Post-surgical physical therapy   in patients with cancer   癌症病人術後物理治療             賴忠駿         臺大醫院物理治療中心
Contents General intervention in post surgical  patients Specific approach in different type of cancer    ◦   Breast can...
Goal of surgery   Debulking a tumor   Diagnosing a tumor (biopsy)   Removing precancerous lesion   Resecting a tumor ...
Post-surgical complication   Cardiopulmonary complications    ◦   Restriction of lung capacities    ◦   Atelectasis    ◦ ...
(Frownfelter D. 2006)2013/1/2                           5
Common rehabilitation themespost surgical patients Early mobilization Pulmonary hygiene Gait training Training in ADLs...
Early mobilization & pulmonary hygiene   Prevention of further immobility-related    complication    ◦   Pneumonia    ◦  ...
Gait & ADLs training   Specific indication    ◦   Status post amputation    ◦   Weight bearing restriction    ◦   Pain → ...
Physical activity post cancer treatment   Beneficial effects of physical activity    ◦ Optimize recovery of physical func...
Breast cancer   Various surgical method    ◦ Sentinel node biopsy→ full axillary dissection    ◦ Lumpectomy or partial ma...
Physical sequelae of treatment   Shoulder mobility and strength ↓    ◦ Cording                                       61% ...
Physical sequelae of treatment   Peripheral neuropathy    ◦ Side-effect of C/T, surgery, spinal cord compression,      ly...
Physical sequelae of treatment   Scar formation   Lymphedema    ◦ Obstruction of the lymphatic vessels    ◦ Accumulation...
Pre-breast surgery   Identification of risk factor for post-OP    ◦ Neurological/ musculoskeletal problems    ◦ Psycholog...
Post-breast surgery   Progressive shoulder ROM program    ◦ All plane of motion    ◦ Flexion/ extension/ abduction/ adduc...
Breast reconstruction   Breast reconstruction    ◦ Implants    ◦ Transverse rectus abdominus myocutaneous flaps (TRAM)  ...
Complications after breastreconstruction                            (McNeely ML, 2012)                 2013/1/2           ...
After breast reconstruction   Acute care role    ◦ Teaching proper body mechanisms within this      limitation prescribed...
Procedure and Restriction    (Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009)             ...
Exercise after surgery    (Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009)                ...
Exercise after surgery              2013/1/2   21
Delayed vs. immediate exercisefollowing surgery – seroma incidence                              (Shamley DR, 2005)        ...
Delayed vs. immediate exercisefollowing surgery – drainage volume andhospital stay                   2013/1/2   (Shamley D...
Head and Neck cancer   Location    ◦ Nasal cavity, nasopharynx, oral cavity,      hypopharynx, larynx   Complication aft...
Surgery of head & neck cancer   Surgery    ◦ Radical neck dissection      Used for large metastatic tumors and large    ...
Common problems   Poor posture    ◦ Forward head, round shoulders, neck rotation      due to pain,    ◦ Tracheostomy, fea...
Other common problems   Severe skin and soft tissue reaction of the    neck, limited ROM of neck   Decreased jaw ROM   ...
Post surgical care   Acute rehabilitation focus on    ◦ Cervical ROM, posture    ◦ Shoulder function, scapular kinematics...
General approach   Neck and shoulder exercise    ◦ Maintain all neck and shoulder movement    ◦ As skin healed: more aggr...
General approach   Chest PT    ◦ Active cycle breathing techniques    ◦ Autogenic drainage    ◦ Assistive cough   Progre...
Effect of deep breathing exercise onPOD 1                          (Genc A, 2008)                   2013/1/2              ...
A patient with oropharyngeal cancers/p surgery and tracheostomy                 2013/1/2         32
Oropharyngeal cancer s/p wide excision,bilateral modified radical neck dissection andtracheostomy                       20...
A patient with left lower gingiva cancer s/pwide excision and modified redical neckdissection                      2013/1/...
Remove spinal accessory nerve Abnormal scapulohumeral rhythm Musculoskeletal abnormalities    ◦   Trapezius atrophy    ◦...
Remove spinal accessory nerve(Malone DJ, editors.Physical therapy in acutecare. 2006)                            2013/1/2 ...
Remove spinal accessory nerve   Specific approach after SAN remove    ◦ Education: supporting the arm during      sitting...
Head and Neck reconstruction   Osteocutaneous/ mycutaneous    reconstruction    ◦ Pectoralis flap       With SAN damage:...
