ORIGINAL Journal of Acute Care Physical Therapy

STUDY

Physical Therapy Intervention

During a Red Blood Cell
Transfusion in an Oncologic
Population: A Preliminary
Study
Anson B. Rosenfeldt, Lauren M. Pilkey, Robert S. Butler

Anson B. Rosenfeldt, PT, DPT,

ABSTRACT NCS, MBA
Department of Rehabilitation and
Purpose: There is little evidence to guide physical therapists regarding Sports Therapy, Cleveland Clinic,
the safety of administering therapeutic intervention to individuals receiving M72, 9500 Euclid, Ave, Cleveland,
a red blood cell (RBC) transfusion. The purpose of this preliminary study OH 44195 (USA). rosenfa2@ccf.org.
was to examine the number of adverse events that occurred among
individuals with an oncologic diagnosis receiving physical therapy Lauren M. Pilkey, PT, DPT
intervention during an RBC transfusion. Department of Rehabilitation and
Sports Therapy, Cleveland Clinic,
Methods: Chart reviews were conducted, and physical therapy sessions Cleveland, Ohio.
were classified into the following groups: (1) physical therapy intervention
alone (PT) (n = 26 events); (2) physical therapy intervention during an Robert S. Butler, MS
RBC transfusion (PT + RBC) (n = 26 events); and (3) RBC transfusion Department of Quantitative Health
without physical therapist intervention (RBC) (n = 26 events). Sciences, Cleveland Clinic, Cleveland,
Ohio.
Results: There were 3 adverse events, all in the PT group: 2 episodes of
symptomatic drop in systolic blood pressure of more than 10 mm Hg with The authors have no conflicts of interest
position change, and 1 episode of the individual requesting to stop the and no source of funding to declare.
therapy intervention. The difference in adverse events between the groups
was not statistically significant (P = .10).
Conclusion: This study provides preliminary evidence that participation
in a well-monitored physical therapy session may be safe for individuals
with hematologic malignancies who are receiving an RBC transfusion
and that adverse events related to RBC transfusion are not influenced by
physical therapy intervention.

Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.

DOI: 10.1097/JAT.0000000000000046

20  JACPT ■ Volume 8 ■ Number 1 ■ 2017

Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.
Unauthorized reproduction of this article is prohibited.

