April 1, 2014
Since the first organ transplant nearly 59 years ago, outcomes have improved dramatically, thanks to refined surgical techniques and more potent immunosuppressive drugs. But the rehab is no less grueling, says R. Samuel Mayer, vice chair for education for the Department of Physical Medicine and Rehabilitation at the Johns Hopkins University School of Medicine. Myriad side effects from the medications can trigger a host of challenges for patients. Medications can cause rare infections and debilitating neuromuscular complications including neuropathy, myopathy, delirium and stroke.
Fortunately, says Mayer, most transplant patients are highly motivated. For their part, Johns Hopkins physiatrists typically intervene early. Working together with the surgery team, they assess patients’ musculoskeletal and neurologic function before and immediately after the transplant. “Getting patients mobilized early after the transplant greatly improves outcomes,” says Mayer. Even simple bedside isometric exercise, he says, can ward off muscle atrophy.
Although some side effects are predictable, Mayer says transplant rehab can never rely on a cookbook approach. Heart transplant patients, for example, have a different physiology from non-transplanted patients, explains Mayer. And, because their hearts are de-enervated, these patients may not feel chest pain. “So we educate them about monitoring other symptoms, like shortness of breath.”
Over the course of the one- to two-week stay on the rehab unit, patients learn how to manage a complicated regimen of medications and side effects. Patients often report trouble swallowing or struggle with low endurance, poor balance or a specific nerve problem that requires electrical stimulation. The entire team, which includes nurses, psychologists, pharmacists, speech language pathologists, physical and occupational therapists, works together to tackle each patient’s setbacks.
Daunting as rehab can be for these patients, says Mayer, “most of them do get better.” Kidney transplant patients do best, with a 90 percent survival rate; five-year survival rates for most other transplants exceed 70%.
Yet even the sickest can rally, he notes, when the team develops individualized care plans. Recently, a 48-year-old liver transplant patient became quadriplegic from neuropathy and myopathy and also suffered with acute delirium and skin eruptions. “She was sick for a long time and had very complex needs,” says Mayer. “We were able to manage her complex multi-organ system impairments and provide her intensive rehabilitation services, and she improved to an independent level.”
With rising transplant rates and the emergence of more diverse and groundbreaking procedures, like face transplants and multiple limb transplantation, says Mayer, the need for rehab services continues to grow.
Unique Rehab Challenges in Organ Transplant Patients
Liver: delirium, metabolic imbalances, nerve palsies
Heart: shortness of breath, sternal precautions, myopathies
Lung: secretions, hypoxemia, dysphagia, tracheostomies, exercise intolerance, muscle atrophy
Kidney: edema, electrolyte abnormalities, neuropathy