Intervention after reconstruction        Pectoralis flap       Fibular flap          Radial forearm flapAcute   Postural t...
Progressive resistance trainingimprove shoulder dysfunction                2013/1/2   (Carvalho APV, 2012) 40
Lung cancer   Two groups of lung cancer    ◦ Non-small-cell lung cancer (NSCLC)       Squamous cell carcinoma, adenocarc...
General intervention in lung cancer   Physical therapy intervention    ◦   Posture correction    ◦   Breathing facilitati...
Surgery of lung cancer   Types of surgery (early stage: I~IIIA)    ◦   Wedge resection    ◦   Segmentectomy    ◦   Lobect...
Prior to surgical resection   Selection of the patient    ◦ General and pulmonary-specific evaluation    ◦ Symptom limite...
Pre-surgical exercise training            (Courneya KS, editors. Physical activity and cancer. 2011)                    20...
Pre-surgical exercise training                          (Jones at al, 2007)               2013/1/2                        ...
Post-surgical complication   Postoperative morbidity is considerable    ◦ Reduction in VO2peak 30% up to 3 years         ...
Post-surgical care   Identify any risk factors    ◦ Smoking, obesity, age   Review complete blood counts (CBC)    ◦ Rais...
Post-surgical intervention   Chest PT    ◦   Positioning    ◦   Breathing exercise    ◦   Chest clearance techniques    ◦...
Post-surgical exercise training                                                      2013/1/2   50(Courneya KS, editors. P...
Post-surgical exercise training                          (Jones et al, 2008)               2013/1/2                       ...
Gastrointestinal tumors   Types of gastrointestinal tumors    ◦ Upper GI cancer      Esophagus/ Gastric/ liver/ pancreas...
Common problem of GI cancer   Significant physical impact on the patient    ◦   Malnutrition: up to 85% patients    ◦   W...
Clinical presentation of GI cancers                     Upper GI cancers                     Lower GI cancers(Rankin J, ...
Types of surgery   Upper GI cancers    ◦ Oesophagectomy    ◦ Radical gastric resection   Lower GI cancers (80%)    ◦   L...
Post-surgical complication   Increase pulmonary complication    ◦ 50% patients (McCulloch et al, 2003)    ◦ Pre-OP: FEV1 ...
Pre-surgical intervention   ↓sputum retention, maximising lung volume    ◦   Prophylactic deep-breathing exercise    ◦   ...
Post-surgical intervention   Upper GI cancers    Prevent complication & progressive exercise    ◦   Deep-breathing exerci...
Following an oseophagectomy                         (Rankin J, editors.                         Rehabilitation in cancer c...
Exercise Caution   High anastomosis associated with an    oesophagectomy    ◦ Head-down postural drainage    ◦ Suction vi...
Post-surgical long term exercise            (Courneya KS, editors. Physical activity and cancer. 2011)                    ...
Neurological tumors   Brain tumor    ◦ Primary: <2 % of all cancers      Gliomas      Meningiomas    ◦ Secondary: up to...
Characteristics of brain tumor              2013/1/2           63
Signs & symptoms   Complex physical, cognitive, psychosocial    tymptoms    ◦   ↑ intercranial pressure    ◦   Local tumo...
Common problem of brain tumors         (Rankin J, editors. Rehabilitation in cancer care 2008.)                           ...
Intracranial neurosurgicalprocedure   Low-grade tumor    ◦ May surgical intervention until symptoms appear    ◦ May elect...
Intervention post brain surgery   Primary aims    ◦   Maintain or improve mobility/ function    ◦   Improve strength and ...
Early rehabilitation post surgery                            (Bartolo M, 2012)                2013/1/2                    68
Primary spinal tumor   Low grade tumors    ◦ Intervention mimics the patients of spinal injury   High grade tumor    ◦ D...
Relative risk for MSCC                     (Rankin J editors. Rehabilitation in cancer care. 2008)   Metastatic compressi...
Spinal neurosurgical procedure   Aim of surgery    ◦ Decompression of the spinal cord    ◦ Excision of tumor bulk   Type...
Passive intervention after surgery   Immobilize phase    ◦ Appropriate handling and positioning    ◦ Prevent prolonged be...
Active intervention after surgery   When spinal condition is stable    ◦   Clinical signs & symptoms relieved    ◦   Head...
Physical intervention for MSCC patient                         2013/1/2                                       74          ...
