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癌症病人常見症狀之物理治療 廖清彬


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癌症病人常見症狀之物理治療 廖清彬

  1. 1. 癌症病人常見症狀(呼吸困難、疲倦、疼痛)之 物理治療醫療財團法人辜公亮基金會和信治癌中心醫院 物理治療師 廖清彬 2012.09.02 1
  2. 2. 參考資料1. Michael DS, Michael WO. editors. Cancer Rehabilitation Principles and Practice. New York: Demos Medical Publishing 20092. Jane R, Karen R, Nicola M, Jill C, Sian L, editors. Rehabilitation in Cancer Care. Wiley-Blackwell 20083. Hermann D. Rehabilitation and palliation of Cancer patients. Springer-Verlag France, Paris 20074. Rehabilitation Oncology ( Oncology Section American Physical Therapy Association )5. Physiotherapy Research International6. Physical Therapy7. Palliative Medicine 2
  3. 3. “Quality of Life”This is part of Comprehensive Cancer CareRehab Goals Based on Many FactorsPrognosisTreatmentCo-morbidity / ImpairmentPainPsychosocial DistressSocioeconomic BackgroundPersonal “Re-prioritization” 3
  4. 4. Continuous Redefining of Treatment Success and Functional GoalsPrognosis:relative to stage / type of static or dynamic lesion(s)Concurrent anti-neoplastic treatmentMedical co-morbidity – functional impairmentsDegree of pain and psychosocial distressSocioeconomic background – domestic and financial resources to facilitate participation in goalsPersonal “re-prioritization” – Symptom versus Disease Oriented Care 4
  5. 5. Avoid functional morbidity resulting from cancer and/or its treatmentStretch irradiated soft tissueProtect skin with chemotherapy-induced neuropathiesAggressive post-thoracotomy chest PT and shoulder range of motionPrevent pathologic fractures with braces 5
  6. 6. Restore pre-morbid level of function when long-term impairment anticipated Post-axillary dissection -- preserve ROM and strength of shoulder; prevent extremities-edema Post-BMT – aerobic reconditioning Post-XRT of bone – prevent pathologic fracture with mobility / ADL retraining 6
  7. 7. Maximize function when long-termimpairment, disability, and/or handicap result from cancer and its treatment – Gait retraining after limb salvage – Cognitive remediation after brain tumor resection / irradiation – Optimization of shoulder function after Spinal Accessory Nerve sacrifice 7
  8. 8. 持續進行• Staging work-up repeated• Further treatment based on, age, stage, type of malignancy, prior treatment response, patient interest in anti-neoplastic therapy, potential for cure• Aggressive high-dose CTX/XRT with high incidence of cumulative toxicity (cardiac, neurological, wound healing, etc.)• Preserve: mobility, community integration, and autonomous self-care: – W/C or scooter, assistive devices – Resistive exercise – Energy conservation / Compensatory strategies – Environmental control devices 8
  9. 9. 持續進行 (ㄧ)• Selection factors Severity of disability, extent and activity of disease, family physical and emotional capability to participate in care, prognosis Benefits of continued rehab balanced against progressive nature of disease Flexible goals/duration due to evolving needs of the patient and family Emotional, functional, and spiritual support 9
  10. 10. 持續進行 (二)• Integrated program based on preventive, restorative, supportive, and palliative needs: 80% of treated patients demonstrated measurable benefits and 68% showed moderate or marked improvement or became fully independent• Goal: Predict & properly treat those at greatest risk for functional decline ….. To add ‘life to years’, not just ‘years’• Increase aerobic condition, strength, flexibility, and mechanical efficiency effect immune status and/or cytokine regulation 10
  11. 11. BreathlessnessA subjective experience of breathing discomfort …interactionphysiological, psychological, social and environmental factors, inducesecondary physiological and behavioral responses. ( American Thoracic Society )Cancer-related breathlessness the cancer itself cancer treatment concurrent conditions: COPD, heart failure and systemic illness individual perception: anxiety, behavioral response 11
  12. 12. Causes of breathlessnessPulmonary : loss of functional lung tissue / M obstruction of airway / M loss of lung elasticity / MNon-pulmonary : weakness of respiratory muscles / M elevation of the diaphragm / M defects of the circulatory system / M,C anemia / C metabolic disorders and renal disease / C anxiety or fear / E* M: mechanical, C: chemical, E: emotional factors 12
  13. 13. Assessment of breathlessness• Medical and physical, social and occupational, spiritual and psychological assessment• Observation skills: respiratory function breathing rate, chest wall movement, breath sounds, posture ( kyphosis and scoliosis ), frequency of sighing / yawning, surgery• Visual analogue scale ( VAS )• Modified Borg scale ( MBS )• Numeric rating scale ( NRS ) 13
