癌症病人之運動處方 曹昭懿


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癌症病人之運動處方 曹昭懿

  1. 1. Exercise of Cancer Patient:Prevention, Survival & End of Life 曹昭懿 臺大物理治療學系
  2. 2. 2007 MaleIncidence Mortality 7210 5650 6040 2558 5898 5458 5006 2152 3367 10032007 FemaleIncidence Mortality 7502 1552 4417 1912 3161 2535 2900 2159 1749 833 BHP, 2010/2
  3. 3. Goals of Oncology Rehabilitation Preventive: to preclude or mitigate functional morbidity Restorative: to return patients to their premorbid functional status Supportive: to maximize function after permanent impairments Palliative: to reduce the dependence and provide comfort and emotional support
  4. 4. Cancer Care Trajectory4
  5. 5. Cancer Rehabilitation System specific problems Activity restrictions  ADL  Ambulation  Mobility  Transfer Psychological problems Immobility syndrome Fatigue Sexuality Quality of life
  6. 6. PEACE: Physical Exercise Across the Cancer Experience PACC: Physical Exercise & Cancer Control DIAGNOSIS HealthPrevention Detection Buffering Coping Rehabilitation Palliation Promotion Survival Prescreening Pre- Treatment Screening Survivorship End of life treatment PRE-DIAGNOSIS POST-DIAGNOSIS Courneya et al, 2001, 2007
  7. 7. Prevention (I) Friedenreich et al, 2002
  8. 8. Prevention (II) Convincing evidence  Colon cancer( ↓ 40-50%)  Breast cancer( ↓ 30-40%) Probable evidence  Prostate cancer( ↓ 10-30%) Possible evidence  Endometrium cancer( ↓ 30-40%)  Lung cancer( ↓ 30-40%)
  9. 9. Detection1. A 3-fold increase in prostate specific antigen concentration after 15-min cycle ergometer exercise (Oremek et al, Clin Chem 1996;42:691-5)2. None after treadmill (Leventhal et al, J Urology 1993;150:893-4)3. Exercise reduced the anxiety from screening and dx (Streggles et al, Cancer Prev & Control 1998;2:213-20)4. PA associated with compliance to cancer screening (Larsen et al, BMC Gastroenterol 2006;6:5)
  10. 10. Buffering (Coping) Cope with disease physically & emotionally while awaiting treatment Improving health/fitness to allow treatment Delaying the need for treatment by managing the disease and its symptoms 20 patients with lung cancer, structured exercise training till resection, VO2peak, 6-min walk increased significantly (Jones et al. Cancer 2007;110:590-8)
  11. 11. 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 leukemia) removal of a limb or organ • Xerophalmia, cataracts • “chemo brain”• Damage to an organ (bowel, • Xerostomia, dental caries • Cardiomyopathy bladder, sexual organ) • Pneumonitis, pulmonary • Renal toxicity• Pain fibrosis • Premature menopause• Scarring/adhesions • Coronary artery, valvular, • Infertility• Incisional hernia conduction, cardiomyopathic, • Osteoporosis• Lymphedema and pericardial disase • neuropathy• Systemic effects (removal of • Bowel stricture endocrine organs, infection • Radiation procicits risk post-splenectomy) • Bladder scariring • Infertility, importence, premature menopause • Lymphedema • Bone fracture
  12. 12. Coping Managing side effects & toxicities Maintaining physical functioning Preventing muscle loss and fat gain Improving mood states and QOL Facilitating the completion of treatment Potentiating the efficacy of cancer treatment Moderate positive effects on: fitness, physical functioning, strength, fatigue, QOL Courneya et al, Seminars in Oncology Nursing 2007;23(4):242-52
  13. 13. Rehabilitation 10 studies: post treatment 3-6 months Feasible and may provide physiological and psychological benefits on  Physical functioning  Fatigue & QOL  Immune  Body composition Spence et al, Cancer Treatment Review 2010;36:185-94.