Musculoskeletal tumor   Types of musculoskeletal tumors    ◦ Primary bone tumor      Osteosarcoma      Chondrosarcoma  ...
Pre- and post-surgical management   Pre-surgical    ◦ Mobilize with PWB or NWB depending on extent      bone destruction ...
General protocols of osteosarcomaPresurgical phase      Acute              Subacute           Chronic                     ...
Physical therapy after LE surgery                           (Punzalan M, 2009)                2013/1/2                    ...
POD 1~3 Days to 1 month      Distal Femur                     Proximal Tibia                     Falling risk             ...
Post-OP to 6 months             Distal Femur                Proximal TibiaBrace    Using for               Using for 6 mon...
Post-OP quadriceps setting              2013/1/2       81
Post-OP hip abduction/adduction                2013/1/2          82
Post-OP / OPD follow-up4-phase straight-leg-raising       平躺抬腿      側躺抬腿                趴姿抬腿側躺夾腿                 2013/1/2 ...
OPD follow-upActive knee flexionPassive knee extension                         2013/1/2   84
OPD follow-up   承重訓練                    穩定訓練                2013/1/2          85
Summary   Physical therapy in pre-/ post- surgical    cancer patients    ◦ Early intervention and monitoring can ameliora...
Reference   Packel L. Oncological diseases and disorders. In Malone DJ,    Lindsay KLB. Physical therapy in acute care: A...
Reference   McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW. A    Prospective Model of Care for Breas...
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癌症病人術後物理治療 賴忠駿

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癌症病人術後物理治療 賴忠駿

  1. 1. Post-surgical physical therapy in patients with cancer 癌症病人術後物理治療 賴忠駿 臺大醫院物理治療中心
  2. 2. Contents General intervention in post surgical patients Specific approach in different type of cancer ◦ Breast cancer ◦ Head & Neck cancer ◦ Lung cancer ◦ Gastrointestinal tumor ◦ Neurological tumor ◦ Musculoskeletal tumor 2013/1/2 2
  3. 3. Goal of surgery Debulking a tumor Diagnosing a tumor (biopsy) Removing precancerous lesion Resecting a tumor Correction of life-threatening conditions caused by cancer Palliation 2013/1/2 3
  4. 4. Post-surgical complication Cardiopulmonary complications ◦ Restriction of lung capacities ◦ Atelectasis ◦ Airway clearance ↓ ◦ Infection Other complications ◦ Muscle wasting ◦ Deconditioned status ◦ Malnutrition 2013/1/2 4
  5. 5. (Frownfelter D. 2006)2013/1/2 5
  6. 6. Common rehabilitation themespost surgical patients Early mobilization Pulmonary hygiene Gait training Training in ADLs (Malone DJ, editors. Physical therapy in acute care: A clinician’s guide 2006) 2013/1/2 6
  7. 7. Early mobilization & pulmonary hygiene Prevention of further immobility-related complication ◦ Pneumonia ◦ Ileus ◦ Deep vein thrombosis ◦ Loss of lean body mass Pulmonary hygiene ◦ Splinted coughing ◦ Diaphragmatic & deep breathing exercise ◦ Postural education → prevent post-OP pulmonary complication 2013/1/2 7
  8. 8. Gait & ADLs training Specific indication ◦ Status post amputation ◦ Weight bearing restriction ◦ Pain → limiting functional mobility ◦ Fatigue→ impeding mobility 2013/1/2 8
  9. 9. Physical activity post cancer treatment Beneficial effects of physical activity ◦ Optimize recovery of physical functioning and quality of life ◦ Manage any chronic and late-appearing effects of treatment  Fatigue, lymphedema, fat gain, bone loss ◦ Reduce the likelihood of disease recurrence ◦ Reduce the likelihood of developing other chronic disease  Osteoporosis, heart disease, diabetes (Courneya KS, editors. Physical activity and cancer. 2011) 2013/1/2 9
  10. 10. Breast cancer Various surgical method ◦ Sentinel node biopsy→ full axillary dissection ◦ Lumpectomy or partial mastectomy ◦ Mastectomy: remove breast tissue  Simple mastectomy  Modified radical mastectomy (MRM)  Skin-sparing mastectomy  Radical mastectomy 2013/1/2 10
