癌症病人之運動處方 林慧芬

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癌症病人之運動處方 林慧芬

  1. 1. 癌症病人之運動處方積極治療期、康復期、生命末期 林慧芬 臺大醫院物理治療師臺灣大學物理治療學研究所博士候選人 1
  2. 2. 癌症治療的目標與策略• 治癒(curative):殲滅• 支持性治療(supportive):防守,和平共存• 安寧療護(palliative):慢慢撤退 2
  3. 3. Cancer care trajectory 3
  4. 4. Common long-term and late effects of cancer treatment Surgery Radiation Systemic therapy• Cosmetic effects • Second malignancies • Second malignancies• Functional disability from • Neurocognitive deficits (myelodysplasia and removal of a limb or • Xerophalmia, cataracts leukemia) organ • Xerostomia, dental caries • “chemo brain”• Damage to an organ • Pneumonitis, pulmonary • Cardiomyopathy (bowel, bladder, sexual fibrosis • Renal toxicity organ) • Coronary artery, valvular, • Premature menopause• Pain conduction, • Infertility• Scarring/adhesions cardiomyopathic, and • Osteoporosis• Incisional hernia pericardial disase • neuropathy• Lymphedema • Bowel stricture• Systemic effects • Radiation procicits (removal of endocrine • Bladder scariring organs, infection risk • Infertility, importence, post-splenectomy) premature menopause • Lymphedema 4 • Bone fracture
  5. 5. 癌症後遺症與共病• 治療相關副作用 – 癌因性疼痛 – 癌因性疲倦 cancer related fatigue – 呼吸困難• 身體組成改變:脂肪、肌肉、骨密度• 神經肌肉骨骼系統後遺症• 心血管系統後遺症• 憂鬱、焦慮等心理影響• 降低活動量• 共病狀態 5
  6. 6. 癌症復健的目標 復健目標Preventive 術前與術後衛教Restorative 回到罹病前功能 最小功能受限Supportive 降低功能障礙 代償永久損傷Palliative 消除或降低併發症如疼痛 Dietz 1980 6
  7. 7. Cancer rehabilitation• System specific problems• Activity restrictions – ADL – Ambulation – Mobility – Transfer• Psychological problems• Immobility syndrome• Fatigue• Sexuality• Quality of life 7
  8. 8. 癌症病人運動的不耐受(exercise intolerance) 8
  9. 9. Physical Activity and Cancer Control framework (PACC) 9
  10. 10. Physical activity and exercise• Physical activity – Human movement that results in a substantial increase in energy expenditure over resting levels• Exercise – A form of physical activity that is performed on a repeated basis over an extended period of time with the intention of improving fitness, performance, or health 10
  11. 11. 身體活動與癌症預防• 很強證據可以預防 – 大腸癌 – 乳癌 74171名停經婦女世代研究 每週75-150分鐘快走可以降低乳癌發生風險18%。• 很有可能預防 有運動量高與癌症風險低趨勢 (JAMA 2003) – 攝護腺癌• 可能預防 – 子宮內膜癌 – 肺癌 11
  12. 12. 身體活動與治療前準備Physical activity and treatment preparation/coping• 等待治療前身體與心理調適• 增進健康/體力足以應付治療的進行• 延緩因處理疾病或症狀的治療需求 12
  13. 13. 治療期與身體活動 Physical activity and treatment effectiveness/coping• 處理治療副作用與毒性• 維持身體功能• 預防肌肉萎縮與脂肪增加• 改善情緒與生活品質• 促進治療的完成率• 可能促進癌症治療的效果 13
  14. 14. Physical activity intervention during treatment• 文獻顯示身體活動有顯著的正面效益於 • 身體活動量 • 有氧適能 • 身體功能(physical functioning) • 上、下肢肌力 • 體重及體脂肪比 • 疲倦 • 功能性的生活品質 • 正向情緒、焦慮、自尊 14
  15. 15. 恢復/復健期之身體活動 Physical activity and recovery/rehabilitation• 10 研究探討在完成治療後3-6 個月(復健 期)運動的效果• Outcomes – 身體功能 – 疲倦與生活品質 – 免疫功能 Feasible and may provide – 身體組成 physiological and psychological benefits for cancer survivors 15