  14. 14. Breathlessness management• Medical intervention: bronchodilators, corticosteroids, benzodiazepine, morphine,O2, nebulized saline• Non-pharmacological intervention: individual patient’s needs ( such as breathing retaining, positioning and carefully graded exercise ), cognitive-behavioral approaches ( education, relaxation and improving symptom awareness ), alter environments ( energy conservation / modification ADL ) 14
  15. 15. Breathlessness management (1)Breathing retraining: step-by-step approachPositioning: high side lying, sitting with support, standing relaxedExercise: aerobic exercise ( walking, stair climbing, static cycle, treadmill ), carefully gradually increase ( frequency, duration, intensity ), avoid distress and set achievable goalsCognitive-behavioral approaches: fear, anxiety, overbreathing, hyperventilation syndrome ( dizziness, headaches, paraesthesia, chest pain, palpitations, blurred vision ), simple breathing exercise, relaxation techniques, passive neuromuscular relaxationAlter environments: task simplification, reduce energy consumption, individual patient’s needs 15
  16. 16. Cancer-Related FatigueDistress persistent, subjective sense of tiredness or exhaustionrelated to cancer or cancer treatment ( NCCN, National Comprehensive Cancer Network, 2006 )CRF: physical, psychological and cognitive componentsNo energy, tired, exhausted, poor concentration, memory loss,irritable, ….Direct effects of the tumor, treatment side effects,anaemia, pain or deconditioning, psychosocial factors such asanxiety and depression 16
  17. 17. CRF- assessment International Classification of Diseases-10 ICD-10, proposing 11 symptoms of CRF ( Cella )*Significant fatigue, diminished energy or increased need to rest, disproportionate to any recent change in activity level• Complains of generalised weakness or limb heaviness• Diminished concentration or attention• Decreased motivation or interest in usual activities• Insomnia or hypersomnia• Experience of sleep as unrefresing or non-restoratives 17
  18. 18. CRF- assessment ( 1 ) International Classification of Diseases-10 ICD-10, proposing 11 symptoms of CRF ( Cella )• Perceived need to struggle to overcome inactivity• Marked emotional reactivity ( e.g. sadness, frustration and irritability ) to feeling fatigued• Difficulty in completing daily tasks attributed to feeling fatigued• Perceived problems with short-term memory• Post-exertional malaised lasting several hours• 6/11, 2wks/month,*, usual function, ca/ca t’x, not psychiatric 18
  19. 19. The role of physiotherapy in the management of CRF• Muscle atrophy and decreased stamina are marked components of CRF.( NCCN,2006;Mock,2004;Tomkins Stricker et al.,2004)• Exercise has the strongest evidence base and is reported as the most effective non-pharmacological intervention.• Exercise program begins when the patients start adjuvant therapy and lasts throughout the treatment.• Low-to-moderate intensity ( 50-70%HRmax,11-13RPE )• Progressive, Aerobic 15-30mins/day, 3-5days/week• Exercise diary, session mode, intensity, duration, target heart rate, symptoms experienced. 19
  20. 20. CRF Clinical Practice GuidelinesThree main stages / physiotherapy & exercise ( NCCN,2006 )During active treatment high levels of fatigue / chemotherapy first 72 hours / radiotherapy course recovery time (should be monitored) ≦30mins swimming*When active treatment if completed and long-term follow-up CRF can be at its peak post-treatment / especially no exercise during t’x short- / long-term goals 3- / 6-month, low-to-moderate intensity, aerobic / resistive, targeting weakened areas, gradually ↑ frequency、duration、intensity, motivation / group therapyAt end of life progression of disease, pain, medication, depression, anemia, poor nutrition, sleep disturbance, PT aim maintain mobility and independence /close consultation 20
  21. 21. Cancer Pain• Pain “ an unpleasant sensory and emotional experience associated with actual or potential tissue damage” IASP ( international association for the study of pain )• Cancer pain “ ..... Composed of acute pain, chronic pain, tumor- specific pain, treatment-related pain, …psychological responses of distress and suffering, …” 1. pain directly due to the cancer, e.g. bony metastatic disease 2. pain indirectly due to the cancer, e.g. spinal nerve root compression by a tumor 3. pain secondary to cancer treatment, e.g. peripheral neuropathy secondary to chemotherapy 4. pain not related to cancer or its treatment but which coexists e.g. painful OA joint 21
  22. 22. Cancer Pain ( 1 )• Patients with cancer often have multiple pains and multiple causes of pain.• Coexist with other symptoms : fatigue nausea and vomiting breathlessness deconditioning (↓ social activity / support ) anxiety ( hopelessness, negative perception ) fear and depression ( pain experience, indicate further damage / worse of disease ) 22