  11. 11. Physical sequelae of treatment Shoulder mobility and strength ↓ ◦ Cording 61% Internal rotation ◦ Stiffness in the tissue 41% Abduction ◦ Pain 34% External rotation 33% Flexion Pain and numbness (Joansson et al, 2001) ◦ Post-surgical pain → complex chronic pain ◦ Post-mastectomy neuritis ◦ 20% at 6 months (Versus et al, 2001); ◦ 25% at 6 months, 29% at 1 year (Karki et al, 2005) 2013/1/2 11
  12. 12. Physical sequelae of treatment Peripheral neuropathy ◦ Side-effect of C/T, surgery, spinal cord compression, lymphoedema ◦ Demyelination of the nerve fibers ◦ Impact on mobility, dexterity, pain, hand function ◦ Symptoms  Parasthesias, hyperarsthesias, clumsiness, loss of proprioception  Weakness and atrophy of intrinsic and extrinsic muscle  Loss of palmar aches and decrease ROM of hand joints 2013/1/2 12
  13. 13. Physical sequelae of treatment Scar formation Lymphedema ◦ Obstruction of the lymphatic vessels ◦ Accumulation of lymph fluid In the tissue Abnormal posture (Karki at al, 2005) ◦ Prolonged protraction of the shoulder ◦ Tightness of the pectoral major muscles 2013/1/2 13
  14. 14. Pre-breast surgery Identification of risk factor for post-OP ◦ Neurological/ musculoskeletal problems ◦ Psychological problems ◦ Respiratory disorders Specific & relevant information and advice 2013/1/2 14
  15. 15. Post-breast surgery Progressive shoulder ROM program ◦ All plane of motion ◦ Flexion/ extension/ abduction/ adduction/ rotation Posture exercise ◦ Pectoralis stretching ◦ Strengthening of posterior shoulder musculature Lymphedema education Post surgical education ◦ Avoid splint their arm ◦ Avoid repetitive motions ◦ Avoid heavy lifting the first few weeks 2013/1/2 15
  16. 16. Breast reconstruction Breast reconstruction ◦ Implants ◦ Transverse rectus abdominus myocutaneous flaps (TRAM) Post reconstruction ◦ Round shoulders, pectoralis tightness, weakness of scapular musculature ◦ Pectoralis spasm ◦ Give gentle exercise: avoid posture changes ◦ Rigorous stretching program is not indicated ◦ Mobility and lifting is limited Maintain health donor and recipient site 2013/1/2 16
  17. 17. Complications after breastreconstruction (McNeely ML, 2012) 2013/1/2 17
  18. 18. After breast reconstruction Acute care role ◦ Teaching proper body mechanisms within this limitation prescribed ◦ Transfer and bed mobility techniques ◦ Lymphedema precaution After flap healing ◦ Common consequences  Breast and trunk lymphedema, shoulder adhesive capsulitis, poor posture, low back pain ◦ PT interventions  Back stability program, shoulder ROM strengthening, myofascial techniques, joint mobilization, body mechanics training 2013/1/2 18
  19. 19. Procedure and Restriction (Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009) 2013/1/2 19
  20. 20. Exercise after surgery (Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009) 2013/1/2 20
  21. 21. Exercise after surgery 2013/1/2 21
  22. 22. Delayed vs. immediate exercisefollowing surgery – seroma incidence (Shamley DR, 2005) 2013/1/2 22
  23. 23. Delayed vs. immediate exercisefollowing surgery – drainage volume andhospital stay 2013/1/2 (Shamley DR, 2005) 23
  24. 24. Head and Neck cancer Location ◦ Nasal cavity, nasopharynx, oral cavity, hypopharynx, larynx Complication after treatment ◦ Dysfunction in mobility, speech ◦ Dysfunction of the eat and swallow ability ◦ Cause emotional and interpersonal distress 2013/1/2 24
  25. 25. Surgery of head & neck cancer Surgery ◦ Radical neck dissection  Used for large metastatic tumors and large palpable nodes ◦ Modified radical neck dissection  Remove SCM and lymph nodes  Preservation of spinal accessory nerves ◦ Selective neck dissection  Remove the mass and any lymph nodes 2013/1/2 25
  26. 26. Common problems Poor posture ◦ Forward head, round shoulders, neck rotation due to pain, ◦ Tracheostomy, fear of damaging the surgical site Exacerbate any shoulder dysfunction Decrease the ability to clear secretions Alter the venous and lymphatic drainage system  Head & neck lymphedema 2013/1/2 26