  16. 16. Physical activity and disease prevention /health promotion• 身體功能與生活品質的最佳狀態• 處理長期或後來發生的併發症• 預防其它慢性病• 降低復發與死亡風險 16
  17. 17. Physical activity intervention post-treatment 文獻顯示身體活動有顯著的正面效益於• 有氧適能 • 疲倦• 上、下肢肌力 • IGF-I, IFG-BP-III • 免疫• 柔軟度 • 疼痛• 瘦肉量 • 相關症狀與副作用• 整體生活品質• 活力 17
  18. 18. 身體活動與癌症預後 physical activity and survival• 降低復發或發生其它癌症風險• 延緩癌症進展• 降低死亡率• 降低心血管疾病與糖尿病 美國護士健康世代研究:運動與癌症死亡率 • 每週相當3小時中度運動可以降低乳癌死亡 率與復發率26-40% (Holmes et al. 2005, JAMA) • 罹癌後運動可以降低大腸直腸癌死亡率 (Meyerhardt et al. 2006, J Clin Oncol) 18
  19. 19. Palliative care• Specific symptoms in terminal cancer patients – Pain 80% – Cachexia(惡病質)-anorexia(厭食) syndrome – Chronic nausea – Asthenia 無力 – Dyspnea 19
  20. 20. 癌症末期療護最常見症狀• 疼痛 70% • 盜汗 25%• 口乾 68% • 吞嚥問題 23%• 缺乏食慾 61% • 泌尿問題 21%• 無力 47% • 神經精神症狀 20%• 便秘 45% • 皮膚問題 16%• 呼吸困難 42% • 消化不良 11%• 噁心、嘔吐 36% • 腹瀉 70%• 失眠 34% 20
  21. 21. 安寧照護與身體活動• 症狀處理• 改善活動力(improve mobility)• 延緩功能下降• 維持生活品質 6週結構性的身體活動,有效降低疲倦、增加體能 表現與情緒功能 顯示運動訓練是合適的,且可能是有益的 Oldervoll et al 2006 21
  22. 22. 癌症治療中/後運動的可能好處• 保持或增進 • 降低 – 肌肉量、肌力 – 症狀與副作用數量 – 心肺適能 – 副作用症狀的強度 – 身體功能 – 住院日數 – 活動量 – 心理與情緒壓力 – 關節活動度 – 憂鬱與焦慮 – 免疫 – 化療完成比例 – 身體形象、自尊與心情 22
  23. 23. Benefits of physical activity• ↓side effects/adverse events• ↑chemotherapy completion rates• ↑overall survival• ↑cancer specific survival• ↓risk of recurrence• ↓new cancer• ↓biological markers – ↓BMI – ↓Insulin – ↓sex hormone Irwin ML, 2009 23
  24. 24. 美國癌症協會防癌指引 對個人• Achieve and maintain a healthy weight throughout life• Adopt a physically active lifestyle – 成人:每周至少150分鐘中等程度運動或75分鐘劇烈運動,或是相當的 運動量,最好平均分配到每一天 – 兒童及青少年:每天至少60分鐘中至強度運動,每週至少3天以上為 劇烈運動量。 – 減少靜態生活,例如坐、躺著、看電視或其它對著螢幕(screen- based )形式的娛樂。 – 除了日常生活外,多增加身體活動,對健康有很多益處。• Consume a healthy diet, with emphasis on plant food• If you drink alcoholic beverage, limit consumption ACS guidelines on nutrition and physical activity for cancer prevention, 2012 24
  25. 25. 25
  26. 26. 運動計畫的目標 26
  27. 27. Medical and pre-exercise evaluation• Comprehensive medical evaluation: medical history, physical exam and physician clearance• Testing to exercise tolerance• Follow-up and re-evaluation at regular interval 27
  28. 28. 癌症病人的評估• 身體結構與功能 – 心智 – 感覺功能與疼痛 – 神經肌骨系統與動作相關結構與功能 – 心血管、呼吸、血液、免疫 – 疲倦 – Red flags and yellow flags• 活動與參與 28
  29. 29. 身體功能分級• Eastern Cooperative Oncology Group (ECOG)• Karnofsky Performance Status Scale (KPS scale) 29
  30. 30. ECOG performance statusGrade ECOG0 Fully active, able to carry on all pre-disease performance without restriction1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair5 DeadOken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.:Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982. 30
