楊靜蘭物理治療師-乳癌病人照顧20130602

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楊靜蘭 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總治療長
國立臺灣大學物理治療學系兼任講師

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楊靜蘭物理治療師-乳癌病人照顧20130602

  1. 1. 乳癌病人照護 楊靜蘭 臺大醫院復健部物理治療技術科 台大物理治療學系兼任講師
  2. 2. 乳癌病人照護 •  Surgical therapy and complications •  Radiotherapy and complications •  Chemotherapy and complications •  Hormonal therapy and complications •  Breast cancer patient •  Post-surgical exercise •  Strengthening exercise •  Lymphedema treatment •  Cancer pain management •  Cancer-related fatigue
  3. 3. 乳癌病人照護 •  Phases  of  cancer  care diagnosis treatment rehabilita3on survivorship recurrent   disease pain fatigue pain pain
  4. 4. Surgical therapy & complications •  Mastectomy •  Lumpectomy (partial mastectomy) •  only the tumor and small section of normal breast tissue is removed •  Complications: breast fibrosis, breast lymphedema, and chronic/recurrent breast cellulitis (Newman, 2007) •  Total (simple) mastectomy: removes the whole breast, but does not remove lymph nodes, for noninvasive cancer •  Modified radical mastectomy: removes the breast, some lymph nodes under the arm, the lining over the chest muscle, pectoralis major muscle is spared, for possibility of cancer cell spreading to the lymph nodes •  Shoulder ROM limitation: mastectomy vs partial mastectomy: 79% vs 35% (Newman, 2007)
  5. 5. Surgical therapy & complications •  Axillary lymph node dissection (ALND) •  Removal of lymph nodes in the armpit, then examine the nodes to see if cancer cell is present •  Complications •  sensory deficits of intercostobrachial nerve •  Skin adhesion at incision •  Impaired shoulder ROM •  Seroma: collection of serous fluid that accumulates within the surgical site •  lymphedema, axillary web formation •  Lymphatic mapping/sentinel lymph node biopsy •  Locate, remove and examine the first lymph node draining the cancerous zone, for axillary staging in breast cancer •  Complications: same as ALND, but <10%
  6. 6. Axillary web syndrome •  hypercoagulation and inflammation of the superficial lymphatic vessel as a result of the ALND (Ferrandez and Serin, 1996) •  band of scar tissues, cordlike structures coursing from the surgical bed toward medial arm, the forearm and occasionally reaching the thumb •  Develop within 2~6-8 weeks after surgery •  significant tightness and limitation of motion, affecting mainly shoulder abduction •  Physical therapy •  manual lymph-drainage technique in axilla •  progressive active and action-assisted shoulder exercises
  7. 7. Surgical therapy & complications •  Reconstruction •  Latissimus myocutaneous flap •  potential morbidity at the donor site on the back •  weakness for adduction and internal rotation of the shoulder •  Transverse rectus abdominis myocutaneous (TRAM) flap •  abdominal weakness •  abdominal bulge or hernia when something heavy (>20pouns) is lifted                                                                                                                          (Cordeiro,  2008)   •                                               
  8. 8. Surgical therapy complications •  General •  Wound infections: 1% ~ 20% •  Hematoma: 2% to 10% of cases •  Seroma: Seroma aspiration is necessary in 10% to 80% of ALND and mastectomy cases •  Chronic incisional pain: 20% to 30% of patients •  Shoulder ROM impairment (2-51%) •  Decreased muscle strength (17-33%) (Rietman,  2003)    
  9. 9. Radiation therapy complications •  Skin changes: redness, itching, lasting about 6 weeks •  Shoulder and Arm Complications: 90%  of  women  with  breast  cancer •  impaired shoulder mobility: •  muscular (pectoralis major) and subcutaneous fibrosis or to vascular injury •  breast fibrosis in 58% stage I-II patients in mid-1980 •  axillary radiation vs no axillary radiation: 73% vs 35% (Sugden, 1998) •  Brachial plexus neuropathy •  rare  complica3on  of  modern  radiotherapy,  irreversible   •  nerve  entrapment  by  radia3on  induced  fibrosis,  chronic  oedema,  or  both   •  paresthesia  in  the  fingers  or  hands,  hypoesthesia,  hypoalgesia,  disesthesia,  paresis,  hyporeflexia  and  muscular  atrophy   •  limb  weakness  may  be  selec3vely  distal,  global  with  more  marked  distal