  14. 14. SurvivalNurses’ Health Study (NHS, N=121700):exercise & cancer recurrence & mortality  Holmes et al. 2005, JAMA  Meyerhardt et al. 2006, J Clin Oncol
  15. 15. 86% 89% 92%93%97% JAMA 2005;293:2479-86
  16. 16. Post Dx PA & Mortality: CC Meyerhardt et al, 2006
  17. 17. Post Dx PA & Mortality: CC
  18. 18. Health Promotion Optimizing QOL & physical functioning Managing the chronic and/or late appearing effects Reducing the likelihood of cancer recurring Reducing the likelihood of developing of other chronic diseases
  19. 19. Palliation (I)Specific symptoms in terminal cancer patients Pain 80% Cachexia(惡病質)-anorexia(厭食) syndrome Chronic nausea Asthenia 無力 Dyspnea
  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%
  21. 21. Palliation (II) Managing symptoms Improving mobility Slowing functional decline Maintaining QOL 6-week structured PA : significant decrease in fatigue & increase in physical performance & emotional functioning (Oldervoll et al, 2005, 2006 ) 50 patients, home-based PA, walking (Lowe, et al. Support Care Cancer 2010;18:1469-75)
  22. 22. 癌因性疲倦 Cancer Related Fatigue常伴隨癌症相關治療引起休息不會降低疲倦感常有睡眠障礙處理原則 輕度適量運動 節省體能措施 心理支持與轉移注意力 睡眠衛生 治療相關症狀如貧血
  23. 23. 美國癌症協會防癌指引 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. 24. 27
  25. 25. Exercise Intolerance Jones et al, Lancet Oncology 2009;10:598-605
  26. 26. 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. 27. 癌症病人的評估身體結構與功能(body structure and function) 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(activity and participation)
  28. 28. Red Flags or Yellow FlagsComplete blood count Anemia Neutropenic ThrombocytopenicNeural impairmentsSkeletal impairmentsCardiovascular or pulmonary system
  29. 29. 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
  30. 30. 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
  31. 31. Health-related Physical FitnessTesting and InterpretationBody composition: BMI, circumference, skinfold, DXACardiorespiratory fitness: VO2max, HRmax, 6- min walking, 3-min stepMuscular strength and muscular enduranceFlexibility ACSM’s guideline for exercise testing and prescription
  32. 32. Physical Functioning Eastern Cooperative Oncology Group (ECOG) scale Karnofsky Performance Status scale (KPS scale)
  33. 33. 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 self care, confined to bed or chair more than 50% of waking hours4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair5 Dead Oken, et al. Am J Clin Oncol 1982;5:649-655
  34. 34. KPS scaleAble to carry on normal 100 Normal no complaints; no evidence of disease.activity and to work; no specialcare 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 dohome and care for most active work.personal needs; varyingamount of assistance needed. 60 Requires occasional assistance, but is able to care for most of his 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 althoughdisease may be progressing death not imminent.rapidly. 20 Very sick; hospital admission necessary; active supportive treatment necessary. 10 Moribund; fatal processes progressing rapidly. 0 Dead
  35. 35. Health-related Quality of Life Generic  SF 36  WHOQOL-BREF Cancer-specific  EORTC  FACT  FLIC  CARES
  36. 36. 運動測試的注意事項Complication RecommendationAnemia Avoid maximal testing or intense PA with significant aerobic demandsLow WBC count Avoid maximal test; avoid situation with an increased risk of infection( swimming, crowded areas)Low platelet count Avoid tests or PA that increase the risk of traumaFever Avoid PA until the cause of fever is determinedDyspnea Investigate cause; limit exercise intensitySevere cachexia Exercise should be low intensity and extremely conservativeExtreme fatigue/weakness Initial exercise intensity should be low, but increase as tolerated; intermittent activities may be perferred to continuous exerciseMouth sores/ulcerations Avoid tests that require a mouthpieceSevere nausea/vomiting Avoid testing or PA until symptoms improve; initiate PA at a level that can be toleratedBone pain Avoid high-impact testing or PA; swimming may be idealCNS abnormality or Avoid testing and PA that require balance and coordinationperipheral neuropathyPoor functional capacity Avoid maximal testing; exercise intensity should be low with extremely conservative increases made in intensity and duration
