癌症病人常見症狀之物理治療 王儷穎

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癌症病人常見症狀之物理治療 王儷穎

  1. 1. 癌症病人常見症狀(呼吸困難、疲倦、疼痛)之 物理治療
  2. 2. 癌症病人常見症狀(呼吸困難、疲倦、疼痛)之物理治療FATIGUE
  3. 3. Definition of Cancer-Related Fatigue• Cancer-related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning NCCN 2012
  4. 4. CTCAE: Fatigue• Grade 1: – Fatigue relieved by rest• Grade 2: – Fatigue not relieved by rest; limiting instrumental ADL• Grade 3: – Fatigue not relieved by rest, limiting self care ADL
  5. 5. Screening• Screen every patient for fatigue at regular intervals Severity: 0-10 Scale
  6. 6. • None to mild (0-3) – Education + general strategies to manage fatigue – Ongoing re-evaluation• Moderate to severe 4-10 – Education + primary evaluation of fatigue (history, assessment of treatable contributing factors) – Active treatment, follow-up, end of life
  7. 7. Treatable contributing factors• Medications/Side effects• Pain• Emotional distress• Anemia• Sleep disturbance• Nutritional deficit / Imbalance• Decreased functional status• Comorbidities
  8. 8. Functional Status Query• Changes in exercise or activity patterns• Influence of deconditioning• Can patients accomplish normal ADL?• Can they participate in formal or informal exercise programs?
  9. 9. Impacts of Current Medications• Narcotics, antidepressants, antiemetics, and antihistamines: Contribute to excessive drowsiness and increasing fatigue• Certain cardiac medications: e.g., beta- blocker: bradycardia and subsequent fatigue
  10. 10. • General Strategies for Management of Fatigue – Self-monitoring of fatigue levels – Energy conservation techniques – Use distraction
  11. 11. Energy conservation techniques• Set priorities• Pace• Delegate• Schedule activities at times of peak energy• Labor saving devices• Limit naps to < 1 hr to not interfere with night- time sleep quality• Structured daily routine• Attend to one activity at a time
  12. 12. • Interventions for CRF – Nonpharmacologic – Pharmacologic
  13. 13. Non-pharmacologic InterventionsFOR PATIENTS ON ACTIVETREATMENT AND POST-TREATMENT
  14. 14. • Activity enhancement• Physically based therapies• Psychosocial interventions• Nutrition consultation• Cognitive behavioral therapy for sleep
  15. 15. Activity Enhancement (active or post-treatment)• Maintain optimal level of activity• Starting and maintaining an exercise program – Endurance + Resistance• Red and Yellow Flags
  16. 16. Some Facts• Cancer-related fatigue interfered with all ADLs in the majority of patients• Interference – Moderate – Higher in women, non-whites and patients with metastatic disease• 3-5 hours of moderate activity per week may experience better outcomes and have fewer side effects of therapy
  17. 17. Physical Therapy Referral (Active Treatment)• Patients with comorbidities (e.g., COPD, cardiovascular disease)• Recent major surgery• Specific functional or anatomical deficits (e.g., decreased neck ROM due to surgery for head and neck cancer)• Substantial deconditioning
  18. 18. Exercise Prescriptions (Active Treatment)• Individualized – Age, gender, type of cancer, physical fitness level• Begin at a low level of intensity and duration• Progress slowly• Modified accordingly with the patient’s condition changes
  19. 19. Evidence - 1• 17 RCTs• Improvement in fatigue – 35% – Weighted pooled mean effect size: -0.42 (95% CI: - 0.599 to -0.231)• Improvement in vigor/vitality – 30% – Weighted pooled mean effect size: -0.69 (95% CI: -0.43 to -0.949)• Effect: administered during therapy > after therapy was completed Kangas and colleagues, 2008
  20. 20. Evidence - 2• 28 RCTs• Overall result: – Exercise is effective in relieving fatigue • SMD: -0.23; 95% CI: -0.33 to -0.13 – Effective both during and after therapy – Patient population: breast and prostate cancer 2008 Cochrane
  21. 21. Physically-based Therapies (Active Treatment)• Acupuncture –?• Massage therapy – One RCT and one retrospective review – Positive effects of massage therapy on fatigue during active therapy
  22. 22. • Nervous tissue – MRI – Compression of neurologic tissue, (ie, spinal cord, nerve roots, or nerve plexus) by tumor or unstable vertebral fractures – Patients with vertebral metastases or spinal cord compression Gilchrist et al., 2009
