Supportive Care in Cancer

, Volume 26, Issue 9, pp 3135–3141 | Cite as

Bleeding frequency and characteristics among hematologic malignancy inpatient rehabilitation patients with severe thrombocytopenia

  • Jack B. Fu
  • Jegy M. Tennison
  • Isabel M. Rutzen-Lopez
  • Julie K. Silver
  • Shinichiro Morishita
  • Seyedeh S. Dibaj
  • Eduardo Bruera
Original Article



To identify the frequency and characteristics of bleeding complications during acute inpatient rehabilitation of hematologic malignancy patients with severe thrombocytopenia.


Retrospective descriptive analysis.


Comprehensive cancer center acute inpatient rehabilitation unit.


Consecutive hematologic malignancy patients with a platelet count of less than or equal to 20,000/microliter (μL) on the day of acute inpatient rehabilitation admission from 1/1/2005 through 8/31/2016.


Medical records were retrospectively analyzed for demographic, laboratory, and medical data. Patients were rehabilitated using the institutional exercise guidelines for thrombocytopenic patients.

Main outcome measures

Bleeding events noted in the medical record.


Out of 135 acute inpatient rehabilitation admissions, 133 unique patients were analyzed with a total of 851 inpatient rehabilitation days. The mean platelet count was 14,000/μL on the day of admission and 22,000/μL over the course of the rehabilitation admission. There were 252 days of inpatient rehabilitation where patients had less than 10,000/μL platelets. A total of 97 bleeding events were documented in 77/135 (57%) admissions. Of the 97 bleeding events, 72 (74%), 14 (14%), and 11 (11%) were considered to be of low, medium, and high severity, respectively. There were 4/97 (4%) bleeding events that were highly likely attributable to physical activity but only 1/4 was considered high severity. Bleeding rates were .09, .08, .17, and .37 for > 20,000, 15–20,000, 10–15,000, and < 10,000/μL mean platelet counts respectively (p = .003). Forty-four percent of patients were transferred back to the primary acute care service with infection being the most common reason for transfer.


This study is the first to examine exercise-related bleeding complications during acute inpatient rehabilitation in severely thrombocytopenic hematologic cancer patients. Bleeding rates increased with lower platelet counts. However, using the exercise guidelines for severely thrombocytopenic patients, the risk of severe exercise-related bleeding events was low.


Thrombocytopenia Cancer Rehabilitation Physical activity Exercise 


Funding information

This study was supported in part by the M.D. Anderson Cancer Center support grant # CA 016672.

