林慧芬物理治療師-乳癌病人照護20130929
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林慧芬物理治療師 國立臺灣大學醫學院附設醫院復健部物理治療技術科物理治療師 國立臺灣大學物理治療研究所博士候選人
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林慧芬物理治療師-乳癌病人照護20130929
- 5. Treatment of breast cancer — Local versus systemic therapy — Local — Surgery — Radiation therapy — Systemic — Chemotherapy — Hormone therapy — Target therapy — adjuvant versus neoadjuvant therapy
- 6. Surgery for breast cancer — Mastectomy — Modified radical mastectomy (MRM) — Breast conserving surgery (BCS) — Breast reconstructive surgery — Breast implant — TRAM — Lymph node surgery — Axillary lymph node dissection (ALND) — Sentinel lymph node biopsy (SLNB)
- 9. 局部 全身性
- 10. Sequelae of the upper quarter a;er breast cancer treatment — Restricted upper quarter mobility — Pain — Lymphedema — Impaired sensation — Impaired strength 10
- 11. Prognosis of the following surgery and radia5on for breast cancer included 32 studies to analyze — shoulder restriction 1%-‐67% — lymphedema 0-‐34% — pain — Shoulder and/or arm pain 9%-‐68% — Breast and/or scar pain 15%-‐72% — weakness — quality of life — prognostic factors 11 ( Lee TS, et al. 2008)
- 12. Contribu5on of type of surgery — MRM versus BCS 12 Outcomes OR 95% CI Shoulder restriction 5.67 1.03-31.06 lymphedema No difference ALND versus SLNB Outcomes OR 95% CI Reference Shoulder restriction 1.27 0.38-4.26 Barranger et al. 2005 lymphedema 11.67 1.45 – 94.65 Barranger et al. 2005 Arm pain 3.73 1.23-11.34 Peintinger et al. 2003 Arm pain 4.61 2.01-10.59 Barranger et al. 2005
- 13. Contribu5on of radia5on to upper limb outcomes Outcomes OR 95% CI Lymphedema 1.46 1.16-1.84 Shoulder restriction 1.67 0.98-2.86 Weakness Not predictive QOL Not prognostic indicator Breast pain at 6 months 1.99 1.41-2.81 Breast pain at 2 years 1 0.65-1.55 Breast pain at 12 months Not predictive 13
- 15. 乳癌術後復健運動 — 第一階段：術後可立即做 — 目的：減輕腫與緊、放鬆肌肉緊張、促進傷口癒合 — 第二階段：至術後6週 — 目的：重回手臂肌力與柔軟度 — 逐漸增加走路的時間已增加元氣與避免肌肉變軟 — 第三階段：術後6-10週 — 中等強度走路運動或其他中等強度有氧運動 — 和緩的柔軟度訓練與肌力訓練 — 第四階段：術後10週以後 — 中等至強度走路運動或其他有氧運動 — 著重全身耐力、肌力與柔軟度與 — 第四階段之外 資料來源：http://www.stayingabreast.com/site/browse/ phase1.htm
- 16. 乳癌術後復健運動： 第四階段之外 — 肌力、恢復性運動、柔軟度運動 — 腹肌與核心訓練 — 體重控制 — 心肺耐力訓練 — 維持骨密度 — 化療期運動 — 物理治療
- 17. 乳癌術後的復健 一般原則 — 呼吸運動：協助放鬆與排痰 — 四肢活動：維持關節活動與預防血栓 — 即早下床活動：幫助體力恢復 — 漸進性肩關節活動 — 注意姿勢
- 18. First few weeks a;er surgery for wound healing — Avoid splinting their arms — Avoid repeated motion — Avoid heavy lifting
- 19. Postsurgical rehabilita5on for breast cancer — Progressive shoulder ROM — Postural exercise — Pectoralis stretching — Strengthening scapular muscles — Lymphedema education — Risk reduction precautions — Life style modification — Gradual strengthening and conditioning exercises — Scar management — Pain and symptom management — Swelling management 19
