癌症病人術後物理治療 蕭淑芳

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  • 1. 癌症病人術後物理治療 1 臺大醫院物理治療師 蕭淑芳
  • 2. Goal of surgery 2 Debulking a tumor:表示腫瘤已無法完全切除,因此開 刀時只將較大,較易切除的腫塊拿掉 Diagnosing a tumor(biopsy) Removing precancerous(癌前期) lesions Resecting a tumor Correction of life-threatening conditions caused by cancer Palliation
  • 3. Theme for postsurgery physical therapy 3 Early mobilization  Prevention of complications: pneumonia, ileus, DVT, loss of lean body mass Lung hygiene  Splinting cough, diaphragm/deep breathing exercise, posture education Gait training  Weight bearing restriction? pain? ADL training
  • 4. Management of some common cancer 4 Breast cancer Head and neck cancer Lung cancer Colorectal cancer Gastrointestinal cancer
  • 5. Breast cancer 5 Introduction of surgery type Post op programs
  • 6. 前哨淋巴切除檢驗(sentinel node dissection) 6 優點:若哨兵淋巴結沒 有癌細胞,則不做腋下 淋巴清除,則減少淋巴 水腫的問題。 缺點:有10﹪的僞陰性 率 建議用在腫瘤2公分以 內及原位癌的患者
  • 7. Lumpectomy or partial mastectomy 7 removal of the breast tumor (the "lump") and some of the normal tissue Lumpectomy : Tumor size<4 cm
  • 8. Mastectomy 8 Removal of the whole breast  Simple/ total mastectomy  Modified radical mastectomy  Radical mastectomy  Partial mastectomy  Subcutaneous (nipple-sparing) mastectomy.
  • 9. Simple Mastectomy 9 removes the entire breast, skin, nipple No muscles are removed from beneath the breast
  • 10. Modified Radical Mastectomy 10 removal of both breast tissue and lymph nodes: 優點:維持胸部肌肉及 手臂肌肉的張力, 手臂腫脹的情形較施行 乳房根除術輕微 乳房重建較易。
  • 11. Radical Mastectomy 11 Most extensive type of mastectomy Removes :  the entire breast,  Levels I, II, and III of the underarm lymph (B, C, and D in illustration),  chest wall muscles under the breast. 缺點:會留下很長的疤痕,胸部也 會凹陷,可能導致淋巴水腫、手臂 無力、痲痹、疼痛、肩膀活動受限 制等,
  • 12. Post op programs 12 Progressive shoulder ROM exercise:  Begin after removal of the drains  http://www.breastcf.org.tw/bloom/personal.php Postural exercise Lymphedema education
  • 13. Head and neck cancer 13 Site: Lip, tongue, floor of mouth, gum, salivary gland, oropharynx, nasopharynx, larynx, nose and sinuses, ear, thyroid Surgery type  Radical neck dissection:  Modified radical neck dissection  Selective neck dissection
  • 14. Head and neck cancer 14 Reconstruction: TMJ dysfunction  Pectoralis flap:  Fibular flap:  reconstruct the mandible bone; non-weight bearing for 4-7 days  Vascular integrity, peroneal nerve function  Transfer skill, bed mobility  Radical forearm flap:  no weight bearing activity on donor site,  ROM limited to 90 degree before drains removed
  • 15. Head and neck cancer 15 Post op care in acute phase  Maintain airway, Lung hygiene and tracheotomy care  Monitor circulation  Prevent infection  Control pain  Postural training  Cervical and shoulder ROM exercise
  • 16. Airway management and tracheostomy care 16 Aim of care  Ensure a patent airway  Maintain comfort  Ensure regular breathing rhythm, depth, and pattern Complication  Bleeding  Tracheoesophageal fistula  Infection  Obstruction or displacement of tracheostomy tube PT programs  Breathing exercise, cleaning of tracheostomy q2-3h(suction), humidification
  • 17. Lung cancer 17 Small cell lung cancer  High growth rate  Worse progonosis Non small cell lung cancer  Squamous cell carcinoma  Adenocarcinoma  Large-cell carcinoma
  • 18. 18 epgonline.org
  • 19. Reduced respiratory capacity after lung surgery 19 ↓25-30%functioning lung tissue after lobectomy or bilobetomy ↓40% after left pneumonectomy ↓60% after right pneumonectomy Indicators for post-op lung function  %FEV1  Diffusion capacity of the lung for carbon monoxide  Maximal oxygen uptake during exercise Provide oxygen
  • 20. Lung cancer 20 Pre-op assessment: ADL, PFT Risk factor: obesity, smoking Review blood counts