  27. 27. Other common problems Severe skin and soft tissue reaction of the neck, limited ROM of neck Decreased jaw ROM Formation of copious amounts of sputum Dysphagia Impaired communication Malnutrition 2013/1/2 27
  28. 28. Post surgical care Acute rehabilitation focus on ◦ Cervical ROM, posture ◦ Shoulder function, scapular kinematics ◦ Cough technique, lymphedema education Post-surgery ◦ Caution: allow for proper wound healing ◦ Shoulder flexion≦90° ◦ Conservative cervical ROM (post op day 6) 2013/1/2 28
  29. 29. General approach Neck and shoulder exercise ◦ Maintain all neck and shoulder movement ◦ As skin healed: more aggressive exercise Active jaw exercise Postural exercise ◦ Pectoralis stretching ◦ Trapezius & rhomboid strengthening Lymphedema education 2013/1/2 29
  30. 30. General approach Chest PT ◦ Active cycle breathing techniques ◦ Autogenic drainage ◦ Assistive cough Progressed functional training ◦ Daily mobilization ◦ Bed exercise ◦ Ambulation, gait correction ◦ Practice steps/ stairs pre-discharge 2013/1/2 30
  31. 31. Effect of deep breathing exercise onPOD 1 (Genc A, 2008) 2013/1/2 31
  32. 32. A patient with oropharyngeal cancers/p surgery and tracheostomy 2013/1/2 32
  33. 33. Oropharyngeal cancer s/p wide excision,bilateral modified radical neck dissection andtracheostomy 2013/1/2 33
  34. 34. A patient with left lower gingiva cancer s/pwide excision and modified redical neckdissection 2013/1/2 34
  35. 35. Remove spinal accessory nerve Abnormal scapulohumeral rhythm Musculoskeletal abnormalities ◦ Trapezius atrophy ◦ Shoulder flexion and abduction< 90° ◦ Pain with shoulder flexion and abduction ◦ Scapular wining and downward rotation ◦ Scapular protraction and depression ◦ Subluxation of the humeral head Levartor scapular, rhomboid strained Capsular tightness and chronic pain 2013/1/2 35
  36. 36. Remove spinal accessory nerve(Malone DJ, editors.Physical therapy in acutecare. 2006) 2013/1/2 36
  37. 37. Remove spinal accessory nerve Specific approach after SAN remove ◦ Education: supporting the arm during sitting and standing activities ◦ Positioning ◦ Training rhomboids to assist stability of scapular 2013/1/2 37
  38. 38. Head and Neck reconstruction Osteocutaneous/ mycutaneous reconstruction ◦ Pectoralis flap  With SAN damage: loss both post. and ant. stabilization of shoulders ◦ Fibular flap  Reconstruct the mandible ◦ Radical forearm flap  Replace skin on the face  Reconstruction of the oral pharynx 2013/1/2 38
  39. 39. Intervention after reconstruction Pectoralis flap Fibular flap Radial forearm flapAcute Postural training •non-weightbearing •Avoid weight Cervical ROM 4~7 days bearing through the •Transfer technique donor site during •Bed mobility transfers and ADLs •Pulmonary hygiene •Shoulder ROM <90° until drains removedLong- Wound healing Weight bearingterm achieved: advanced: Scapular retraction •Household/ and latissimus community strengthening for ambulation posterior stability •Verbal feedback to avoid compensatory gait deviation 2013/1/2 39
  40. 40. Progressive resistance trainingimprove shoulder dysfunction 2013/1/2 (Carvalho APV, 2012) 40
  41. 41. Lung cancer Two groups of lung cancer ◦ Non-small-cell lung cancer (NSCLC)  Squamous cell carcinoma, adenocarcinoma, large cell carcinoma ◦ Small-cell-lung cancer (SCLC)  High growth rate, worse prognosis Symptoms of lung cancer ◦ Cough, hemoptysis, dyspnea, wheezing ◦ Invasion of the brachial plexus: shoulder pain and weakness 2013/1/2 41
  42. 42. General intervention in lung cancer Physical therapy intervention ◦ Posture correction ◦ Breathing facilitation technique ◦ Conditioning of the musculature system ◦ If metastatic disease  Gait training, pain control, cognitive rehabilitation Acute care ◦ Symmetrical movement of the thoracic cage ◦ Splinted coughing ◦ Shoulder ROM ◦ Pacing & energy conservation techniques education 2013/1/2 42