W
ith more than 13 million units of blood trans-
fused annually in the United States,1 physical
therapists in the acute care setting are likely
to be faced with the decision of whether to provide
treatment to individuals receiving a red blood cell
(RBC) transfusion. Currently, there is little evidence
to guide physical therapists with the decision-making
process regarding the safety of treating this patient
population.
Red blood cells contain hemoglobin (Hb), the mol-
ecule that binds oxygen and transports it throughout
the circulatory system.2 Anemia, a decrease in RBCs,
may result in fatigue, weakness, dizziness, decreased
exercise tolerance, shortness of breath, and changes in
mental status.3 When Hb concentration is low, an RBC
transfusion can be administered to restore Hb concen-
tration, thus improving the amount of oxygen deliv-
ered to tissues.3 While Hb concentrations that trigger
transfusion may vary depending on the patient popula-
tion and individual situation, the AABB (formerly the
American Association of Blood Banks) recommends a
transfusion trigger of 7.0 g/dL or less in stable adult and
pediatric populations and Hb concentration of 8.0 g/dL
or less for individuals postoperatively or for symptoms
such as chest pain, orthostatic hypotension, tachycar-
dia or, congestive heart failure.4 Individuals can receive
multiple units of RBCs in a single day, each unit tak-
ing approximately 2 hours to transfuse. If therapeutic
intervention is withheld until transfusion completion,
an individual may miss an entire day of physical ther-
apy. Delaying therapeutic intervention decreases over-
all rehabilitation time, which has the potential to impact
length of stay and functional outcomes.5
While evidence guiding clinical decision mak-
ing about providing physical therapy intervention to
individuals receiving an RBC transfusion is sparse,
there is evidence to support that individuals with both
acute and chronic anemia can tolerate rehabilitation
programs.6-8 This evidence is relevant when making
clinical decisions about the provision of physical ther-
apy services to individuals during an RBC transfusion
since individuals who receive RBC transfusions are
almost always anemic. When examining individuals
who experience acute anemia after orthopedic and
cardiac surgical procedures, these individuals experi-
ence deficits in short-term functional outcomes and
increased length of hospitalization stays compared
with those without anemia; however, long-term func-
tional outcomes are similar.7,9-14
While individuals postoperatively tend to have
acute drops in Hb levels, individuals with an onco-
logic diagnosis tend to have chronically low Hb lev-
els for reasons including blood loss, displacement of
normal bone marrow cells by malignant cells, myelo-
toxic therapy, and tumors.15 The body is generally
able to adapt to mild and moderate chronic anemia
JACPT ■ Volume 8 ■ Number 1 ■ 2017
Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.
Unauthorized reproduction of this article is prohibited.
Physical Therapy During RBC Transfusion
through changes in the cardiovascular system, such as
a right shift in the oxyhemoglobin dissociation curve,
reduced blood viscosity, and increased sympathetic
response.16-18 A 2014 Cochrane review concluded that
aerobic exercise is feasible and can improve quality
of life, physical function, depression, and fatigue in
individuals with hematologic malignancies.6 When
specifically examining studies regarding exercise
among individuals with hematologic malignancies
in the inpatient setting, a variety of aerobic, strength,
and flexibility activities were found to be feasible
and result in maintenance or improvement in aerobic
endurance, fatigue, anxiety, and activity of daily liv-
ing performance.8,19,20
A recent survey found that physical therapists
and physical therapist assistants in the state of Ohio
reported variability in practice patterns regarding
the delivery of physical therapy intervention during
an RBC transfusion, with 54.8% of therapists feel-
ing comfortable administering therapy intervention to
an individual receiving an RBC transfusion.21 Prac-
titioners reported several reasons why they would
not evaluate or treat individuals who are receiving an
RBC transfusion including the individual would be
too ill or would not be able to tolerate the therapy, fear
of causing unstable vital signs or causing bleeding,
fear of dislodging the transfusion intravenous line,
and nurses or physicians would not allow it.21 In addi-
tion, the survey revealed that only 9.2% of therapists
reported that their hospital had a policy on adminis-
tering therapy during an RBC transfusion, meaning
that therapists were generally relying on their own
level of comfort to make the clinical decision to treat
or not treat these individuals.21 The decision to deliver
therapeutic intervention during an RBC transfusion
may be challenging for therapists when deliberating
the benefits of exercise and mobility compared with
the limitations of exercising with anemia along with
unclear guidelines and risks regarding this patient
population.
There are known medical risks to blood transfu-
sions, which can be categorized as infectious and
noninfectious.3 Medicine has made significant prog-
ress in reducing infectious risks of transfusions (ie,
hepatitis, HIV/AIDS, bacterial infections), and non-
infectious risks are currently the more common com-
plication.22 Briefly, more common noninfectious risks
of blood transfusions include transfusion-associated
circulatory overload, allergic reaction, transfusion-
related acute lung injury, hemolytic reaction, and
febrile reaction.3,22,23 Because of the pathology of
these risks, it is unlikely that participation in physical
therapy intervention would alter these medical risks.
However, it is not known whether physical therapy
intervention during an RBC transfusion would pose
additional risk.
21
Physical Therapy During RBC Transfusion