- 20. 20 PEDro scale 作者/發表年 國家 研究目的 主要結果 5 Lacomba MT,et al 2010 Spain 早期物理治療運動是否可以預防 淋巴水腫 追蹤2年，早期物理治療運動，比控制 組淋巴水腫發生率低 8 Sagen A, et al. 2009 Norway 不限制患側活動對淋巴水腫的影 響 乳癌開刀後應鼓勵維持活動，並不會 增加淋巴水腫 7 Todd J,et al 2008 UK 術後一週內限制關節活動與不限 制關節活動在1年後的結果 術後一週內不限制肩關節活動， 1年後 發生淋巴水腫比較高。其餘在肌力、 關節角度、功能、QOL無差異 Cinar N,et al 2008 Turkey 術後開始復健比照居家自行運動 的療效 術後早期復健在關節活動度及功能恢 復較好 7 Beurskens CHG, et al 2007 Netherland 術後PT比照居家自己運動的效果 在術後 3個月、6個月，有接受物理治 療組在肩關節前屈、外展、功能及疼 痛顯著比控制組好 7 Lauridsen, et al. 2005 Denmark 團體物理治療的在肩關節功能的 效果 團體物理治療在肩關節功能有顯著效 果 4 Box RC, et al. 2002a Australia 術後運動治療與控制組肩關節活 動度的恢復情形與危險因子 術後運動恢復較快較好 5 Box RC, et al 2002b Australia 術後運動治療與控制組淋巴水腫 的發生率 術後 2年後，運動治療組淋巴水腫發生 率較低 5 Bendz I, Olsen MF 2002 Sweden 術後第一天開始PT與術後2週開 始PT的效果 術後第一天開始作PT，恢復較快。在 2年後肩關節外展與前屈有差異。
- 21. Time-‐related change of shoulder mobility 21 Box et al. 2002a D 5 1m 3m 6m 12m 24 m ns ns P0.0 5 P0.0 1 abduction
- 22. Delayed versus early mobiliza5on of shoulder — 術後一週內限制關節活動與不限制關節活動在1年 後的結果 (Todd et al.,2008) — 術後一週內不限制肩關節活動， 1年後發生淋巴水腫比 較高。 — 在肌力、關節角度、功能、QOL無差異 — 術後第一天開始PT與術後2週開始PT的效果 (Bendz Olsen, 2002) — 術後第一天開始作PT，恢復較快。在2年後肩關節外展 與前屈有差異。 22
- 23. Early versus Delayed full ROM of shoulder — Early exercise — more effective in the short term recovery of shoulder flexion — Delay exercise — ↓Seroma — ↓Lymphedema 23 Shamley et al., 2005
- 24. Exercise interven5ons for upper-‐limb dysfunc5on due to breast cancer treatment — Post-‐operative: early versus delayed exercises — Ten studies including 1304 participants — Implementing early exercise was more effective than delayed exercise in the short term recovery of shoulder flexion — early exercise also resulted in a statistically significant increase in wound drainage volume and duration Cochrane Review, 2010
- 25. Post-‐opera5ve: Structured exercise programs versus comparison — Significantly improved shoulder flexion ROM in the short-term — Additional benefit for shoulder function post- intervention and at six-month — No evidence of increased risk of lymphedema from exercise at any time point 25 Exercise interventions for upper-limb dysfunction due to breast cancer treatment (Cochrane Review, 2010)
- 26. 結論 — 乳癌手術後早期給予物理治療運動訓練，對關節 活動度、功能恢復較快也恢復較好。 — 運動訓練並不會增加淋巴水腫的風險。 — 術後運動訓練淋巴水腫發生率及腫脹程度比控制 組低。 — 術後早期（5天-2週）限制肩關節活動角度，可以 有效降低血清腫、1年後淋巴水腫的發生率。 26
- 27. Pain — Nociceptic pain — Surgical wound pain — Scar pain — Neuropathic pain — Postmastectomy pain syndrome (PMPS) — Myofascial pain — Side effects of anticancer drug — Aromatase inhibitors
- 28. Periopera5ve nerve injury — Thoracodorsal nerve — la5ssmus dorsi — Long thoracic nerve — serratus anterior — Intercostobrachial nerve — Sensory deficit — Chronic neuropathic pain — Postmastectomy pain syndrome (PMPS) — Medial and lateral pectoral nerve — Pectoralis 28