  23. 23. Red and Yellow Flags• Skeletal system – Dual-energy x-ray absorptiometry • Diagnostic test for osteopenia and osteoporosis – Radiography or computed tomography scan • If 25%–50% of the cortex of bone is degraded, then partial weight bearing precautions should be instituted. If greater than 50% bone degradation, then touch-down or non–weight-bearing precautions are recommended • Multiple myeloma Gilchrist et al., 2009 Karavatas et al., 2006
  24. 24. Red and Yellow Flags• Hematologic system functions – Might alter during anticancer treatment – Complete blood count (ie, hemoglobin, hematocrit, white blood count, platelet count) • Diagnostic test to detect anemia, neutropenia, and thrombocytopenia • These values also are useful in exercise prescription, particularly in choosing safe mode and intensity of exercise Gilchrist et al., 2009
  25. 25. Red and Yellow Flags• Cardiovascular system functions – Might be affected due to anticancer treatment – Echocardiogram • Assesses ventricular function, including ejection fraction, wall movement, and cardiac output – Treatment related cardiotoxicity • Hodgkin’s disease treated with ABVD or BEACOPP • Breast cancer treated with doxorubicin and cyclophosphamide Gilchrist et al., 2009
  26. 26. Risk factors for fatigue in post- treatment, disease-free patients• Many….• Pretreatment fatigue, depression, anxiety, comorbidities, cytokines, etc.
  27. 27. Activity Enhancement (Post Treatment)• Post-treatment, disease-free• Patients to survivors transition• Regular exercise – Improving strength, energy, and fitness – Decreased anxiety and depression – Improve body image – Increase tolerance for physical activity
  28. 28. Physical Therapy Referral (Post Treatment)• Specific issues that should trigger a referral of PT if the patient – Is significantly deconditioned, weak – Have relevant late effects of treatment (such as cardiopulmonary limitations)
  29. 29. Evidence• 44 Studies, 3,254 cancer survivors – Exercise reduced fatigue – Moderate-intensity, resistance exercise – Older cancer survivors Brown and colleagues, 2011
  30. 30. Interventions for Patients at the End of Life• In palliative care unit: 100% reported fatigue• General Strategies for Management of Fatigue – Energy conservation – Use distraction
  31. 31. Energy conservation techniques (end-of-life)• Set priorities• Pace• Delegate• Schedule activities at times of peak energy• Labor saving devices and assistive devices• Eliminate nonessential activities• Structured daily routine• Attend to one activity at a time• Conserve energy for valued activities
  32. 32. Activity Enhancement (end-of-life)• Optimize level of activity with careful consideration of the following constraints: – Bone metastases – Thrombocytopenia – Anemia – Fever or active infection – Assessment of safety issues (risk of falls, stability)
  33. 33. Evidence• Pilot• Small sample size• But promising results – Better activity level – Increased QoL – Less anxiety Porock and colleagues, 2000
  34. 34. Activities (End of Life)• Walking• Arm exercises with resistance• Marching in place• Dancing
  35. 35. 癌症病人常見症狀(呼吸困難、疲倦、疼痛)之物理治療PAIN
  36. 36. Definition of Pain• Pain is defined by the International Association for the Study of Pain (IASP) as an unpleasant multidimensional, sensory and emotional experience associated with actual or potential tissue damage, or described in relation to such damage Merskey and Bugduk 1994; NCCN 2012
  37. 37. • Screen for pain – Pain present or not – Anticipated painful events and procedures
  38. 38. If pain present• Quantify pain intensity and characterize quality• Severe uncontrolled pain is a medical emergency and should be responded to promptly
  39. 39. Pain Intensity Rating• Minimum assessment – In the past 24 hours: Current pain, Worst pain, Usual pain, Least pain• Comprehensive assessment – Worst pain in past week, pain at rest pain with movement
  40. 40. Numerical Rating Scale• Numerical rating scale (0 to 10: no pain to worst pain you can imagine) – Verbal – Written• Categorical scale: – None (0); Mild (1-3); Moderate (4-6); Severe (7-10)