  31. 31. KARNOFSKY PERFORMANCE STATUS SCALE KPS scaleAble to carry on normal 100 Normal no complaints; no evidence of disease.activity and to work; nospecial care needed. 90 Able to carry on normal activity; minor signs or symptoms of disease. 80 Normal activity with effort; some signs or symptoms of disease.Unable to work; able to live at 70 Cares for self; unable to carry on normal activity or to do active work.home and care for mostpersonal needs; varying 60 Requires occasional assistance, but is able to care for most of hisamount of assistance needed. personal needs. 50 Requires considerable assistance and frequent medical care.Unable to care for self; 40 Disabled; requires special care and assistance.requires equivalent ofinstitutional or hospital care; 30 Severely disabled; hospital admission is indicated although death notdisease may be progressing imminent.rapidly. 20 Very sick; hospital admission necessary; active supportive treatment necessary. 10 Moribund; fatal processes progressing rapidly. 0 Dead 31
  32. 32. Red flags or yellow flags• Neural impairments• Skeletal impairments• Complete blood count• Cardiovascular or pulmonary system 32
  33. 33. 中樞與周邊神經系統• 顱內壓增加症狀• 癲癇• 動作與平衡• 脊椎神經壓迫• 感覺、疼痛• 自主神經系統 33
  34. 34. 運動測試或訓練的禁忌症或特別注意事項: 神經系統• 禁忌 • 注意 – 認知功能明顯降低 – 輕到中度認知障礙: – 頭暈或頭重腳輕 確認可以聽從指令 – Disorientation – 平衡不佳、周邊感 – 視力模糊 覺障礙:預防跌倒 – ataxia 34
  35. 35. 骨骼轉移• 60%的癌症復發會轉移到骨骼,其中一半轉移到脊椎骨• 癌症對骨骼的影響 – Loss of bone material (lytic tumor) – Invasion of bone (sclerotic tumor) – Osteonecrosis – Reduced bone mineral density• 主要症狀 – 疼痛 – 脊髓神經症狀 – 病理性骨折 35
  36. 36. 運動測試或訓練的禁忌症或特別注意事項: 肌肉骨骼系統• 禁忌 • 需要調整及/或醫師同 – 最近新生的骨頭、 意 背部、頸部疼痛 – 有疼痛或抽筋現象 – 異常肌肉無力 – 骨質疏鬆 – 嚴重惡病質 – 類固醇引起的肌肉 – 異常/非常疲累 病變 – KPS小於65%不做 – 惡病質 運動測試 – 輕到中度疲累 36
  37. 37. Hematologic values and exercise modificationPlatelet count 血小板<10,000 此時病人通常需輸血,輸血後要再確認血小板值才能決定運 動是否合適。病人有出血的危險,不建議運動。<20,000 ADL’s, AAROM, AROM但不抗重力或阻力;須小心引導。20,000- 輕度運動( no PROM; light AROM permitted; walking as30,000 tolerated)30,000- AROM, submaximal isometric, stationary bicycle, walking50,000 as tolerated, 水中運動; 不可長時間牽拉或阻力運動。50,000- 允許輕到中度阻力運動;性生活;游泳、低的階梯運動、平150,000 地無坡度騎腳踏車。>150,000 正常生活無限制。 37
  38. 38. Hematologic values and exercise modificationHemoglobin (Hgb) 血紅素 建議暫停運動* (必須與醫師討論,考量目前的醫療與身體狀況<8g/dL )8-10g/dL 可以做輕度運動;不做有氧運動。 可以做低衝擊及低強度有氧運動(如固定式腳踏車),等長運動,10-12g/dL 阻力運動。>12g/dL 正常生活無限制。Hematocrit (Hct) 血球容積< 25% 不建議運動*。25%-30% 可以做輕度運動;漸進的阻力運動。>30% 正常生活無限制。White blood count (WBC) 白血球<5,000/mm3 有 不建議運動*。發燒>5,000/mm3 可以做輕度運動;漸進的阻力運動。 38
  39. 39. 癌症病人運動處方之特別考量• 身上有傷口、管路• 發燒• 貧血、白血球、血小板低下• 骨骼疼痛、轉移、骨質密度下降• 神經系統損傷• 嚴重疲累• 生命徵象 39
  40. 40. 運動測試或訓練的禁忌症或特別注意事項:系統性• 禁忌 • 需要調整及/或醫 – 急性感染 師同意 – 發燒 – 最近有急性疾 – 全身不舒服 病或感染,應 等症狀消失48 小時再開始 40
  41. 41. 運動測試或訓練的禁忌症或特別注意事項: 腸胃系統• 禁忌 • 需要調整及/或醫師同 – 嚴重噁心 意 – 過去24-36小時有嘔 – 水分或食物攝取有 吐或腹瀉, 問題:多專業照護, – 脫水 照會營養師 – 營養不良:體液或/ 及食物攝取不足 42
  42. 42. 運動測試或訓練的禁忌症或特別注意事項: 心血管系統• 禁忌 • 需要調整及/或醫師同意 – 胸痛 – 有心臟血管疾病 – 休息心跳 >100 bpm或 – 有用降血壓藥物或調整 <50bpm 心率藥物 – 休息血壓 – 有淋巴水腫 • SBP > 145 mmHg • DBP > 95 mmHg – DPB <50 mmHg – 心率不整 – 腳踝水腫 43