  • 21. Lung cancer 21 Post op care  Symmetrical movement of the thoracic cage  ROM of shoulder  Breathing training: pursed lip and diaphragmatic breathing  Drainage of secretions/ percussion, use of nebulizers  Splinting cough  Reconditioning: early ambulation, functional independent
  • 22. Symptoms and signs of Radiation pneumonitis 22 Dyspnea Non-productive cough Tachypnea Low grade fever Fullness in the chest ↑ESRTreatment: corticosteroids,
  • 23. Cardiovascular complications after pneumonectomy 23 Arrhytmias: 20-25%  Atrial fibrillation, supraventricular tachycardia, artial flutter  ↑mortality Myocardial infarction Acute heart failure Pulmonary emboli stroke
  • 24. Possible organ displacement after right pneumonectomy 24 Displacement of the tracheal to the right side Displacement of esophagus Mediastinal displacement to the empty pleural space Elevation of diaphragm and liver Deviation of the vertebral column
  • 25. Superior vena cava obstruction 25 Tumor compress Neck swelling Distended veins over chest Swelling of one or both arms Dyspnea Hoarse voice Stridor Headache
  • 26. 26http://www.aboutcancer.com/svco_cuases_nejm_507.gif
  • 27. PT intervention for SVCO 27 Elevate the patient‘s head Oxygen therapy Modified chest care skill Avoid compression therapy
  • 28. Colon cancer 28 Ileostomy: after removal of colon and rectum, externalized ileum Colostomy: rectum removed, distal colon attached to abdominal Ileo-anal reservoir surgery
  • 29. Somatic rehabilitation requirements after hemilectomy 29 Hernias Diarrhea/constipation Adhesions Anemia Diet/obesity
  • 30. Precautionary measures to prevent abdominal wall hernia 30 Caution in lifting and carrying heavy loads Loads should never lifted suddenly Excess weight should be avoided Abdominal bandage
  • 31. Example of physical therapeutic interventions for abdominal surgery 31 Breathing exercise  Deep breathing/ inspiratory holds  Incentive spirometry  Huffing/ directed cough  Chest percussion/vibration Early mobilization  Log-rolling /bracing with pillow  Transfer/ gait training  Progressive ambulation
  • 32. Gastrointestinal surgery 32 Thoracoscopy Laparoscopy Esophagectomy Esophagus reconstruction
  • 33. Pre/post upper abdominal and thoracic surgery 33 Pre op assessment: FEV1 Post op increased risk of respiratory complication:50%  Disruption of abdominal and diaphragmatic muscles ↓30%FRC for days  Impaired mucociliary function PT programs  Breathing exercise, Deep breathing, Incentive spirometry, Huffing, Chest percussion/vibration  Early mobilization
  • 34. Precaution for PT programs after upper abdominal and thoracic surgery 34 Avoid head down postural drainage: Suction ?? Drips and drains Shoulder ROM
  • 35. The environment and patient support/non- intravenous equipment after GI sugery 35 IV fluid TPN Enteral nutrition: PEG (percutaneous enteral gastrostomy), J-tube (jejonostomy), NG PRBC (paced red blood cell): ↑the O2 carrying capacity of blood FFP(fresh frozen plasma): ↑blood volume Stop PT JP (Jackson-Pratt) drain Sump drain Foley
  • 36. Breathlessness management 36 Breathing exercise Positions  High side lying  Sitting upright in a chair with feet, back, and arm support  Forward lean sitting with arm resting on pillows on a table
  • 37. Bone metastasis 37 Location of metastatic bone disease  Vertebrae 69%  Pelvis 40%  Femur 25%  Ribs 25%  Humerus 20%
  • 38. Pain characteristics that may indicate fracture or impending fracture 38 Pain with weightbearing Pain in the groin Pain with hip external rotation and abduction Pain with deep breathing Pain in a ban around the chest wall Increased pain with supine Increased pain with valsava
  • 39. Goal of Surgery for pathological fracture 39 Excision of tumor Cure Stabilization of bone Prevention sequela from bed rest Palliation
  • 40. Reference 40 Physical therapy in acute care : a clinicians guide . Edited by Daniel Malone Thorofare, NJ : Slack, 2006. Rehabilitation in cancer care. edited by Jane Rankin Chichester, UK ; Ames, Iowa : Wiley-Blackwell, 2008.