Because of the potential direct effect of this topic
on patient care and patient outcomes, a retrospective
chart review was conducted. The purpose of this pre-
liminary study was to examine safety of administer-
ing physical therapy intervention to individuals dur-
ing an RBC transfusion by comparing adverse events
in an oncologic population under the following condi-
tions: (1) physical therapy intervention alone (PT); (2)
physical therapy intervention during an RBC transfu-
sion (PT + RBC); and (3) RBC transfusion without
physical therapy intervention (RBC).
METHODS
This study was approved by the Institutional Review
Board of the Cleveland Clinic in Cleveland, Ohio.
A retrospective chart review was conducted over a
6-month period between September 1, 2012, and
March 1, 2013. An adult oncologic population was
selected because of the chronicity of low Hb counts
and the frequency of RBC transfusions in this patient
population. The charts of patients with inpatient hos-
pital admission to the Cleveland Clinic’s 44-bed leu-
kemia, lymphoma, and bone marrow transplant unit
were used for this review.
There were 3 primary groups of interest: (1)
physical therapy intervention alone (PT); (2) physical
therapy intervention during an RBC transfusion (PT
+ RBC); and (3) RBC transfusion without physical
therapy intervention (RBC). The physical therapists’
electronic documentation system contained branch-
ing logic that allowed study personnel to determine
whether an RBC transfusion had occurred during a
physical therapy treatment session and whether an
adverse event had subsequently occurred during that
same session. The adverse events listed in Table 1 were
compiled from a comprehensive literature review
as well as expert opinion from practitioners with
acute care experience.24-26 Using a patient-centered
therapeutic approach, as an individual requesting to
stop exercise was classified as an adverse event. The
branching logic also included a free-text option in
case the patient experienced an adverse event that was
not included on the list.
During this time period, there were a total of
30 physical therapy sessions, which were referred to
as events, in the PT + RBC group. Thus, an equal
number of individual events were reviewed in the
remaining 2 groups for a total of 90 events. Since there
were more than 30 events available for the PT and
RBC groups, a table of random numbers was used to
select the 30 events that would be reviewed. To create
3 independent groups, individuals who were in mul-
tiple groups were only included in 1 group, as detailed
in the “Results” section. Individuals were permitted to
have multiple events within the same group.
Variables of interest included Hb and hematocrit
from the day of interest, pre- and post-treatment vital
signs from the therapy session or RBC transfusion,
and the occurrence of adverse events during the ther-
apy session or RBC transfusion. For the PT and PT
+ RBC groups, the daily laboratory values as well as
the physical therapy treatment notes were reviewed to
gather the variables of interest. In addition, because
therapists were only in the room for a portion of the
transfusion process in the PT + RBC group, nursing
documentation was reviewed to ensure the capture of
any adverse events that had occurred during the entire
transfusion process. For the RBC group, nursing doc-
umentation was reviewed. Charts of adult patients on

TABLE 1. Classification of Adverse Events Documented in Physical Therapy Note

Unsafe change in vital signs

Drop in systolic blood pressure >10 mm Hg with exercise with symptoms such as dizziness, lightheadedness,
  headache, nausea24

Excessive rise in blood pressure: systolic pressure >200 mm Hg or diastolic pressure >115 mm Hg26

Heart rate: >85% of estimated maximal heart rate based on the individual’s age24

Oxygen saturation by pulse oximetry: <88% for 30 s25

Other events

Dislodging of intravenous site

Syncope

Individual requests to stop exercise

Reaction to blood products (hives, rigors, headache, chest pain, nausea, emesis, etc)25

22  JACPT ■ Volume 8 ■ Number 1 ■ 2017

Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.
Unauthorized reproduction of this article is prohibited.
 Physical Therapy During RBC Transfusion

the leukemia, lymphoma, and bone marrow unit who
had a referral for physical therapy were eligible for
review, regardless of specific diagnoses. Charts were
excluded if vital signs were not documented. RedCap,
a secure electronic database (https://projectredcap
.org/index.php), was used to store data and demo-
graphic information from selected charts.27
In addition, as a way to quantify the therapeutic
intervention performed by the patient, physical thera-
pist billing codes were recorded from the charts of
individuals in the PT and PT + RBC groups.
Statistical Analysis
The test for analysis of differences in individual
demographic variables across the 3 test groups was
run using analysis of variance methods for continuous
measures. Categorical measures were assessed using
a Chi-square test for gender differences and a Fisher’s
exact test for advent event occurrence. The choice of
test for the categorical variables was driven by the cell
count sizes and zero cell counts. The reported P values
in Table 2 are the overall P values for the comparison
across groups. Tukey-Kramer adjustments were made
for all pairwise comparisons. Those significant pair-
wise differences with an adjusted P value of less than
.05 are indicated in Table 2.
Comparisons of the frequency of type of billings
between the PT and PT + RBC groups were analyzed
using either χ2 tests or Fisher’s exact test. As with the
analysis of demographics, cell count sizes determined
the type of test used. A χ2 test was used for the billing
analysis, with the exception of the reevaluation and
neuromuscular reeducation where a Fisher’s exact test
was used because of the low cell count size.
RESULTS
A total of 65 individuals experienced 90 unique events.
Diagnoses were as follows: acute myeloid leukemia
(n = 33), acute lymphoid leukemia (n = 8), chronic
lymphocytic leukemia (n = 4), chronic myeloid leuke-
mia (n = 2), multiple myeloma (n = 4), myelodysplas-
tic syndrome (n = 3), type of lymphoma (n = 8), and

