Phase 1. Pre-rehabilitation
The physical function of HSCT patients is already impaired prior to HSCT.46) In addition, patients experiencing sarcopenia prior to HSCT experience decreased muscle strength and are generally more fatigued than non-sarcopenic patients.47) Furthermore, the QOL of patients with sarcopenia has been found to be lower than that of patients without sarcopenia.47)
Recently, the safety and feasibility of exercise therapy initiated prior to HSCT have been reported.11) Exercise therapy should be started as early as possible after diagnosis of hematological disease to prevent pre-transplant physical function decline. Rupnik et al.17) reported that the exercise prescription included 20-30 min of aerobic exercises at least 4 days per week and 10-20 min of strength exercises at least 3 days per week.
In the “pre-rehabilitation” period, an initial assessment is performed and the goal is to maintain physical activity (Fig. 2).
Phase 2. Admission to HSCT
At the start of exercise therapy during the HSCT inpatient period, the need for exercise therapy, an exercise program, self-directed exercise, and handling of complications should be fully explained. Regimen-related toxicity (RRT), such as nausea and diarrhea caused by preconditioning treatment, makes rehabilitation difficult for many patients. If RRT is observed, low-intensity interventions such as stretching and relaxation should be continued. In terms of physical activity, the total number of daily steps and the proportion of activity performed at 1.6-2.9 metabolic equivalents (METs) and > 3.0 METs were positively correlated with the 6 min walk distance.30) The physical therapist should also be aware of the importance of maintaining activity in their approach, because maintaining physical activity can prevent decline in physical function after transplantation. During the preconditioning treatment period, the patient is often in relatively good physical condition; thus, the physical therapist should focus on endurance training as much as possible (Fig. 2,3).
Phase 3. The day of HSCT to engraftment
On the day of HSCT, exercise therapy should be continued if possible. After HSCT, RRT is observed, making it difficult for patients to maintain physical activity. It is also important for the therapist to encourage the patient to continue stretching and promote sitting alone even when they are experiencing nausea, diarrhea, and fever (except for body temperatures over 38°C4)), with a full explanation on why it is important. The goals of rehabilitation intervention during this period are to maintain the patient's ADLs and to continue exercise therapy, even for short periods of time. Even if rehabilitation cannot be performed, it is also important to continue to evaluate patients’ movements such as basic activities (sitting and standing up) and walking to the toilet. During the period of low blood cell counts before engraftment, it is necessary to thoroughly manage the risks when performing exercise. Patients are also encouraged to manage their own risk by the attending physician, nurse or physical therapist, by explaining to them the precautions they should take in performing daily activities when anemia and low platelet counts are observed. Particular attention should be paid to the prevention of head bruising and falls when platelets are low. During the period of myelosuppression, the patient is susceptible to infection, so the therapist should pay close attention to infectious diseases and continue exercise intervention (Fig. 2,3).
Phase 4. Engraftment to discharge from the hospital
After WBC engraftment, patients may experience a variety of symptoms, including difficulty eating, persistent fatigue, and persistent diarrhea due to GvHD.13,48) Fatigue is also a significant factor that can limit the effectiveness of exercise therapy.48) When these symptoms are observed, rehabilitation becomes difficult and patients may need assistance with ADL. It is important to maintain the patient’s activity level by continuing daily exercise, even if only for short periods of time, if possible.
Many patients who are hospitalized for an extended period of time become less motivated to be active. Positive feedback from the therapist on improvements such as muscle strength, endurance, and activity level may lead to an improvement in the patient's motivation.
Falls are also a concern in long-term hospitalization. They are reported to occur more frequently after engraftment than before engraftment, and are related to the use of opioids and lower limb muscle weakness.49) Patients may have difficulty walking due to bed rest caused by GvHD (especially in the gastrointestinal) or viral infections after HSCT, so daily assessment and appropriate movement instruction (particular measures to prevent falls) are important.
At the time of discharge from hospital, the ability to move (walk) is the main concern, but it is also necessary to confirm that the patient is able to perform the activities necessary for living at home. Especially when the ability to climb steps and stairs is necessary to return home, such exercise should be continued from an early stage.
In this phase, the goals of exercise therapy are to restore decreased physical function and ADLs, and discharge from the hospital (Fig. 2, 3).
Phase 5. Outpatient rehabilitation
In Japan, many HSCT facilities provide rehabilitation during HSCT hospitalization, but after discharge from the hospital, patients are left to perform voluntary activities on their own. Therefore, prior to discharge, patients need to be instructed on the exercises that they should do at home (Fig. 2). In recent years, support has been provided by the Long-term Follow-up (LTFU) outpatient clinic. LTFU is carried out at 3 months, 6 months and 1 year following discharge, then every year thereafter.50) The role of the physical therapist in the LTFU is to conduct an assessment, understand the patient’s current physical function and activity level based on the assessment results, and adjust the patient’s exercise program accordingly.
The recommended amount of physical activity after discharge from the hospital is aerobic exercise for a weekly total of at least 150 minutes (for moderate load) over 3-5 days per week, daily stretching, and strength training two or three times per week.29,36,43) Risk management in post-discharge rehabilitation includes ultraviolet protection (prevention of GvHD of the skin) and infection control (e.g., herpes zoster, aspergillus pneumonia, viral cystitis). For patients on long-term steroid administration due to chronic GvHD, it is important to watch for complications of osteonecrosis, osteoporosis, and myopathy.