  43. 43. Surgery of lung cancer Types of surgery (early stage: I~IIIA) ◦ Wedge resection ◦ Segmentectomy ◦ Lobectomy ◦ Bilobectomy ◦ Pneumonectomy 2013/1/2 43
  44. 44. Prior to surgical resection Selection of the patient ◦ General and pulmonary-specific evaluation ◦ Symptom limited cardiopulmonary exercise test  Independent predictor of surgical complication rate (Courneya KS, editors. Physical activity and cancer. 2011) Pre-surgery exercise training ◦ VO2peak improve ◦ Lower perisurgical complication ◦ Improve postsurgical recovery 2013/1/2 44
  45. 45. Pre-surgical exercise training (Courneya KS, editors. Physical activity and cancer. 2011) 2013/1/2 45
  46. 46. Pre-surgical exercise training (Jones at al, 2007) 2013/1/2 46
  47. 47. Post-surgical complication Postoperative morbidity is considerable ◦ Reduction in VO2peak 30% up to 3 years (Bolliger et al, 1996; Nagamatsu et al, 2007) ◦ Reduce ventilatory capacity and reserve ◦ Deconditioned ◦ Present concomitant cardiovascular disease 2013/1/2 47
  48. 48. Post-surgical care Identify any risk factors ◦ Smoking, obesity, age Review complete blood counts (CBC) ◦ Raised WBC → infection ◦ Reduced RBC → breathlessness ◦ Low platelet count → precaution while prescribing exercise 2013/1/2 48
  49. 49. Post-surgical intervention Chest PT ◦ Positioning ◦ Breathing exercise ◦ Chest clearance techniques ◦ Supported cough Aerobic exercise training and early ambulation Functional training Shoulder ROM exercise Pain control Breathlessness and relaxation technique 2013/1/2 49
  50. 50. Post-surgical exercise training 2013/1/2 50(Courneya KS, editors. Physical activity and cancer. 2011)
  51. 51. Post-surgical exercise training (Jones et al, 2008) 2013/1/2 51
  52. 52. Gastrointestinal tumors Types of gastrointestinal tumors ◦ Upper GI cancer  Esophagus/ Gastric/ liver/ pancreas  Cancer incidence of upper GI ◦ Lower GI cancer  Small intestine/ colon/ rectum 2013/1/2 52
  53. 53. Common problem of GI cancer Significant physical impact on the patient ◦ Malnutrition: up to 85% patients ◦ Weight loss, deconditioning and fatigue ◦ Anxiety, reduce independence ◦ Loss of role in family ◦ Change with body image, tube feeding, stoma bags 2013/1/2 53
  54. 54. Clinical presentation of GI cancers  Upper GI cancers  Lower GI cancers(Rankin J, editors. Rehabilitation in cancer care 2008.) 2013/1/2 54
  55. 55. Types of surgery Upper GI cancers ◦ Oesophagectomy ◦ Radical gastric resection Lower GI cancers (80%) ◦ Local excision ◦ Resection followed by anastomosis ◦ ileostomy ◦ Colotsomy ◦ With stoma formation Ileostomy, 2013/1/2 55
  56. 56. Post-surgical complication Increase pulmonary complication ◦ 50% patients (McCulloch et al, 2003) ◦ Pre-OP: FEV1 reduced 20% predicted value ◦ Upper abdominal/ thoracic surgery Large decrease in lung volume ◦ Functional residual capacity ↓ 30% ◦ Remain for several days Impaired mucociliary action → ◦ Small airway closure ◦ Ventilation/perfusion mismatch ◦ Impaired gas exchange 2013/1/2 56
  57. 57. Pre-surgical intervention ↓sputum retention, maximising lung volume ◦ Prophylactic deep-breathing exercise ◦ Supported expectoration techniques ◦ Early mobilization ◦ Adequate functional pain control ◦ Incentive spirometry 2013/1/2 57
  58. 58. Post-surgical intervention Upper GI cancers Prevent complication & progressive exercise ◦ Deep-breathing exercise ◦ Supported coughing ◦ Incentive spirometry ◦ Early mobilization ◦ Shoulder exercise Lower GI cancers Lower incidence of pulmonary complications ◦ Independent exercises ◦ Encourage gradual return to normal function 2013/1/2 58
  59. 59. Following an oseophagectomy (Rankin J, editors. Rehabilitation in cancer care 2008.) 2013/1/2 59
  60. 60. Exercise Caution High anastomosis associated with an oesophagectomy ◦ Head-down postural drainage ◦ Suction via oropharyngeal/ nasopharyngeal airway ◦ Positive pressure technique (Aston T et al, multi-professional management of gastrointestinal tumors) 2013/1/2 60