  43. 43. 運動測試或訓練的禁忌症或特別注意事項: 呼吸系統• 禁忌 • 需要調整及/或醫師同 – 呼吸急促 意 – 咳嗽、哮喘 – 輕到中度呼吸急促: – 深呼吸時有胸痛 避免maximal tests 44
  44. 44. 癌症病人的運動測試 目的治療前 對運動的反應 有無其他健康問題治療中 量化手術或佐藥治療後身體能力與體適能的 改變治療後與定 評估運動處方的效果期長期追蹤 監測恢復期可能影響身體健康的治療後遺症 確認是否具有正常日常生活所需的足夠體適 能 45
  45. 45. Exercise testing• Cardiorespiratory fitness• Muscular strength and endurance• Flexibility and joint ROM• Body composition 46
  46. 46. 癌症治療中運動原則• 根據病人狀況與個別喜好給予個別化運動計畫• 本來已有運動者可以降低強度及/或縮短時間, 但主要目標要盡量維持活動• 如果之前不太活動,先從輕度活動慢慢增加• 小心有跌倒或受傷風險• 最好有人在旁邊• 如果病人在臥床,建議物理治療協助維持肌力 與關節活動度,以及幫助抵抗疲倦與沮喪 48
  47. 47. 癌症治療後的運動原則建議• 根據運動測試結果給予個人化運動計畫• 根據個人需求、目標與喜好• 影響運動的障礙、影響運動能力的長期副 作用• 考量運動處方的一般原則• 運動處方的各參數• 重新評估與調整運動處方 49
  48. 48. Exercise prescriptions for oncology patients: aerobiccomponent AerobicFrequency 3-7 x/week 40%-60% of HR reserve or Oxygen uptake reserve, orIntensity 60%-80% of max HR, or RPE of 12-15Mode Start with walking or recumbent bike Start with 5-20 minutes depending on exercise tolerance,Duration including warm-up and cool-down. Goal is 20-60 minutes of continuous exerciseProgression Duration > frequency> intensity > mode HR, BP, O2 sat, RPE, and painPatient Avoid group exercise during periods of neutropeniamonitor Avoid training with presence of a new migrating central lineconsideration Avoid aquatics if neutropenic or with central line 50
  49. 49. Exercise prescriptions for oncology patients: strength trainingcomponent Strength trainingFrequency 2-3 x/week, 48 hour recovery between sessionsIntensity 40%-60% of 1 RM or 6-12 reps 8-10 dynamic exercises involving, functional task training, using weight machines or free weights. Recommend caution withMode TheraBand resistance. Target large, major muscle groups, performing concentric, and eccentric contractions, in supine, sitting or standing positions Start with 1 set of 8-12 reps;.Duration Goal is 1-3 sets of 8-15 reps Frequency > intensity: 2-3 x/week with 48 hr recoveryProgression Add TheraBand only if no additional hematologic or orthopedic precautions are present HR, BP, O2 sat, RPE, DOE and painPatient monitor Avoid group exercise during periods of neutropeniaconsideration Avoid training with presence of a new migrating central line Avoid aquatics if neutropenic or with central line 51
  50. 50. Exercise prescriptions for oncology patients: flexibilitycomponent Flexibility trainingFrequency 2-7 days/weekIntensity Slow static stretches only to the end rangeModeDuration 4 reps of 10-60 seconds per stretchProgression Duration > frequency > intensity >modePatient HR, BP, O2 sat, RPE, DOE and painmonitor Avoid group exercise during periods of neutropeniaconsideration 52
  51. 51. 其它運動方式• 太極拳• 瑜珈• 皮拉提斯• 舞蹈• 支持團體戶外與體育活動 53
  52. 52. Exercise is medicine Thanks for your attention 54

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