  23. 23. Cancer Pain - Assessment• Description of the pain severity, irritability, nature terminal disease and severe pain vs no evidence of cancer but chronic cancer-treatment-related pain• Responses to the pain effective pain relief as quickly as possible cognitive-behavioral therapy to improve function• Impact of pain on the patient’s life 23
  24. 24. Cancer Pain – Assessment ( 1 )☆ Activity limitation / functional limitation□ Physical impairmentsVisual analogue scale ( VAS )Numerical ratings scale ( NRS ) mild moderate severe pain0 1 2 3 4 5 6 7 8 9 10no pain worst pain 24
  25. 25. Management of cancer-related painThe majority of cancer pain is due to tumor effects.bone metastases : 8 Gy / radiation fractionMedical approachesPharmacological approachesNon-opioidsOpioidsAdjuvantsRadiotherapyPhysical therapy interventions 25
  26. 26. Management of cancer-related pain ( 1 )• Physical therapy interventions relieve pain improve function improve quality of life physical, psychosocial, lifestyle adjustment / educational approaches 26
  27. 27. Management of cancer-related pain ( 2 )• Physical approaches therapeutic exercise graded and purposeful activity postural re-education massage and soft-tissue mobilization transcutaneous electrical nerve stimulation ( TENS ) heat and cold 27
  28. 28. Management of cancer-related pain ( 3 ) Activity Reduces Resulting in Pain Stiffness Causing increased Causing loss of Function 28
  29. 29. American Physical Therapy Association’s Guide to Physical Therapist Practice• A physical therapist may use physical agents and modalities to• decrease neural compression• decrease pain and swelling• decrease soft tissue and circulatory disorders 29
  30. 30. American Physical Therapy Association’s Guide to Physical Therapist Practice• A physical therapist may use physical agents and modalities to• enhance airway clearance• enhance movement performance• enhance or maintain physical performance 30
  31. 31. American Physical Therapy Association’s Guide to Physical Therapist Practice• A physical therapist may use physical agents and modalities to• improve joint mobility• improve tissue perfusion• prevent or remediate impairments、 functional limitations、disabilities to improve physical functions• reduce edema• reduce risk factors and complications 31
  32. 32. Physical agents and modalitiesPhysical agentsIncrease tissue extensibility rate of wound healingModulate painReduce soft tissue swelling or inflammationRemodel scar tissueTreat skin conditions 32
  33. 33. Physical agents and modalities ( 1 )Physical agentsCryotherapy cold packs, ice massage, vapocoolant sprayHydrotherapy contrast baths, pools, whirlpool tanksLight agents infrared, laser, ultravioletSound agents ultrasound, phonophoresisThermotherapy deep heat, hot packs, paraffin 33
  34. 34. Physical agents and modalities ( 2 )• Mechanical modalities improve circulation increase range of motion modulate pain decrease and control edema stabilize an area that requires temporary support 34
  35. 35. Physical agents and modalities ( 3 )• Mechanical modalities Compression therapies ( compression bandaging, compression garments, taping, ) Gravity-assisted compression ( standing frame, tilt table ) Continuous passive motion devices ( CPM ) Traction devices ( intermittent, positional, sustained ) 35
  36. 36. Physical agents and modalities ( 4 )• Electrotherapeutic modalities assist functional training assist muscle force generation and contraction increase the rate of healing decrease unwanted muscular activity modulate / decrease pain reduce soft tissue swelling、inflammation、 restriction. 36
  37. 37. Physical agents and modalities ( 5 )• Electrotherapeutic modalities Biofeedback Electrical stimulation electrical muscle stimulation EMS, functional electrical stimulation FES, neuromuscular electrical stimulation NMES, transcutaneous electrical nerve stimulation TENS 37
  38. 38. Physical agents and modalities ( 6 )• Indications• Precautions• Contraindications General precautions and absolute contraindications*Each patient must be carefully considered on an individual basis.* 38
  39. 39. Physical agents and modalities ( 7 )• Contraindications Patient-centered surveys 1.cryotherapy to reduce the severity of oral mucositis (C/T) 2.TNES electrodes or an electrical stimulation band placed acupuncture points to reduce the incidence and severity of nausea and vomiting (C/T) 39
  40. 40. Therapeutic Exercise in Cancer• Goals• ↓risk, impairments, ↑function, fitness, well- being preventive restorative supportive palliative 40
  41. 41. Therapeutic Exercise in Cancer ( 1 )• Strengthening Exercise• Aerobic Exercise• Range of Motion and Flexibility• Coordination and Balance Training• Chest Physical Therapy• Considerations Fatigue Pain 41
  42. 42. 謝謝聆聽 敬請指教 42