  10. 10. Radiation therapy complications •  Arm lymphoedema •  Fatigue •  Nutrition: loss of appetite and difficulty in digestion during radiation •  Sometimes related to drop of counts of RBC, WBC, and platelets during radiation •  Radiation-induced fatigue usually lasts 4-6 weeks •  Pulmonary complications: 0-31% radiation pneumonitis •  Radiation-induced second malignancies: 16~19%  in  breast  cancer  pa3ents,  contralateral  breast  cancer,  skin,  endometrial,  colorectal  and  pancrea3c  cancers
  11. 11. Chemotherapy & complications   •  Purpose of chemotherapy •  Shrink a tumor prior to surgery •  Decrease chances of recurrence following surgery •  Prevent metastasis •  Cytotoxic: poison frequently dividing cells by preventing them from dividing
  12. 12. Chemotherapy & complications •  Complications •  Hair loss •  Nausea/vomitting: 73  to  82%                                            (Dibble  2003)   •  Pain •  Fatigue: 60%  to  90%                                                                                      (Feyer  2001) •  Lymphedema •  Neurotoxicity: peripheral neuropathy •  Anthracycline-related long-term cardiac toxicity •  Menopausal symptom •  Secondary leukemia
  13. 13. Hormonal therapy & complications   •  Estrogen-receptor positive (ER+) /progesterone -receptor positive cancer: some cancer divide more frequently in the presence of hormone •  Purpose of hormonal therapy: third line of defense by blocking one’s own natural hormones •  Complications •  Bone loss •  Menopausal symptom
  14. 14. Post-surgical exercise   •  beneficial effect of delayed exercise on the incidence of seroma, no conclusion regarding fluid drainage and hospital stay, long-term damage to arm movements (Shamly, 2005) •  early versus delayed implementation of post -operative exercise •  early exercise was more effective than delayed exercise in the short term recovery of shoulder flexion ROM •  however, early exercise also resulted in a statistically significant increase in wound drainage volume and duration                      (Cochrane review, 2010)
  15. 15. Post-surgical exercise   (Harris, 2012)
  16. 16. Post-surgical exercise •  Structured exercise programs in the post-operative period significantly improved shoulder flexion ROM in the short-term •  Physical therapy treatment yielded additional benefit for shoulder function post-intervention and at six -month follow-up          (Cochrane  review,  2010)
  17. 17. Strengthening exercise •  Proper and progressive strengthening exercise •  A program of slowly progressive weight lifting did not result in increased incidence of lymphedema.   •  Upper-­‐body  exercises:  seated  row,  chest  press,  lateral  or  front  raises,  bicep  curls,  and  tricep  pushdowns   •  Lower-­‐body  exercises: leg  press,  back  extension,  leg  extension,  and  leg  curl                                                                                                                                                                                    (Schmitz  et  al.,  2009)   •  A 6-month intervention of resistance exercise did not increase the risk for or exacerbate symptoms of lymphedema. (Ahmed  et  al.,  2006)   •  Active resistive exercise with complex decongestive physiotherapy did not cause additional swelling, and it significantly reduced proximal arm volume and helped improve QOL. (Kim  et  al.,  2010)  
  18. 18. 18   Breast Cancer-related Lymphedema •  Abnormal accumulation of tissue proteins and swelling •  reduced lymphatic regeneration after surgical interruption •  radiation induced fibrosis, causing venous and lymphatic vessel obstruction and lymphocyte depletion with fatty replacement and local fibrosis •  concomitant use of tamoxifen or chemotherapy •  May accompanied by pain, skin changes, decreased joint range of motion and recurrent infections. •  Incidence: 28% (Mortimer, 1996)
  19. 19. PT for lymphedema   •  Complex physical therapy (Complete decongestive physiotherapy, decongestive lymphatic therapy) •  Manual lymph drainage •  Compression therapy •  Short-stretch bandage •  Special garment •  Exercise •  Abdominal breathing exercise for clearance of deep trunk area •  Lymph drainage exercise •  Stretching and flexibility exercise •  Aerobic exercise •  Skin care (healthy advice)
  20. 20. 20   Healthy Advices to BCRL Women •  Keeping the lymphedematous arm elevated •  Air travel may not induce or deteriorate lymphedema •  Proper and progressive exercise would be helpful •  Body weight control is necessary (BMI<26) •  Avoid pressure on the involved extremity •  Avoid constrictive clothing •  Avoid strong massage •  Avoid heat •  Avoid vigorous activity •  Keep skin in good condition- moisture lotion •  Avoid infection and injury