TABLE 2. Summary of Laboratory Values and Vital Signs by Groupa

Total PT-Only RBC-Only PT + RBC
(N = 78) (n = 26) (n = 26) (n = 26) P
Hemoglobin, g/dL 8.2 ± 1.0 9.2 ± 0.8b,c 7.7 ± 0.9d 7.8 ± 0.5d <.01

Hematocrit, % 24.3 ± 3.3 27.1 ± 2.7b,c 23.1 ± 3.3d 22.7 ± 1.6d <.01

Pretreatment systolic blood pressure, 123.8 ± 16.3 121.9 ± 18.5 123.2 ± 13.2 126.4 ± 17.0 .59
mm Hg

Posttreatment systolic blood pressure, 128.1 ± 15.5 122.4 ± 17.7 131.1 ± 14.3 130.7 ± 13.0 .07
mm Hg

Pretreatment diastolic blood pressure, 68.8 ± 10.5 68.4 ± 11.6 67.9 ± 9.2 70.2 ± 10.9 .70
mm Hg

Posttreatment diastolic blood pressure, 72.0 ± 10.6 70.3 ± 9.4 73.7 ± 10.7 71.9 ± 11.7 .52
mm Hg

Pretreatment heart rate, bpm 88.4 ± 17.3 96.8 ± 16.3b,c 84.5 ± 16.5d 83.9 ± 16.6d .01

Posttreatment heart rate, bpm 91.6 ± 17.3 101.9 ± 14.2b,c 84.2 ± 14.4d 88.8 ± 18.2d <.01

Pretreatment oxygen saturation, % 97.3 ± 2.3 96.7 ± 2.7 …e 97.9 ± 1.6 .05

Posttreatment oxygen saturation, % 97.1 ± 2.5 96.6 ± 3.2 …e 97.6 ± 1.5 .17
Abbreviations: bpm, beats per minute; PT-Only, physical therapy intervention alone; PT + RBC, physical therapy intervention during an
RBC transfusion; RBC, red blood cell; RBC-Only, RBC transfusion without physical therapist intervention.
a
Values presented as mean ± SD. Analysis of variance used for all variable analysis.
b
Significantly different from RBC-only.
c
Significantly different from PT + RBC.
d
Significantly different from PT-only.
e
Data not available for all subjects. Nursing staff did not document oxygen saturation during an RBC transfusion.