  61. 61. Post-surgical long term exercise (Courneya KS, editors. Physical activity and cancer. 2011) 2013/1/2 61
  62. 62. Neurological tumors Brain tumor ◦ Primary: <2 % of all cancers  Gliomas  Meningiomas ◦ Secondary: up to 50 % of all intercranial tumors Primary spinal tumors ◦ Extramedulary tumor  Schwannomas, meningiomas, gliomas ◦ Intramedullary tumor 2013/1/2 62
  63. 63. Characteristics of brain tumor 2013/1/2 63
  64. 64. Signs & symptoms Complex physical, cognitive, psychosocial tymptoms ◦ ↑ intercranial pressure ◦ Local tumor invasion ◦ Hydrocephalus ◦ Cerebral ischemia ◦ Non-specific headache ◦ Specific depends on the site and size of lesion 2013/1/2 64
  65. 65. Common problem of brain tumors (Rankin J, editors. Rehabilitation in cancer care 2008.) 2013/1/2 65
  66. 66. Intracranial neurosurgicalprocedure Low-grade tumor ◦ May surgical intervention until symptoms appear ◦ May elective surgery to ↓ “ticking time bomb” High-grade tumor ◦ Rapidly deteriorating symptoms→ emergency surgery Types of surgery ◦ Craniostomy ◦ Craniectomy (decompression) ◦ Cranioplasty (3~6 months after craniectomy) 2013/1/2 66
  67. 67. Intervention post brain surgery Primary aims ◦ Maintain or improve mobility/ function ◦ Improve strength and ROM ◦ Prevent contracture and deformities ◦ Optimise safety Treatment technique ◦ Progressive exercise program ◦ Balance training ◦ Gait re-education ◦ Transfer practice and assistive device education 2013/1/2 67
  68. 68. Early rehabilitation post surgery (Bartolo M, 2012) 2013/1/2 68
  69. 69. Primary spinal tumor Low grade tumors ◦ Intervention mimics the patients of spinal injury High grade tumor ◦ Deteriorate rapidly ◦ Need immediate intervention Malignant spinal cord compression ◦ Compression of spinal cord or cauda equina ◦ Need urgent investigation and immediate intervention 2013/1/2 69
  70. 70. Relative risk for MSCC (Rankin J editors. Rehabilitation in cancer care. 2008) Metastatic compression lesion ◦ 70% thoracic spine ◦ 20% lumbar spine ◦ 10% cervical region 2013/1/2 70
  71. 71. Spinal neurosurgical procedure Aim of surgery ◦ Decompression of the spinal cord ◦ Excision of tumor bulk Types of surgery ◦ Disectomy ◦ Laminectomy ◦ Microdisectomy ◦ Foraminotomy 2013/1/2 71
  72. 72. Passive intervention after surgery Immobilize phase ◦ Appropriate handling and positioning ◦ Prevent prolonged bed rest complication  Improve respiratory function  Prevent circulatory complication  Stokings, passive movements, calf massage  Pumping exercise 2013/1/2 72
  73. 73. Active intervention after surgery When spinal condition is stable ◦ Clinical signs & symptoms relieved ◦ Head up to 45°without increase in symptoms ◦ Transfer and mobility with equipment ◦ Problem solving approach  Washing, dressing, bathing  Coping with compensation strategy  Assistive device prescription 2013/1/2 73
  74. 74. Physical intervention for MSCC patient 2013/1/2 74 (Rankin J editors. Rehabilitation in cancer care. 2008)
  75. 75. Musculoskeletal tumor Types of musculoskeletal tumors ◦ Primary bone tumor  Osteosarcoma  Chondrosarcoma ◦ Bone metastasis Types of surgery ◦ Amputation ◦ Limb salvage surgery  Resection of tumor without replacement  Endoprosthetic replacement (75% of the patients)  Rotationplasty  Autografts or allografts 2013/1/2 75
  76. 76. Pre- and post-surgical management Pre-surgical ◦ Mobilize with PWB or NWB depending on extent bone destruction ◦ Maintenance of ROM and strength Post-surgical ◦ Restore muscle strength, ROM ◦ Balance exercise, gait re-education ◦ Full weight-bearing (tolerate weight bearing) with prosthesis keep knee extension 2013/1/2 76