Compliance with ethical standards

The approval for this study was obtained from the institutional review board (IRB). A waiver of informed consent was granted by the IRB in compliance with federal and institutional guidelines.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Liebman HA (2014) Thrombocytopenia in cancer patients. Thromb Res 133(Suppl 2):S63–S69CrossRefPubMedGoogle Scholar
  2. 2.
    Kantarjian H, Giles F, List A, Lyons R, Sekeres MA, Pierce S, Deuson R, Leveque J (2007) The incidence and impact of thrombocytopenia in myelodysplastic syndromes. Cancer 109(9):1705–1714CrossRefPubMedGoogle Scholar
  3. 3.
    Kuznetsov AI, Ivanov AL, Idelson LI, Mazurov AV (1992) Mechanisms of thrombocytopenia in patients with lymphoproliferative diseases. Eur J Haematol 49:113–118CrossRefPubMedGoogle Scholar
  4. 4.
    Johnson RA, Roodman GD (1989) Hematologic manifestations of malignancy. Dis Mon 35(11):721–768CrossRefPubMedGoogle Scholar
  5. 5.
    Dorgalaleh A, Mahmudi M, Tabibian S, Khatib ZK, Tamaddon GH, Moghaddam ES, Bamedi T, Alizadeh S, Moradi E (2013) Anemia and thrombocytopenia in acute and chronic renal failure. Int J Hematol Oncol Stem Cell Res 7(4):34–39PubMedPubMedCentralGoogle Scholar
  6. 6.
    Reese JA, Nguyen LP, Buchanan GR, Curtis BR, Terrell DR, Vesely SK, George JN (2013) Drug-induced thrombocytopenia in children. Pediatr Blood Cancer 60(12):1975–1981CrossRefPubMedGoogle Scholar
  7. 7.
    Hütter G, Ganepola S, Hofmann WK (2009) The hematology of anorexia nervosa. Int J Eat Disord 42:293–300CrossRefPubMedGoogle Scholar
  8. 8.
    Juvela S, Hillbom M, Palomäki H (1995) Risk factors for spontaneous intracerebral hemorrhage. Stroke 26:1558–1564CrossRefPubMedGoogle Scholar
  9. 9.
    Winningham ML, MacVicar MG, Burke CA (1986) Exercise for cancer patients: guidelines and precautions. Physician Sports Med 14:125–134CrossRefGoogle Scholar
  10. 10.
    Jarden M, Hovgaard D, Boesen E, Quist M, Adamsen L (2007) Pilot study of a multimodal intervention: mixed-type exercise and psychoeducation in patients undergoing allogeneic stem cell transplantation. Bone Marrow Transplant 40(8):793–800CrossRefPubMedGoogle Scholar
  11. 11.
    Baumann FT, Zopf EM, Nykamp E, Kraut L, Schüle K, Elter T, Fauser AA, Bloch W (2011) Physical activity for patients undergoing an allogeneic hematopoietic stem cell transplantation: benefits of a moderate exercise intervention. Eur J Haematol 87(2):148–156CrossRefPubMedGoogle Scholar
  12. 12.
    Maltser S, Cristian A, Silver JK, Morris GS, Stout NL (2017) A focused review of safety considerations in cancer rehabilitation. PMR 9(9 Suppl 2):S415–S428CrossRefGoogle Scholar
  13. 13.
    Tompkins J, Norris T, Levenhagen K, et al. (2017) Academy of acute care physical therapy task force on lab values. Laboratory Values Interpretation Resource Available at Accessed Sept 2017
  14. 14.
    Morishita S, Kaida K, Setogawa K, Kajihara K, Ishii S, Ikegame K, Kodama N, Ogawa H, Domen K (2013) Safety and feasibility of physical therapy in cytopenic patients during allogeneic haematopoietic stem cell transplantation. Eur J Cancer Care 22(3):289–299CrossRefGoogle Scholar
  15. 15.
    Elter T, Stipanov M, Heuser E, von Bergwelt-Baildon M, Bloch W, Hallek M, Baumann F (2009) Is physical exercise possible in patients with critical cytopenia undergoing intensive chemotherapy for acute leukaemia or aggressive lymphoma? Int J Hematol 90(2):199–204CrossRefPubMedGoogle Scholar
  16. 16.
    Shin KY, Bishop M, Kendall D, Washington C, Yi A (2002) Bleeding complications after physical therapy in the thrombocytopenic patient. Multinational Association of Supportive Care in Cancer 14th International Symposium, Boston, Massachusetts, June, 2002Google Scholar
  17. 17.
    Shahpar S, Gamble GL, Marciniak CM, Spill GR (2011) Poster 23 are there adverse effects to rehabilitation in cancer patients with thrombocytopenia? PM R 3(10 Suppl 1):S183CrossRefGoogle Scholar
  18. 18.
    Center for Medicare & Medicaid Services, Inpatient Rehabilitation Therapy Services: Complying with documentation requirements. Accessed 5 Jul 2017. Available at:
  19. 19.
    Klein JH (1990) Muscular hematomas: diagnosis and management. J Manip Physiol Ther 13:96–100Google Scholar
  20. 20.
    Engbers MJ, Blom JW, Cushman M, Rosendaal FR, van Hylckama Vlieg A (2014) The contribution of immobility risk factors to the incidence of venous thrombosis in an older population. J Thromb Haemost 12(3):290–296CrossRefPubMedGoogle Scholar
  21. 21.
    Bergenthal N, Will A, Streckmann F, Wolkewitz KD, Monsef I, Engert A, Elter T, Skoetz N (2014) Aerobic physical exercise for adult patients with haematological malignancies. Cochrane Database Syst Rev 11:CD009075Google Scholar