JACPT ■ Volume 8 ■ Number 1 ■ 2017 23

Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.
Unauthorized reproduction of this article is prohibited.
Physical Therapy During RBC Transfusion
other (n = 3). With the exception of 1 individual with
endometrial cancer, all individuals had a diagnosis of
a hematologic malignancy. Figure 1 is a flowchart pre-
senting the design of this retrospective study. Several
individuals were eligible for inclusion in more than 1
group. For example, a patient was seen for physical
therapy on Monday (PT group) and underwent physi-
cal therapy treatment during an RBC transfusion on
Thursday (PT + RBC group). To create 3 independent
groups for analysis, crossover was eliminated. Four
patients were in more than 1 group and had more than
1 recorded measurement in each. These patients were
assigned to the group in which they had recorded the
most measurements. Six patients had single measure-
ments in 2 groups. For purposes of analysis, these
patients were randomly assigned to either one or the
other group. Seven patients, including the 4 mentioned
earlier, had multiple measures within the same treat-
ment group. Since 7 patients with repeated measures
were too few to permit a repeated-measures analysis,
these patients too were randomly sampled to provide a
data set with a single measure per patient. The patients
with repeated measures were resampled and the analy-
sis was repeated. Across the resampled data sets, there
were no significant changes in outcomes. As a result,
repeated measures were included within a group. This
resulted in a total of 26 unique events in each group,
with a total number of subjects being 18, 26, and 21 in
the PT, RBC, and PT + RBC groups, respectively. For
FIGURE 1. Study flowchart. RBC indicates red blood cell.
24 
Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.
Unauthorized reproduction of this article is prohibited.
the PT, RBC, and PT + RBC groups, the mean sub-
ject age was 62.3 ± 12.3 years, 57.1 ± 16.5 years, and
52.5 ± 16.6 years, respectively (P = .16), whereas the
percentage of individuals who were male was 66.7%,
65.4%, and 61.9%, respectively (P = .95). Table 2 pro-
vides a summary of mean laboratory values and vital
signs for each group. The RBC and PT + RBC groups
had significantly lower Hb and hematocrit levels than
the PT group (P < .01). In addition, the PT group’s
pre- and post-treatment heart rate (HR) was statistically
greater than that of the RBC and PT + RBC groups
(P = .01 and P < .01, respectively). Nursing staff did
not document oxygen saturation in those patients in the
RBC group; therefore, this variable could not be com-
pared across all 3 groups.
There were a total of 3 adverse events, all in the
PT group. These adverse events were as follows:
symptomatic drop in systolic blood pressure of more
than 10 mm Hg with positional change (n = 2), and
the individual requesting to stop the therapy interven-
tion (n = 1). There were no adverse events in the PT
+ RBC or RBC group. The differences between the
3 groups were not statistically different, as calculated
with a Fisher’s exact test (P = .10).
The type of intervention provided was also exam-
ined in the PT + RBC and PT groups. The RBC-
only group did not have any physical therapy billing
information since the group members did not receive
any therapeutic intervention. There was no significant
JACPT ■ Volume 8 ■ Number 1 ■ 2017

