Disclosures Rehabilitating Pre- and Post-liver I have nothing to - - PowerPoint PPT Presentation

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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.

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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

• xygen 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

ADLs IADLs Work Leisure Social Participation Bowel & bladder mangement Safety procedures/emer gency response Employment seeking Leisure participation Community Bathing, showering Care of

• thers/pets

Employment interest/prusui ts Leisure exploration Family Dressing Community mobility Job performance Leisure participation Peer, friend Feeding Financial management Functional mobility Health maintenance Hygiene and Grooming Home management Sleep/rest Meal prep Sexual activity Shopping

Areas of Occupation

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):261-271. Bloomfield, S. A. (1997) “Changes in musculoskeletal structure and function with prolonged bed rest.” Medicine and Science in Sports and Exercise. 29 (2), 197-206.

Complications of immobility

Gastrointestinal Musculoskeletal Psychological Integumentary Inflammation Respiratory Cardiovascular Hematologic Metabolic

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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):225-37.

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: 1870-1879

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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

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): 747–762. 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): 901–8. Lai, J.C.., et al. (2014). “Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: 1870-1879

Short Physical Performance Battery

Balance Test

Feet Side by Side Semi-Tandem Stand Tandem Stand

Gait Speed Test 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

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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): 7286- 7297 Lai, J.C.., et al. (2014). “Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: 1870-1879

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 Encephalopathy Attention deficits Hypereflexia/impaired motor planning Impaired sleep patterns Inability to manage medications Inability to manage finances Unable to work Unable to drive 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 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), 119-136.

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Impact of Liver Disease on ADLs and Participation

Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational Therapy in Health Care, 25:4, 240-256.

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

Occupational Therapy Objectives in Pre- transplant Patients

“individuals in the prolonged transplant pipeline must learn either independently

• r with assistance, to cope with the serious limitations and restrictions to

performance of ADLs and participation in valued occupations” 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, 240-256.

So you had a liver transplant…

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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):213-9.

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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

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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): 747–762.

• Bloomfield, S. A. (1997) “Changes in musculoskeletal structure and function with prolonged

bed rest.” Medicine and Science in Sports and Exercise. 29 (2), 197-206.

• Brown, J., Sorrell, J H., McClaren., & Crewel,J.W. (2006). Waiting for a liver transplant.

Qualitative Health Research, 16(1), 119-136.

• 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): 340-344.

• Dasarathy S. “Consilience in sarcopenia of cirrhosis. J Cachexia Sarcopenia Muscle.”

2012;3(4):225-37.

• 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: 1870-1879

• Makary MA, Segev DL, Pronovost PJ, et al. (June 2010). "Frailty as a predictor of surgical outcomes in
• lder patients". J. Am. Coll. Surg. 210 (6): 901–8.
• 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):213-9.

• Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation.

Occupational Therapy in Health Care, 25:4, 240-256.

• Toshikuni N et al, “Nutrition and exercise in the management of liver cirrhosis”. World J

Gastroenterol 2014 June 21; 20(23): 7286-7297

• 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):261-271.

Thank you

Young Na Lee OT Jamie Krueger PT Cate McDonough OT Heidi Engel PT DPT Shin Tatabe PT