  77. 77. General protocols of osteosarcomaPresurgical phase Acute Subacute Chronic postsurgical phase postsurgical phase subsurgical phase 0~2 weeks 2~6 weeks >6 weeks• Correct • Minimal • Begin to wean off • Restoration of limitations or assistance to assistive device joint stability and improve current modified • Restore full range functions functions independence in of motion • Advancing• Identify needs functional • Progressive strength and from other transfer resistance training endurance members • Maximum • Progressive gait training• Identify realistic protection of training • Incoporating postsurgical/ affected joint/ sports-related treatment goals limb functional training (Punzalan M, 2009) 2013/1/2 77
  78. 78. Physical therapy after LE surgery (Punzalan M, 2009) 2013/1/2 78
  79. 79. POD 1~3 Days to 1 month Distal Femur Proximal Tibia Falling risk Bed exercise Ambulation with tolerated weight bearing knee locked at 0° with braceROM exercise begin after Knee locked at 0° with Post-op 1 week, brace for 1 month progress to 90° slowly. No ROM exercise!! 2013/1/2 79
  80. 80. Post-OP to 6 months Distal Femur Proximal TibiaBrace Using for Using for 6 months with 1 year with 90° restriction, then, no restriction of 6-12 months with no knee motion restrictionAssisted 6 months, depends on strengthdeviseROM Post-op Post-op 6 month: 90°Exercise 3 month: 140° then, progress slowly to 120° in 3months.Strength 1.SLR exercise with knee locked at 0°Training 2. Functional Electric Stimulation for Quadriceps 2013/1/2 80
  81. 81. Post-OP quadriceps setting 2013/1/2 81
  82. 82. Post-OP hip abduction/adduction 2013/1/2 82
  83. 83. Post-OP / OPD follow-up4-phase straight-leg-raising 平躺抬腿 側躺抬腿 趴姿抬腿側躺夾腿 2013/1/2 83
  84. 84. OPD follow-upActive knee flexionPassive knee extension 2013/1/2 84
  85. 85. OPD follow-up 承重訓練 穩定訓練 2013/1/2 85
  86. 86. Summary Physical therapy in pre-/ post- surgical cancer patients ◦ Early intervention and monitoring can ameliorate the negative effects ◦ Prevention and restoration of impairments and functional limitation ◦ Familiar with treatment strategies and side effects to provide quality, appropriate interventions 2013/1/2 86
  87. 87. Reference Packel L. Oncological diseases and disorders. In Malone DJ, Lindsay KLB. Physical therapy in acute care: A clinician’s guide. Thorofare, NJ: Slack; 2006, 503-544. Rankin J, Robb K, Murtagh N, Cooper J and Lewis S, editors. Rehabilitation in cancer care. Chichester UK: Wiley-Blackwell, 2008. Courneya KS, Friedenreich CM, editors. Physical activity and cancer. Heidelberg: Springer, 2011. Stubblefield MD, O’Dell MW, editors. Cancer rehabilitation: Principles and practice. New York: Demos Medical. 2009 Frownfelter D, Dean E. Cardiovascular and pulmonary physical therapy: evidence and practice. St. Louis, Mo.: Mosby/Elsevier. 2006. Raven RW, editors. A practical guide to rehabilitation oncology. Carnforth, Lancs, UK; Park Ridge, N.J., USA: Parthenon Pub. Group. 1992 2013/1/2 87
  88. 88. Reference McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW. A Prospective Model of Care for Breast Cancer Rehabilitation: Postoperative and Postreconstructive Issues. Cancer 2012;118:2226-36. Shamley DR, Barker K, Simonite V, Beardshaw A. Delayed versus immediate exercises following surgery for breast cancer: A systematic review. Breast Cancer Res Treat 2005;90:263-71. Genc A, Ikiz AO, Guneri EA, Gumerli A. Effect of deep breathing exercises on oxygenation after major head and neck surgery. Otolaryngol Head Neck Surg. 2008;139:281-5. Garvalho APV, Vital FMR, Soares BGO. Exercise interventions for shoulder dysfunction in patients treated for head and neck cancers. Cochrane Database Syst Rev 2012;18:CD008693. Bartolo M, Zucchella C, Pace A, Lanzatta G, Vecchione C, BartoloM, et al. Early rehabilitation after surgery improves functional outcome in inpatients with brain tumours. J Neurooncol 2012;107:537-44. Punzalan M, Hyden G. The role of physical therapy and occupational therapy in the rehabilitation of pediatric and adolescent patietns with osteosarcoma. Cancer Treat Res 2009;152:367-84. 2013/1/2 88
  89. 89. Thanks for your listening!!

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