  41. 41. Top: Faces Pain Scale (Bieri et al., 1990), scored 0 to 6Bottom: Faces Pain Scale-Revised, scored 0-2-4-6-8-10 (or 0-1-2-3-4-5).Instructions: “These faces show how much something can hurt. This face[point to left-most face] shows no pain. The faces show more and more pain[point to each from left to right] up to this one [point to right-most face] - itshows very much pain. Point to the face that shows how much you hurt[right now]. Hicks et al., 2001
  42. 42. Comprehensive Pain Assessment• In order to identify – Etiology – Pathophysiology – Specific cancer pain syndrome – Determine patient goals for comfort, function
  43. 43. Red Flag• Pain related to an oncologic emergency – Bone fracture or impending fracture of weight bearing bone – Brain metastases – Epidural metastases – Leptomeningeal metastases – Pain related to infection – Obstructed or perforated viscus
  44. 44. CTCAE: Pain• Grade 1 – Mild pain• Grade 2 – Moderate pain; limiting instrumental ADL• Grade 3 – Severe pain; limiting self care ADL
  45. 45. Classification of pain management strategies in cancer patients• By cause – tumor-induced pain, iatrogenic pain, unspecific pain• By quality – nociceptive pain, neuropathic pain• By duration – acute pain, chronic pain, breakthrough pain• By severity – weak, moderate, strong• By site of origin – visceral pain, bone pain, soft tissue pain• By psychosocial status
  46. 46. Cancer-induces pain: mechanisms• Cancer tissue infiltrating nerves• Cancer tissue blocking or destroying nerves• Peritumoural edema compressing nerves• Cancer tissue secreting substances that irritate the nerves or lower the pain threshold• Pathologic fractures inducing functional instability Mechanisms
  47. 47. Anticancer treatment-induced pain• Pain syndromes due to loss of organs• Post radiation pain syndromes• Chemotherapy-induced polyneuropathy
  48. 48. Pain of unknown origin….
  49. 49. Classification by site of origin• Periosteal and/or bone pain – dull, boring, deep, but may also be sharp and lancinating. lt is usually easy to locate and tends worsen during motion.• Pain of soft tissue and muscles – often permanent and is usually dull, boring, continuous and diffuse in terms of location. It occurs independently of motion.• Visceral pain – mainly due to infiltration, ulceration or compression in the gastrointestinal, respiratory or urogenital tract. Visceral pain is typically dull, deep, hard to localize, and may be colicky.
  50. 50. Therapeutic measures• Causal (anti-tumor therapies)• Symptomatic (therapies influencing the pain sensitivity)• Co-analgesic interventions (therapies influencing the biopsychosocial environment)
  51. 51. Anticancer therapies for pain relief• Surgery• Chemotherapy• Hormone therapy• Radiotherapy
  52. 52. Symptomatic pain management strategies• Most used approach• Systemic pharmaceutical approach – Non-opioid analgesics – Opioids – Antidepressants – Co-analgesics
  53. 53. WHO step system for cancer pain management
  54. 54. NON-PHARMACOLOGICTREATMENTS
  55. 55. Physical therapy in pain management for patients with cancer• Higher awareness of motion patterns• Relaxation of painfully tense muscles• Relaxation of fibrotic subcutaneous tissue• Patient is taught behaviors calculated to relieve pain• Patient learns relaxation techniques• Patient learns postures designed to reduce pain
  56. 56. Postural re-education• For patients who have altered posture or movement secondary to pain – Breast cancer • Correct protective posture – Head and neck • Shoulder dysfunction
  57. 57. Physical Modalities• Bed, bath, and walking supports• Positioning instruction• Energy conservation, pacing of activities• Massage• Heat and/or ice• TENS• Acupuncture or acupressure• Ultrasonic stimulation
  58. 58. Massage and warm baths• Mechanisms: – Resolve painful tension – Rebound vasodilation – Mentally soothing and relaxing effects on the limbic system• Most beneficial to patients with high levels of psychological distress• Contraindications: – Tumor regions, thrombocytopenia, high BP, severe heart failure, etc. (Soden et al., 2004)
  59. 59. Massage and soft tissue mobilization• Scar mobilization/massage, myofascial techniques and connective tissue massage (Hunter, 1994; Mannheim, 2001).