  37. 37. 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/或醫師同意  急性感染  最近有急性疾病或感  發燒 染,應等症狀消失48  全身不舒服 小時再開始
  38. 38. 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。20,000-30,000 輕度運動( no PROM; light AROM permitted; walking as tolerated)30,000-50,000 AROM, submaximal isometric, stationary bicycle, walking 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。
  39. 39. 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 有發 不建議運動*。燒>5,000/mm3 可以做輕度運動;漸進的阻力運動。
  40. 40. 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
  41. 41. 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/或醫師同意  最近新生的骨頭、  有疼痛或抽筋現象 背部、頸部疼痛  骨質疏鬆  異常肌肉無力  類固醇引起的肌肉病  嚴重惡病質 變  異常/非常疲累  惡病質  KPS小於65%不做運  輕到中度疲累 動測試
  42. 42. 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/或醫師同意  嚴重噁心  水分或食物攝取有問  過去24-36小時有嘔 題:多專業照護,照 吐或腹瀉, 會營養師  脫水  營養不良:體液或/ 及食物攝取不足
  43. 43. 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 <50bpm 整心率藥物  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
  44. 44. 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/或醫師同意  呼吸急促  輕到中度呼吸急促:避  咳嗽、哮喘 免maximal tests  深呼吸時有胸痛
  45. 45. Principles of ExerciseOverloadAdaptationSpecificityReversibilityModification: for cancer setting and during adjuvant therapy
  46. 46. 運動處方運動方式 有氧運動訓練:心肺適能 肌力與肌耐力訓練 柔軟度:關節活動與牽拉運動劑量 強度 頻率 時間Home-based VS supervised group
  47. 47. 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. 48. 癌症病人運動處方之特別考量 生命徵象 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
  49. 49. 有 氧 運 動 型態:走路、跑步機、固定式腳踏車、手搖腳踏車。太極?瑜珈?氣功?(化療期間不建議游泳) 時間:15~30 分鐘(可增至40~50分鐘) 強度:低至中度(一點點喘,50%最大心跳MHR開始或是40%之保留心跳HRR+休息心跳)  MHR=220-年齡  =40% *HRR(最大心跳-休息心跳)+休息心跳 頻率:每週2~3次→3~5次
  50. 50. 阻 力 運 動 型態:啞鈴(水瓶)、彈力帶、體重  體重:蹲站、坐站、爬樓梯、踮腳走、翹腳 走、仰臥起坐、引體向上、伏地挺身 次數:5~15下/1~3次/天 強度:60%~80%之1RM,12-15 RM(中度) ~8-12 RM(強度) 頻率:每週2~3次→3~4次
  51. 51. 癌症治療後的運動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
  52. 52. 57
  53. 53. Exercise 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, including warm-up andDuration cool-down. Goal is 20-60 minutes of continuous exerciseProgression Duration > frequency> intensity > mode HR, BP, O2 sat, RPE, 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
  54. 54. Exercise 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 with TheraBand resistance.Mode 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
  55. 55. Exercise 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 monitor HR, BP, O2 sat, RPE, DOE and painconsideration Avoid group exercise during periods of neutropenia
  56. 56. Other Types TaiChi Yoga Dancing Pilates Other outdoor activities (mountain climbing, bike…)
  57. 57. Interventions: End of Life
  58. 58. Activity Enhancement (I) Fatigue: **  during cancer treatment  following cancer treatment Aerobic capacity:  11/22: significant difference between intervention and control group  3/22: significant pre-post difference  8/22: non significant difference Quality of life: -- Anxiety: -- Depression: -- Cramp et al, 2008
  59. 59. Activity Enhancement (II) ↑functional capacity so↓effort in activities 15~45min/session (no more than I hour) 1-5 sessions/week 3~32 weeks, average: 12 weeks 25~80% age-predicted HRmax (220-age) walk, bicycle, ergometer, treadmill, yoga, tai-chi, multidimensional (aerobic+stretching+resistance exercise) group/individualized, supervised/home-based , mixture of supervised and home-based
  60. 60. Psychosocial Interventions Education:  energy conservation and activity management to balance rest and activity  planning, delegating, prioritizing, pacing, resting Support group Individual counseling Comprehensive coping strategy Stress management training Behavioral intervention
  61. 61. Sleep Therapy Stimulus control  go to bed when sleepy, get out of bed after 20 min of wakefulness  Have a routine bedtime and rising time Sleep restriction  avoidance of long or late day naps  Limiting total time in bed Sleep hygiene  caffeine and exercise avoidance near bedtime  comfortable sleep surroundings (dark, relaxing…)  soothing activities at bedtime (music, …)
  62. 62. Thank You!