1. Exercise of Cancer Patient:
Prevention, Survival & End of Life
曹昭懿
臺大物理治療學系

2. 2007 Male
Incidence Mortality
7210 5650
6040 2558
5898 5458
5006 2152
3367 1003
2007 Female
Incidence Mortality
7502 1552
4417 1912
3161 2535
2900 2159
1749 833
BHP, 2010/2

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. Cancer Care Trajectory
4

5. Cancer Rehabilitation
 System specific problems
 Activity restrictions
 ADL
 Ambulation
 Mobility
 Transfer
 Psychological problems
 Immobility syndrome
 Fatigue
 Sexuality
 Quality of life

6. PEACE: Physical Exercise Across the Cancer Experience
PACC: Physical Exercise & Cancer Control
DIAGNOSIS
Health
Prevention 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. Prevention (I)
Friedenreich et al, 2002

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. Detection
1. 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. 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. 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. 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. 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. Survival
Nurses’ Health Study (NHS, N=121700):
exercise & cancer recurrence & mortality
 Holmes et al. 2005, JAMA
 Meyerhardt et al. 2006, J Clin Oncol

15. 86％
89％
92％
93％
97％
JAMA 2005;293:2479-86

16. Post Dx PA & Mortality: CC
Meyerhardt et al, 2006

17. Post Dx PA & Mortality: CC

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. 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. 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. 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. 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. 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

26. 27

27. Exercise Intolerance
Jones et al, Lancet Oncology 2009;10:598-605

28. 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

29. 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)

31. Red Flags or Yellow Flags
Complete blood count
Anemia
Neutropenic
Thrombocytopenic
Neural impairments
Skeletal impairments
Cardiovascular or pulmonary system

32. 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

33. 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

34. Health-related Physical Fitness
Testing and Interpretation
Body composition: BMI, circumference,
skinfold, DXA
Cardiorespiratory fitness: VO2max, HRmax, 6-
min walking, 3-min step
Muscular strength and muscular endurance
Flexibility
ACSM’s guideline for exercise
testing and prescription

35. Physical Functioning
 Eastern Cooperative Oncology Group (ECOG)
scale
 Karnofsky Performance Status scale (KPS scale)

36. ECOG performance status
Grade ECOG
0
Fully active, able to carry on all pre-disease performance without restriction
1
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 work
2 Ambulatory and capable of all selfcare but unable to carry out any work
activities. Up and about more than 50% of waking hours
3 Capable of only limited self care, confined to bed or chair more than 50% of
waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or
chair
5 Dead
Oken, et al. Am J Clin Oncol 1982;5:649-655

37. KPS scale
Able to carry on normal 100 Normal no complaints; no evidence of disease.
activity and to work; no special
care 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 do
home and care for most active work.
personal needs; varying
amount 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 of
institutional or hospital care; 30 Severely disabled; hospital admission is indicated although
disease 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

38. Health-related Quality of Life
 Generic
 SF 36
 WHOQOL-BREF
 Cancer-specific
 EORTC
 FACT
 FLIC
 CARES

39. 運動測試的注意事項
Complication Recommendation
Anemia Avoid maximal testing or intense PA with significant aerobic demands
Low 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 trauma
Fever Avoid PA until the cause of fever is determined
Dyspnea Investigate cause; limit exercise intensity
Severe cachexia Exercise should be low intensity and extremely conservative
Extreme fatigue/weakness Initial exercise intensity should be low, but increase as tolerated; intermittent
activities may be perferred to continuous exercise
Mouth sores/ulcerations Avoid tests that require a mouthpiece
Severe nausea/vomiting Avoid testing or PA until symptoms improve; initiate PA at a level that can be
tolerated
Bone pain Avoid high-impact testing or PA; swimming may be ideal
CNS abnormality or Avoid testing and PA that require balance and coordination
peripheral neuropathy
Poor functional capacity Avoid maximal testing; exercise intensity should be low with extremely
conservative increases made in intensity and duration

40. 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

41. Hematologic values and exercise modification
Platelet 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。

42. Hematologic values and exercise modification
Hemoglobin (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。

43. 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

44. 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

45. 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

46. 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

47. 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

48. Principles of Exercise
Overload
Adaptation
Specificity
Reversibility
Modification: for cancer setting and during
adjuvant therapy

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 57

56. Exercise for Oncology Patients: aerobic
component Aerobic
Frequency 3-7 x/week
40%-60% of HR reserve or Oxygen uptake reserve, or
Intensity 60%-80% of max HR, or
RPE of 12-15
Mode Start with walking or recumbent bike
Start with 5-20 minutes depending on exercise tolerance, including warm-up and
Duration cool-down.
Goal is 20-60 minutes of continuous exercise
Progression Duration > frequency> intensity > mode
HR, BP, O2 sat, RPE, and pain
Patient monitor Avoid group exercise during periods of neutropenia
consideration Avoid training with presence of a new migrating central line
Avoid aquatics if neutropenic or with central line

57. Exercise for Oncology Patients: strength training
component Strength training
Frequency 2-3 x/week, 48 hour recovery between sessions
Intensity 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 recovery
Progression
Add TheraBand only if no additional hematologic or orthopedic precautions are
present
HR, BP, O2 sat, RPE, DOE and pain
Patient monitor Avoid group exercise during periods of neutropenia
consideration Avoid training with presence of a new migrating central line
Avoid aquatics if neutropenic or with central line

58. Exercise for Oncology Patients: flexibility
component Flexibility training
Frequency 2-7 days/week
Intensity Slow static stretches only to the end range
Mode
Duration 4 reps of 10-60 seconds per stretch
Progression Duration > frequency > intensity >mode
Patient monitor HR, BP, O2 sat, RPE, DOE and pain
consideration Avoid group exercise during periods of neutropenia

59. Other Types
 TaiChi
 Yoga
 Dancing
 Pilates
 Other outdoor activities (mountain
climbing, bike…)

60. Interventions: End of Life

61. 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

62. 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

63. 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

64. 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, …)

65. Thank You!