A.J. Costin Callie Eaves Dan Purdy and Lauren Willis from the Pathophysiology of Complex Patient Problems Program at Bellarmine University’s Physical Therapy Program.
Hodgkin lymphoma is a cancer of unknown cause. Important clinical features include: Origin and spread of cancer in lymph nodes. Symptoms most commonly listed included: painless lymphadenopathy and systemic symptoms. an uncommon nonspecific symptom One mentioned in the study but commonly experienced by patients is low back pain (LBP). Perhaps due to the sheer commonality of LBP, LBP and lymphoma are rarely associated. Lymphoma-associated LBP can occur due to pressure on muscles, nerves and other sites from enlarged lymph nodes in the abdomen There is a high incidence of tissues and metastases complementary to LBP, such as in this case. The following case study describes a 61-year-old man who complained of low back and hip pain that did not return with exercise, along with fatigue and generalized discoordination. 
- Demographic Information: Mr. Hodgkin is a 61 year old white male. He worked as an electrical engineer for 30 years. 
- Medical Diagnosis: Referral by primary care physician for low back pain (LBP) due to history of herniated disc. No recent images. MRI 5 years ago.
- Comorbidities: HTN BMI = 27 Hyperlipidemia
- Previous Physical Therapy: Mr. Hodgkin had received physical therapy five years ago for a herniated disc at L4-L5.
Mr Hodgkins reported a four-month history of low back pain, which had recently shifted to his left hip. He said the pain was different from his previous low back pain; it was just below his hip, and this was the first time he had experienced hip pain. His main complaint is that when He comes home from get off work, too tired to go fishing or work in his lumber shop. He says his doctor directed him to diet and exercise to lose weight and lower his HTN and cholesterol, but says he just doesn’t have the energy to exercise or pursue his usual hobbies. However he has Though he’s not sure how much weight he’s lost. Pt reported that the pain kept him awake at night and seemed unable to feel comfortable, and that sitting for long periods of time at work bothered him. He said that he recently started doing some His final therapists; they helped a little at first, but didn’t seem to make much of a difference.
- Patient’s past medical history: The patient reported that both HTN and high cholesterol were treated with medication. The patient was hospitalized 10 years ago for infectious mononucleosis and he reported that his mother had died 10 years earlier from CA of the breast. Patient reports no other significant past medical history (liver lung DM kidney) and he does not smoke and rarely drinks alcohol in social situations as he has noticed that drinking makes his pain worse.
- Medication: Lisinopril Crestor and Aleve (prn)
- Patient Goal: His main goal is to reduce pain and increase his stamina so he can get back to fishing and working in the woodshop.
- Self-reported outcome measures: Numeric Pain Scale (0-10) 4 at best, 5 at worst, persistent pain ; Oswestry Disability Index (46%) 
- Physical performance measure: 2-minute walk test RPE: 16 (distance 125 m; cardiovascular response WNL distance reduction may be due to fatigue and need for rest)
- ROM: Lumbar spine ROM was 75% of normal with no increase in pain with exercise; hip ROM was 75% of normal with no increase in pain with exercise. All other ROM measurements within functional limits are painless.
- Reflexes: +2 for L3/4, L5, and S1
- Sensation: Normal
- MMT: 4+/5 on LE general exam
- Palpation: Hip pain not recurring, center of sacrum tender, Castell positive on percussion and palpation
- Special tests: + Slump test  Negative SLR on both sides  – FABER test 
Mr. Hodgkin presented physical therapy for low back pain and left hip pain. He has a history of LBP and has responded well to prior physical therapy. His present symptoms were not consistent with his previous symptoms nor consistent with musculoskeletal pain.  The following symptoms appear Guaranteed need for further systematic screening by his primary care physician: Pain is constant and does not reproduce with exercise Fatigue during low-intensity activities General malaise with cancer history in major family member Infectious mononucleosis Shi Fei loses weight on purpose + Castell’s and lumbar percussion tests were positive. 
Summarization of Examination Findings
1. Cancer – metastases to lumbar/sacral region 
The following findings point to this potential working diagnosis: Age-constant non-acute pain that does not recur with movement and wakes the patient at night The dominant family member who consumed alcohol had CA and positive Castell’s percussion and lumbar percussion tests.