difference in the number of units physical therapists
billed in each group in the following categories: evalu-
ations, reevaluations, gait training, and neuromuscular
reeducation. The therapists treating individuals in the
PT group billed significantly more units of therapeutic
activity (P < .01), whereas therapists treating individ-
uals in the PT + RBC group billed significantly more
units of therapeutic exercise (P < .01) (Table 3).
DISCUSSION
Participation in physical therapy interventions during
an RBC transfusion did not result in a single adverse
event. This study provides preliminary evidence that
participation in a well-monitored physical therapy
session may be safe for individuals with hematologic
malignancies who are receiving an RBC transfusion
and that adverse events related to RBC transfusion are
not exacerbated by physical therapy intervention. In
this review, a well-monitored session was considered
to be one where vital signs were monitored pre- and
post-treatment and therapists monitored for signs of
adverse events associated with the physical therapy
intervention and RBC transfusion (Table 1).
Table 2 reveals a significant difference in Hb and
hematocrit laboratory values, with the PT group hav-
ing significantly higher concentrations than the PT +
RBC and RBC groups. This is an expected difference,
given that at the Cleveland Clinic, a Hb concentra-
tion of less than 8.0 g/dL is the trigger for an RBC
transfusion in this patient population. Another signifi-
cant difference between the groups was in pre- and
posttreatment HR, with the PT group having a sig-
nificantly higher HR than the other 2 groups. It is not
known why the PT group at baseline had a higher HR,
TABLE 3. Units Billed by Physical
Therapist per Group
PT + RBC PT-Only
Evaluation, units 6 6
Reevaluation, units 1 0
Therapeutic activity, 7 23
units
Therapeutic 30 10
exercise, units
Gait training, units 8 11
Neuromuscular 1 0
reeducation, units
Abbreviations: PT, physical therapy; PT-Only, physical therapy
intervention alone; PT + RBC, physical therapy intervention
during an RBC transfusion; RBC, red blood cell.
JACPT ■ Volume 8 ■ Number 1 ■ 2017
Copyright © 2017 Academy of Acute Care Physical Therapy, APTA.
Unauthorized reproduction of this article is prohibited.
Physical Therapy During RBC Transfusion
although this could be due to the limited sample size.
Both the PT and PT + RBC groups had an increase
in HR from pre- to posttreatment of approximately 5
beats per minute, whereas the RBC group had essen-
tially no change in HR from pre- to posttreatment.
Given that individuals in both the PT and PT + RBC
groups were engaged in physical activity, it is reason-
able to speculate that the physical activity lead to an
increase in HR.
A recent survey revealed that 62.2% of physical
therapists and physical therapy assistants indicated fear
of dislodging an intravenous line, excessive bleeding,
or causing unstable vitals as a reason that they would
not administer physical therapy services to an individ-
ual receiving an RBC transfusion.21 This chart review
did not find that any of these specific adverse events
occurred during the therapy session; although because
of the limited sample size, an increased risk of these
adverse events cannot be ruled out. In addition, the
perception that physical therapists have regarding indi-
viduals receiving physical therapy intervention during
an RBC transfusion would be too ill to tolerate therapy
treatment was not supported, as the individuals in all
26 sessions tolerated the entire physical therapy ses-
sion without adverse event.21 This could be attributed
to good clinical reasoning of the therapists in patient
selection combined with appropriate monitoring and
safe practices while implementing interventions.
Although there are no recommendations regarding
the provision of physical therapy intervention for indi-
viduals receiving an RBC transfusion, in 2013, APTA
updated its Acute Care Lab Value Recommendations for
anemia.28 Prior to 2013, the recommendation called for
no participation in exercise training if Hb concentration
was less than 8.0 g/dL; as of 2013, the recommenda-
tion changed so that essential daily activities can be per-
formed when Hb concentration is less than 8.0 g/dL.28
A retrospective chart review of more than 3000 physi-
cal therapy treatment sessions in the inpatient acute care
setting concluded that there was no increase in adverse
P events associated with physical therapy intervention
1.00 when comparing individuals with an Hb concentra-
tion of less than 8.0 g/dL with individuals with an Hb
1.00 concentration of 8.0 g/dL or more.29 To the best of the
authors’ knowledge, the current study is the first pub-
<.01
lished study to report the occurrence of adverse effects
in individuals receiving an RBC transfusion.
<.01 This study quantified the type of therapy adminis-
tered by examining the number of billable units. Inter-
estingly, physical therapist billed more units of therapeu-
.39
tic activity in the PT-only group, and a greater number
1.00 of therapeutic exercises in the PT + RBC group, while
there was no difference in evaluation, reevaluation, gait
training, and neuromuscular reeducation. It is difficult
to surmise what accounted for the differences in billing
with therapeutic activity and therapeutic exercise, as
25
Physical Therapy During RBC Transfusion
each therapist prescribed activities and exercises as he
or she deemed appropriate for a given patient. Examin-
ing the clinical rationale behind the type of intervention
provided, as well as further quantification of the type
of physical activity prescription, is an excellent future
direction for this area of research.
There are several limitations to this study. First,
this retrospective chart review was primarily limited
to a population with hematologic malignancies and
chronically low Hb concentrations, thus limiting the
generalizability of these findings to other patient pop-
ulations. Second, the sample size was relatively small.
Climent-Peris and Velez-Rosario30 reported the over-
all rate of immediate medical transfusion reactions to
be 0.2% for all blood products. Because the overall
risk of immediate medical reaction is relatively low
and the sample size was small, the results should be
interpreted with caution. Third, this chart review only
accounted for transfusion reactions that occurred
within the time period of the RBC transfusion itself.
Acute transfusion reactions are classified as occurring
within 24 hours from transfusion onset3; therefore, all
acute reactions may not have been captured. Finally, it
is likely that therapists’ clinical decision making cre-
ated a bias in patient selection and exercise prescrip-
tion. It is possible that due to the acuity of the RBC +
PT group, therapists were more cautious with patient
selection and may have changed their exercise pre-
scription due to the RBC transfusion.
This study provides preliminary evidence that par-
ticipation in physical therapy intervention during an
RBC transfusion in a hematologic malignancy popu-
lation may be safe if vital signs and signs of medical
adverse events are monitored. Future studies should
consider a prospective design, a larger sample size,
and a wider range of patient populations including
those with both acute and chronic anemia. In addi-
tion, it would be beneficial to further quantify the
intensity of the intervention provided and examine
the efficacy of treatment.
ACKNOWLEDGMENTS
The authors thank the Journal of Acute Care Physical
Therapy Writing Scholarship and Dr Lori J. Tuttle for
her mentorship in the development of the manuscript.
The authors appreciate the Cleveland Clinic Depart-
ment of Rehabilitation and Sports Therapy for mon-
etary support for the statistical analysis of this survey.
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