Aquatic physiotherapy and cytotoxic agents
Guideline number: QH-GDL-500:2022
Effective date: 8 November 2022
Review date: 8 November 2025
Supersedes: Nil - first issue
On this page:
- Background
- Purpose and intent
- Scope and target audience
- Process
- Documentation
- Partnering with consumers
- Supporting documents
- Related documents
- Appendix 1: Cytotoxic drugs and hydrotherapy referral flowchart
- Appendix 2: Disease modifying anti-rheumatic drugs (DMARD) risk rating
- Appendix 3: Excretion times for common cytotoxic medicines
- Appendix 4: Aquatic physiotherapy and cytotoxic agents management plan
Background
Aquatic physiotherapy is recommended for various conditions for which patients may be taking cytotoxic agents, such as rheumatoid arthritis. Additionally, patients who are taking cytotoxic agents for an unrelated medical condition may be attending aquatic physiotherapy for treatment of their musculoskeletal condition.
Cytotoxic agents have known teratogenic, mutagenic and/or carcinogenic effects when exposed to humans. Whilst patients taking cytotoxic agents are in the pool, physiotherapists, therapy assistants and other patients are at risk of exposure to these substances or their metabolites contained in patient body fluids (urine, faeces, vomit and fluid drained from body cavities). This is of particular concern if the patient has urinary or faecal urgency or incontinence.
While there is no established minimal safe exposure level, there is evidence to suggest negative health effects result from occupational contact with these agents. Occupational exposure may occur through inhalation, ingestion, dermal absorption, mucosal absorption and/or percutaneous/needle stick injury.
Clinical practices which reduce the risk of exposure to the levels ‘as low as reasonably achievable’ must be employed, and workplace health and safety standards are to be maintained.
Any decision to exclude a patient from aquatic physiotherapy must be based on a risk assessment on a case-by-case basis (Australian Guidelines for the prevention and control of infection in Healthcare 2019).
Purpose and intent
This guideline outlines the management of patients taking cytotoxic drugs, who are referred for aquatic physiotherapy.
Scope and target audience
Physiotherapists referring patients for aquatic physiotherapy.
Process
- All patients referred for aquatic physiotherapy will be screened for general precautions and contraindications via the Aquatic Physiotherapy Referral and Safety Checklist (on the Aquatic Physiotherapy Referral Form).
- Should a cytotoxic agent/disease modifying anti-rheumatic drug (Appendix 2) be identified, the patient will be notified about the risks of exposure to others and the need to ask further questions. The patient should be asked whether they have urinary and/or faecal incontinence. This will be documented on the Aquatic Physiotherapy Safety Checklist.
- Patients with urinary and/or faecal incontinence, unreliable historians or having cognitive impairment will be excluded from aquatic physiotherapy.
- The risk of cytotoxic exposure during an accidental leak (urine and/or faeces) is very low and should not be a reason to exclude continent patients from receiving aquatic physiotherapy.
- On presentation to every aquatic physiotherapy session, patients on cytotoxic agent(s) shall be asked whether they currently are experiencing any nausea, diarrhoea or urinary incontinence. If the answer is “yes”, they will be excluded from sessions until symptoms have resolved. (Appendix 1)
Documentation
The referral and safety checklist should be documented in the patient's medical record.
Partnering with consumers
Patients and family members are to be encouraged and given the opportunity to ask questions, clarify information and identify goals of care during communication processes. Staff are responsible for providing information in a way that is understandable and that meets patient’s needs and are to use perception checking techniques to ensure patient and family’s understanding of discussions.
Supporting documents
- Guide for handling cytotoxic drugs and related wastes - Qld 2017
- Australian Guidelines for the prevention and control of infection in Healthcare 2019
Related documents
Aquatic Physiotherapy Referral and Safety Checklist (on the Aquatic Physiotherapy Referral Form)
Appendix 1: Cytotoxic drugs and hydrotherapy referral flowchart
Appendix 2: Disease modifying anti-rheumatic drugs (DMARD) risk rating
| Drug | Dosage | Purpose | Risk | Guidelines |
|---|---|---|---|---|
| Azathioprine (Imuran) | 20-50 mg/day | Rheumatology | Low | If continent and no nausea and vomiting: normal care |
| 100-150 mg/day | Lupus | Medium | Cytotoxic precautions | |
| Cyclophosphamide | All oral doses | Rheumatology/Inflammatory | Medium | Cytotoxic Precautions |
| Cancer /Vasculitis | High |
1-6/52 cycle Must wait 4 weeks before commencing hydrotherapy | ||
| Leflunomide (Arava) | 20 mg/day | Rheumatology specific drug | Low | If continent and no nausea and vomiting: normal care |
| Methotrexate (Methoblastin) | 10-30 mg x 1/week | Rheumatology | Low | If continent and no nausea and vomiting: normal care |
| 1000 mg / cycle | Cancer | High | Cytotoxic precautions |
From the 2015 Oncology nursing drug handbook.
Barton-Burke, M, Wilkes, G, 2014, 2015 oncology nursing drug handbook, Jones & Bartlett.
Eitel, A. Scherrer, M. & Kümmerer, K. 1999. Handling Cytostatic Drugs.
Polovich, M. and Olsen, M.M. eds., 2003. Safe handling of hazardous drugs. Pittsburgh, PA: Oncology Nursing Society.
Appendix 4: Aquatic physiotherapy and cytotoxic agents management plan
Download the Aquatic physiotherapy and cytotoxic agents management plan (DOCX 47 kB).