2. Biomechanical lumbar spine dysfunction (possibly hernia) with hip pain 
The following findings point to this potential working diagnosis: Past medical history of disc herniation and positive response to physical therapy Age of possible radiculopathy Complaints of increased flexion pain (sitting position) Decreased lumbar ROM and positive Slump test.
3. Relapse of Epstein Barr virus/mononucleosis 
The following diagnosis determined this potential syndrome: weight loss fatigue positive Castell’s Percussion and history of the disease.
Mr. Hodgkin returned to his PCP. After further medical examination and testing, she was diagnosed with Hodgkin’s lymphoma that had spread to the spinal cord (L5-S1). The patient began using chemotherapy and radiation after undergoing surgery to remove a malignant tumor in the spinal cord. He continuing exercise with each PCP in order to increase cardiovascular/pulmonary health improves strength and flexibility improves lymphedema and reduces fatigue and symptoms from cancer and treatments . . . .
Phases of Interventions
- Phase I – primary goals reduce fatigue reduce risk of falls and promote endurance. Interventions include patient education on fatigue management fall risk assessment general aerobic exercise with cycle ergometer ambulation cycling (anitoring cardiovascular/pulmonary response) and spreading to encourage change. Initiate lymphedema therapy and teach the patient about lymphedema management at home. Incorporate balance training to address the risk of falling due to any vestibular issues or other balance issues caused by cancer treatment.
- Phase 2 – Continued expansion of general aerobic exercise program and lymphedema management at home; initiate progressive resistance exercise (PRE) to improve strength and enhance function through both ADLs and community involvement. Include interventions to improve functional movement and promote correctness movement program (walk training squat training standing ADLs) .
- Phase 3: Promote independence with ADLs IADLs and both strength training and aerobic exercise. Reintegration into community life. Meet patient goals; encourages the patient’s ability to fish and continues woodworking.
Dosage and Parameters:
- Aerobic training: Start with low impact aerobic traning (cycle ergometer bike) progressing to ambulation on the floor. Start with 10 minutes a day and progress to 30 minutes a day 3-4 times/week.
- Strength and resistance training: Functional closed chain exercises (mini-squats lunge matrix stair training etc.) for LE resistance band/weight training for posture stabilizers and UE for increasing core strength). Perform each exercise 8-12 reps 2-3 sets to point of fatigue but not beyond that point. 20-30 minutes 2-3 times per week and progress as tolerated.
Rationale for Progression
- Patients are enhanced to maintain/improve fitness status during treatment and enhance overall quality of life. Patient develops as he/she can tolerate to experience the effects of treatment. Collaborate with PCP and oncologist.
- Appropriate chemotherapy radiation diet and psychological counseling
The Patient Health Questionnaire (PHQ-9) was administered to assess quality of life/risk of depression after the patient was diagnosed with CA. Mr. Hodgkin’s initial score was 14 with moderate depressive symptoms. When he was released his score was a 9 indicating he had moved from moderate depressive symptoms to mild depressive symptoms. The patient reported that therapy gave her something to do helped her feel better throughout her CA treatment and improved her quality of life.
At the time of discharge the patient had increased 2-minute walking distance and her RPE at the time of examination had decreased to 12; oswestry scores had decreased to 27% disabled; and the patient’s back and hip pain had decreased. He did have other side effects from the chemotherapy and radiation therapy but these were not PT related.
Back pain as in this case is a very common musculoskeletal condition that is treated with physical therapy; but it is also a common referral point for other systemic resources. In Mr. Hodgkin’s situation it was critical that the physiotherapist be able to correctly identify given red flags and was able to recognize when appropriate discipline needed to be directed so as not to delay appropriate treatment.
According to Goodman and Fuller “There are currently no formal policies addressing the problems associated with cancer and cancer treatment faced by the physical therapist.” However due to adverse effects of cancer including renal impairment and postoperative complications including limited ROM pain disuse pain sensory loss weakness DVT and lymphedema physical therapist can play a significant role in maintaining a cancer patient’s functional ability and quality of life. Additionally emerging research shows that exercise works to increase it exercise improves general self-efficacy and mastery reduces fatigue and distress and improves quality of life for patients completing cancer treatment. This study also revealed a direct correlation between physical activity and quality of life. This can be used support the need for physical therapy for cancer patients both during and after treatment. There is currently no protocol for these patients but with the support of emerging research one should be developed for this population. This also opens the door for niche practices of physical therapy in oncology.
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