  60. 60. Lymphatic drainage• Mechanisms: reduces excess limb volume and dermal thickness• Effective for edema-related pain relief• Methods: – Manual – Compression garments• Contraindications:
  61. 61. Heat• Mechanisms: – relaxing effects• Many concerns:
  62. 62. Ice• Mechanisms: – Reducing inflammation, swelling, decelerates neurotransmission, etc. – Less risk while applying to patients with cancer• Contraindication: – Patients with peripheral arterial occlusive disease (PAOD) history
  63. 63. Hydrotherapy• Mechanisms: – Mechanical + thermal stimulation – Beneficial effects on muscle, circulation, and immune system• Contraindications:
  64. 64. Electrotherapy• TENS – for treatment induced pain – No formal guideline – Conventional TENS – Applied on painful area or an adjacent dermatome – Intensity: “strong but comfortable” – Duration: several minutes up to several hours• Contraindications:
  65. 65. Therapeutic exercise• Start cautiously, build up gradually and be within the patient’s tolerance levels• Graded and purposeful activity
  66. 66. Chronic pain syndromes: s/p surgical intervention• S/P – mastectomy – gastrectomy – proctectomy – thoracotomy – amputation• Phantom pain• Lymphedema
  67. 67. Adverse effects of non-opioids• Risk of ulceration• Risk of bleeding• Impaired renal function• Cardiovascular risks?
  68. 68. Adverse effects of opioids• Addition tendency• Excessive sedation• Respiratory depression
  69. 69. 癌症病人常見症狀(呼吸困難、疲倦、疼痛)之物理治療DYSPNEA
  70. 70. Definition of Dyspnea• A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity American Thoracic Society 1999
  71. 71. Causes of dyspnea in patients with cancer• Disease related • Airway obstruction – Malignant pleural • Hypoxemia effusion • Psychogenic• Treatment related dyspnea – RT related • Cardiovascular pneumonitis failure• Comorbidities • Neurologic disorder – Example: COPD • Anemia
  72. 72. CTCAE: Dyspnea• Grade 1 – Shortness of breath with moderate exertion• Grade 2 – Shortness of breath with minimal exertion; limiting instrumental ADL• Grade 3 – Shortness of breath at rest; limiting self care ADL• Grade 4 – Life-threatening – consequences; urgent intervention indicated• Grade 5 – Death
  73. 73. Interventions• Assess symptom intensity• Treat underlying causes/comorbid conditions• Relieve symptoms
  74. 74. Treat underlying causes/comorbid conditions• Radiation/Chemotherapy• Therapeutic procedure for cardiac, pleural, or abdominal fluid• Bronchoscopic therapy• Bronchodilators, diuretics, steroids, antibiotics, or transfusions
  75. 75. Relieve symptoms• O2 for hypoxia• Educational, psychosocial, and emotional support for the patient and family• Nonpharmacologic therapies• Morphine• Benzodiazepines• Temporary ventilator (CPAP, BiPAP) – Non-invasive in nature
  76. 76. Non-pharmacological measures to relieve dyspnea• Positioning – Forward lean sitting • Elbows resting on knees or a table when seated, or on a suitable surface, for example a windowsill or wall, when standing – Advise on passively fixing the shoulder girdle for optimizing ventilatory muscle efficiency and relief of breathlessness • Hands/thumbs resting in/on pockets, belt loops, waistband, or across the shoulder handbag strap when ambulating
  77. 77. Non-pharmacological measures to relieve dyspnea• Breathing techniques – Breathing control – Diaphragmatic – Pursed lip – Exhalation on effort (“blow as you go!”) – Paced breathing • Paced with activity
  78. 78. Non-pharmacological measures to relieve dyspnea• Non-invasive ventilation• Oxygen therapy• Airway clearance techniques – Active cycle of breathing techniques – Positive expiratory pressure (PEP)
  79. 79. Non-pharmacological measures to relieve dyspnea• Energy conservation techniques: Reduction in the energy expenditure• Combined of techniques – Using a WC and portable O2 during hygiene/toileting/outing
  80. 80. Non-pharmacological measures to relieve dyspnea• Fans• Cooler temperature
  81. 81. Oncology Rehabilitation• To help patients stay physically strong so they can tolerate conventional cancer treatment and continue to participate in everyday activities• Continue services before after treatment treatment during treatment

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