  22. 22.
    Zhou Y, Zhu J, Gu Z, Yin X (2016) Efficacy of exercise interventions in patients with acute leukemia: a meta-analysis. PLoS One 11(7):e0159966CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Smith-Turchyn J, Richardson J (2015) A systematic review on the use of exercise interventions for individuals with myeloid leukemia. Support Care Cancer 23(8):2435–2446CrossRefPubMedGoogle Scholar
  24. 24.
    Almstedt HC, Grote S, Korte JR, Perez Beaudion S, Shoepe TC, Strand S, Tarleton HP (2016) Combined aerobic and resistance training improves bone health of female cancer survivors. Bone Rep 5:274–279CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Morishita S, Tsubaki A, Fu JB (2017) Does physical activity improve survival and mortality among patients with different types of cancer? Future Oncol 13(12):1053–1055CrossRefPubMedGoogle Scholar
  26. 26.
    Broderick CR, Herbert RD, Latimer J, Barnes C, Curtin JA, Mathieu E, Monagle P, Brown SA (2012) Association between physical activity and risk of bleeding in children with hemophilia. JAMA 308(14):1452–1459CrossRefPubMedGoogle Scholar
  27. 27.
    Frey PM, Méan M, Limacher A, Jaeger K, Beer HJ, Frauchiger B, Aschwanden M, Rodondi N, Righini M, Egloff M, Osterwalder J, Kucher N, Angelillo-Scherrer A, Husmann M, Banyai M, Matter CM, Aujesky D (2015) Physical activity and risk of bleeding in elderly patients taking anticoagulants. J Thromb Haemost 13(2):197–205CrossRefPubMedGoogle Scholar
  28. 28.
    National Cancer Institute, Division of Cancer Treatment & Diagnosis, NCI common toxicity criteria. Accessed 5 Jul 2017. Available at:
  29. 29.
    Slichter SJ (2004) Relationship between platelet count and bleeding risk in thrombocytopenic patients. Transfus Med Rev 18(3):153–167CrossRefPubMedGoogle Scholar
  30. 30.
    Freireich EJ (1966) Effectiveness of platelet transfusion in leukemia and aplastic anemia. Transfusion 6(1):50–54CrossRefGoogle Scholar
  31. 31.
    Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, Cipolle MD, Cohn CS, Fung MK, Grossman BJ, Mintz PD, O'Malley BA, Sesok-Pizzini DA, Shander A, Stack GE, Webert KE, Weinstein R, Welch BG, Whitman GJ, Wong EC, Tobian AA, AABB (2015) Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med 162(3):205–213CrossRefPubMedGoogle Scholar
  32. 32.
    Gmür J, Burger J, Schanz U, Fehr J, Schaffner A (1991) Safety of stringent prophylactic platelet transfusion policy for patients with acute leukaemia. Lancet 338(8777):1223–1226CrossRefPubMedGoogle Scholar
  33. 33.
    Beutler E (1993) Platelet transfusions: the 20,000/microL trigger. Blood 81(6):1411–1413PubMedGoogle Scholar
  34. 34.
    Gyan E, Dreyfus F, Fenaux P (2015) Refractory thrombocytopenia and neutropenia: a diagnostic challenge. Mediterr J Hematol Infect Dis 7(1):e2015018CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Baharoglu MI, Cordonnier C, Al-Shahi Salman R, de Gans K, Koopman MM, Brand A, Majoie CB, Beenen LF, Marquering HA, Vermeulen M, Nederkoorn PJ, de Haan RJ, Roos YB, PATCH Investigators (2016) Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 387(10038):2605–2613CrossRefPubMedGoogle Scholar
  36. 36.
    Fu JB, Lee J, Smith DW, Bruera E (2013) Frequency and reasons for return to the primary acute care service among leukemia patients undergoing inpatient rehabilitation. Am J Phys Med Rehabil 92(3):215–222CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Fu JB, Lee J, Smith DW, Guo Y, Bruera E (2013) Return to primary service among bone marrow transplant rehabilitation inpatients: an index for predicting outcomes. Arch Phys Med Rehab 94(2):356–361CrossRefGoogle Scholar
  38. 38.
    Fu JB, Lee J, Shin BC, Silver JK, Smith DW, Shah JJ, Bruera E (2017) Return to the primary acute care service among patients with multiple myeloma on an acute inpatient rehabilitation unit. PM R. 9(6):571–578CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Jack B. Fu
    • 1
  • Jegy M. Tennison
    • 1
  • Isabel M. Rutzen-Lopez
    • 1
  • Julie K. Silver
    • 2
  • Shinichiro Morishita
    • 3
  • Seyedeh S. Dibaj
    • 4
  • Eduardo Bruera
    • 1
  1. 1.Department of Palliative, Rehabilitation & Integrative Medicine, Unit 1414University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Physical Medicine & RehabilitationHarvard Medical School & Spaulding Rehabilitation HospitalBostonUSA
  3. 3.Institute for Human Movement and Medical SciencesNiigata University of Health and WelfareNiigataJapan
  4. 4.Department of BiostatisticsUniversity of Texas MD Anderson Cancer CenterHoustonUSA

Personalised recommendations