskila, Gale, Greenfield, & Chen, 2013); and
A home exercise, range-of-motion, and stretching program to address fatigue (Andersen et al., 2013; Kangas, Bovbjerg, & Montgomery, 2008; Kuchinski, Reading, & Lash, 2009; McNeely et al., 2006; Wanchai, Armer, & Stewart, 2011).
Isabella also asked Randall whether he had concerns regarding his sexual health and sexuality and assured him that it was appropriate to address these concerns in occupational therapy (Cormie et al., 2013) as well as to discuss issues related to body image with his psychologist (Manne, Ostroff, & Winkel, 2007; Northouse, Templin, & Mood, 2001). Treatment sessions on energy conservation and work simplification incorporated IADL work and leisure occupations, and Randall was referred to an interprofessional return-to-work program near his home that addressed physical, psychological, vocational, and environmental concerns (de Boer et al., 2011).
Intervention Session 1.
Randall’s biggest concern was his fatigue, which he seldom rated as less than a 4 out of 10 and by midday often became severe. Therefore, Isabella focused first on energy conservation, work simplification, and other CRF management strategies. Randall agreed to begin a daily fatigue journal to learn when he became most fatigued and what strategies were effective. He also worked with Isabella to develop a weekly calendar to plan his activities, schedule rest breaks, and prioritize his most valued occupations. Isabella had Randall use the occupation of making a simple lunch for his children to help him understand how he could change activity demands, pace his work, and alter tasks to lower energy demands, such as sitting while preparing meals. Isabella collaborated with Randall’s physical therapist to develop a home exercise, range-of-motion, and stretching program because exercise and movement are some of the most effective strategies for managing CRF.
Intervention Session 2.
Randall expressed high levels of stress and anxiety and some depression. Therefore, Isabella integrated stress management as well as complementary health approaches and integrative health with Randall’s fatigue management and exercise programs. In addition to his fatigue journaling, Isabella asked Randall to write down when he felt anxious or stressed and what was the possible cause. Isabella taught Randall simple stress reduction strategies such as deep breathing, visual imaging, and mindfulness approaches to use in response to stress triggers. Randall and his family already enjoyed yoga as a family activity, and Isabella helped Randall use the many strategies he was learning during yoga and other co-occupations with his family. Randall found that his journaling helped him to express his emotions and to respond more realistically and proactively to what he was experiencing.
Intervention Session 3.
As Randall’s outpatient treatments continued, he complained of increased levels of pain. This problem further increased his anxiety about his occupational performance as a father and a spouse. Isabella introduced Randall to guided imagery and reinforced the use of slow, deep breathing techniques to help him manage his pain and the associated stress. Randall had expressed an appreciation for spiritual approaches to his health; therefore, Isabella reinforced the use of meditation to help address his pain. Integrating these strategies as part of Randall’s planned daily routine helped him prioritize these activities, and Randall reported positive results and improvement in CRF and pain.
Intervention Session 4.
Randall continued to express concerns about being able to return to work and to fulfill his role as a father for his two children. Isabella used some work occupations as examples to apply fatigue and pain management strategies. In addition, Isabella routinely assesses patients for sexuality and body image concerns and openly communicates that these issues are common and appropriate for clients to discuss in occupational therapy. Isabella gave permission to Randall to be a sexual being by using therapeutic listening, validating his concerns, and supporting him in raising these concerns with his physician and psychologist. She discussed strategies to address his body image concerns such as mirror viewing and planning how he would begin to reengage with friends and coworkers and let them know in advance that he had some physical changes resulting from lymphoma and its treatment.
Conclusion
Through the use of evidence-based, occupation-focused, and client-centered occupational therapy interventions, Randall met his goals by the end of his 3-mo outpatient treatment and follow-up for his SCT. He reported levels of performance and satisfaction that were improved from his initial visit. Although fatigue and pain continued to present challenges, Randall reported feeling highly confident in the use of the strategies he learned in therapy to proactively manage these symptoms. Randall was participating in most of his primary occupational roles and making plans to return to work. He felt more confident about his self-image and body image and reported lower levels of stress and anxiety and improved quality of life.
Isabella’s discharge recommendations included continued use of all strategies, including the home exercise and stretching program. She referred Randall to a work rehabilitation program and for additional outpatient occupational therapy if he encountered any symptoms of lymphedema or GVHD.