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erythematous rash thar can progress to blistering and desquamation.

Liver manifestations include increased liver enzymes and bilirubin,

right upper quadrant pain, hepatomegaly, and jaundice. Gastrointestinal tract manifestations include nausea, vomiting, diarrhea, malabsorption, ileus, sloughing of intestinal mucosa, abdominal pain, cramping, and bloody stools.6,44 GYHD is treated with immunosuppressive medications, sllch as intravenous methylprednisolone and oral prednisone.46

Physical Therapy {or 80lle Marrow Trallsplalltatioll Recipients

Physical therapy is beneficial to BMT recipients during their long hospital stay. Discharge from the hospital typically occurs 2-4 weeks post transplantation. Prolonged bouts of malaise, fever, diarrhea, nausea, and pain from inflammation of mucous membranes of the mouth and digestive tract that usually accompany BMT can be debilitating

to patients. Initially, physical therapists provide a gentle exercise program to prevent deconditioning and muscle atrophy from disuse and improve functional mobility as patients slowly regain their strength.

When patients are confined to their rOOmS because of protective isolation, they often use a stationary bicycle or resrorator (a portable device that a patient can pedal seated at the bedside Ot in a chair) as

part of their exercise prescription. BMT recipients typically require 6

months to a year before they recover full strength and return to a normal lifestyle.46

General Physical Therapy Guidelines for

Transplant Recipients

Physical therapists play an integral role in the rehabilitation of transplant recipients. With the exception of BMT recipients, the length of stay in an acute care hospital, depending on the type of organ transplantation and barring any complications, ranges from 3 to 16 days:

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AClIrE CARE HANDBOOK FOR PHYSICAL THERAPISTS

kidney, 3-7 days; liver, heart, and lung, 10-H days; pancreas, 5-12

days; kidney-pancreas, 10-16 days7.1J.Il,J9 Given the short length of

stay for transplant recipients, physical therapists are consulted in the

early postoperative period to provide treatment and assist the transplant team with a safe discharge plan. If patients are medically stable but need assistance for activities of daily living and ambulation, they

will require transfer to a rehabilitation facility for further physical

and occupational therapy before discharge home.

Goals

In the acute care setting, the primary physical therapy goals are similar to those of postoperative abdominal or cardiothoracic surgical patients. They include maximizing functional mobility and endurance; improving range of motion, strength, balance, and coordination; and progressing the recipient to his or her maximum independent functional level safely.

Many transplant recipients have experienced end-stage organ disease for multiple years before receiving their transplant and may present with other medical comorbidities. As a result, they are usually

physically deconditioned and present with a marked reduction in

exercise capacity and skeletal muscle strength owing to long-standing

pretransplant physical inactivity. For example, extreme fatigue and

weakness are exhibited in patients with chronic liver disease, reduced

muscle endurance is seen in patients with chronic heart failure, and

decreased oxygen uptake capacity is exhibited in heart and lung disease.1 Generalized weakness results from the disease process, fluid and electrolyte imbalance, and poor nutrition. After their transplant,

recipients generally require a longer time frame ro regain their

strength and endurance and to achieve their goals.

Basic COllcepts for the Treatment of Trallsplallt Recipiellts

• Coordinate the best time for physical therapy with the patient'S

nurse each day. The patient may be fatigued after nursing intervention or medically inappropriate for exercise owing to a decline in medical status, especially in the intensive care unit or early in the

postoperative course.

ORGAN TRANSPLAI'ITATION

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• Analyze laboratory values daily, as they may change dramatically from day to day. Many recipients have very low platelet counts immediately post transplantation. Patients with low platelet

counts or increased PT, PTT, Ot both are at risk for bleeding. It is

usually contraindicated to perform percussion on patients with a

platelet count less than 50,OOO/mmJ. Therefore, in this situation,

bronchopulmonary hygiene consists of coughing and performing

deep-breathing exercises, using the incentive spirometer, and

encouraging the patient to splint their incision to cough and mobilize to prevent pneumonia.

• Supine therapeutic exercise in the acute care setting is implemented only if necessitated by the recipient'S condition, such as high fever, chills, bed rest restriction secondary to ventilator use, or

low platelet count. (A high temperature will result in elevated respiratory and heart rates; therefore, it is important to avoid strenuous cardiovascular and resisted exercise during this time.)

• Generally, patients with an uncomplicated postoperative course

should be out of bed to chair and ambulating in their rooms with

assistance 24-48 hours after surgery, with close monitoring of vital

signs. Early ambulation helps to decrease the risk of cardiovascular

and pulmonary infection, increase blood circulation, stimulate gastrointestinal function, relieve gas pains, and maintain muscle tone7•18 Many post-transplant patients retain fluid, especially in

the lower extremities. Weight bearing may be painful; however,

ambulation for shorr periods of time should still be encouraged.

The recipient's balance may be altered secondary to increased fluid

retention, and he or she may require the use of an assistive device.

The physical therapist will be required to provide assistance or

appropriate guarding to maintain maximum safety.

• Always monitor and document vital signs, oxygen saturation,

and RPE (for cardiac transplant recipients) before, during, and

after physical therapy intervention. Report any abnormal change

in the patient's response to activity to the patient's nurse. An activity log or flow sheet may be used to document daily progress or decline and vital sign responses.

• Many patients experience some form of organ rejection. If

approved by the transplant team, exercise generally continues if

their rejection episode is mild to moderate."·41

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AcmE CARE HANDBOOK FOR PHYSICAL THERAPISTS

• The adverse effects of corticosteroids produce delayed wound

healing and can contribute to osteoporosis. Upper-extremity resistive training (for cardiac and lung rransplanr recipients) should be delayed until 6 weeks post transplant, when wound and tissue

healing is complete.4I Patienrs should be instructed in postural

awareness, alignment, exercise, and optimal body mechanics to

com bar rhe effects of osteoporosis.J7

• In addition to the recipient's current medical staws, other preexisting impairments or medical conditions, such as low back pain, peripheral neuropathy, or arthritis, may affect the recipient's activity tolerance. Thus, exercise should be modified according to the patient's ability.

Activity Progressioll

• Activity is increased gradually, and treatment continues until the

parient is ambulating independently with sufficient endurance to

function safely ar home. At first, recipienrs will fatigue easily and

require frequent rest periods. Thus, shorrer and more frequent

treatment sessions are beneficial to patients.

• Ambulation is progressed in terms of frequency, pace, and duration. Stair climbing is progressed with the goal of achieving one to two flights of reciprocal stair climbing.

Patient Education

• Physical therapists assist in the education of transplant recipients. Recipients must assume an active role in their health care post transplantation. Patients are educated about what to expect after

transplantation. Initially, the recipient is very weak and may have

difficulty learning during the early post-transplant rehabilitation

phase. The physical therapist reinforces the activity protocol with

the patient. The transplant team usually provides the recipient with

a comprehensive guide that includes information on medications,

proper diet, exercise, and psychosocial changes. The patient must