- 29. Neuromuscular complica5ons a;er surgery for breast cancer — Neuropathy — Scar adhesion — Pectoral area tightness — AWS — Shoulder tendinopathy — Frozen shoulder 29
- 30. 腋網症候群 axillary web syndrome 30
- 31. 腋網症候群 — 發生率6%-‐72% — 限制外展角度 — 腋下到前臂有索狀 — 開刀後1-‐8週發生 — 多在2-‐3個月緩解 — 物理治療建議： — 牽拉 — 按摩 31
- 32. Incidence of Myofascial pain syndrome （MPS）a;er breast cancer surgery — n=116 s/p unilateral breast surgery + ALND — assessed pre-‐op, post-‐op at discharge day, f/u 4 weeks, 3m, 6m, 12m — 52/116 was detected active MPS (44.8%, 95%CI 35.6-‐54.3) — MPS developed mainly during the 6-‐month period after surgery 32 Lacomba MT 2010
- 33. Pain a;er breast cancer surgery 33
- 35. Longitudinal Change of Treatment-‐Related Upper Limb Dysfunc5on — The major post-‐operative ULD — pectoralis tightness at 3 and 6 months — lymphedema at 12 months. — Late ULD such as rotator cuff disease were associated with pectoral tightness or lymphedema at earlier stages. — Diagnosis and treatment of ULD should take place as soon as possible after surgery. Yang et al., 2010
- 37. Postural correc5on and exercise — Pectoralis stretching — Strengthening scapular muscles
- 38. Check muscle length — Pectoralis major — Pectoralis minor — Latissmus dorsi
- 39. 伸展胸⼤大肌
- 40. Strengthening scapular muscles — Scapula protraction — Scapula retraction — External rotation — Lateral pull down
- 41. 疤痕按摩
- 42. For women at risk of lymphedema — Get regular check-‐up — Report changes — Try to get to and/or stay at a healthy weight — Exercise — Try to avoid infection — Be aware of cellulitis — Try to avoid burns and extreme temperatures — Try to avoid limb constriction — Use of compression garments — Air travel 42
- 43. 預防淋巴水腫 — 減少干擾淋巴液回流的因子 — 減少組織間液（淋巴液）產生 — 保護皮膚，避免皮膚有傷口或感染 — 注意身體變化，維持身體整體健康 — 舉高及輕微運動 — 認識腫脹感 43
- 44. 淋巴水腫自我檢查 你覺得兩隻手大小差別的程度? 沒有感覺差 別 有一點差， 但只有我知 道 有差別，但只 有跟我很熟的 人才發覺得到 很明顯 手掌與手指 0 1 2 3 前臂(下手臂) 0 1 2 3 上臂(上手臂) 0 1 2 3 0分:沒有水腫 1-3分:輕度水腫 4分以上:中度以上水腫
- 45. Tram Flap Abs: — Approximately 10 weeks after Tram Flap reconstruction, perform gentle, specifically designed abdominal and lower back exercises with guidance from physicians and physical therapists. — To support the lower back and abdominals during floor exercises, place a thinly rolled towel horizontally under the tailbone and lower buttocks. This will help stabilize the spine and allow for a mild contraction of lower abdominals.
- 46. Implant Reconstruc5on: — Avoid overhead arm motions until well after the implant has settled into a satisfactory shape and placement — Refrain from performing exercises that involve pushing motions (e.g. Chest Presses) or excessive pulling motions — Be certain to receive full clearance from your surgeon — Gentle exercise — Avoid vigorous stretching