  21. 21. Lymph drainage exercise  
  22. 22. Lymph drainage exercise
  23. 23. Lymph drainage exercise
  24. 24. Physical therapy for cancer pain   •  Cancer related pain is often intractable and unremitting, responding poorly to simple analgesics •  insidious onset and is typically worst at rest or at night •  Description or quality •  Aching, well-localized, stabbing, throbbing, pressure, often associated with somatic pain in skin, muscle, bone •  Gnawing, diffuse, cramping, aching, often associated with visceral pain in organs or viscera •  Sharp, tingling, ringing, shooting, burning, often associated with neuropathic pain caused by nerve damage •  Pathophysiology •  Nociceptive/Neuropathic
  25. 25. Physical therapy for cancer pain •  Pain related to oncologic emergency •  Bone fracture or impending of weight-bearing bone •  Brain Epidural, leptomeningeal metastases •  Pain related to infection •  Obstructed or perforated viscus (acute abdomen) •  Pain intervention •  Pharmacologic: cornerstone of cancer pain management •  Nonpharmacologic •  Massage •  Heat and/or ice •  Transcutaneous electrical nerve stimulation (TENS) •  Cognitive modalities: Distraction, Relaxation, active coping training, spiritual care (NCCN CPG, 2010)
  26. 26. Physical therapy for cancer pain •  Massage •  Classical massage seems to be an effective adjuvant treatment for reducing physical discomfort and fatigue, and improving mood disturbances in women with early stage breast cancer (Lis3ng  M,  2009)   •  An 8-week multidimensional program including strengthening exercises, and massage as major components was effective for improving neck and shoulder pain and reducing widespread pressure hyperalgesia in breast cancer survivors                                                (Fernández-­‐Lao  C,  2012)  
  27. 27. Physical therapy for cancer pain •  Electrophysical agents •  Therapeutic ultrasound applications are absolutely contraindicated directly over cancerous lesions •  Superficial warming and cooling •  safest,  non-­‐pharmacological  op3ons  for  the  management  of  malignant  pain  that  is  unresponsive  to  medica3on,  regardless  of  the  stage  of  cancer   •  Transcutaneous electrical nerve stimulation (TENS)   •  limit  the  use  of  TENS  to  the  pallia3ve  stage  only,  as  a  means  of  symptom  control                                                              (hall,  2004)   •  insufficient available evidence to determine the effectiveness of TENS in treating cancer-related pain (Cochrane  Systema3c  Review,  2012)  
  28. 28. Postmastectomy pain syndrome •  pain in the anterior aspect of the thorax, axilla, and /or upper half of the arm after mastectomy for more than 3 months (Wood, 1970) •  neuropathic – resulting from damaged nerves or dysfunction of the nervous system •  phantom breast pain •  intercostobrachial neuralgia: PMPS •  pain secondary to the presence of a neuroma – it includes pain in the surgical scar, thorax, or arm, which is triggered by percussion (Tinel’s sign) •  pain due to damage to other nerves: medial pectoral, lateral pectoral, thoracodorsal, and long thoracic nerves
  29. 29. Postmastectomy pain syndrome •  Incidence: 20 to 50% •  Development of axillary hematoma, and postoperative radiotherapy are possible causes of PMPS •  use of drugs, such as amitriptyline, venlafaxine, and capsaicin
  30. 30. PT for cancer-related fatigue   •  distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning •  Associated with cytotoxic chemotherapy, radiation therapy, surgery, and biotherapies •  30% of breast cancer survivors reporting moderate to severe symptoms of fatigue •  influenced by psychological, physical, and biological factors •  Not a symptom to treat by medication (unless drop of RBC) •  strongly correlated with psychological distress and depression coping strategies •  impaired quality of sleep or pain
  31. 31. PT for cancer-related fatigue •  Decreased level of activity during adjuvant treatment cause reduction in the capacity for physical performance •  Physical fitness •  exercise improved cardiorespiratory fitness (Crowley  2003;  Drouin  2002;MacVicar  1989)   •  physical performance assessed via timed walking distances (Campbell  2005;  Mock  1997)   •  no evidence that exercise is effective in increasing strength during adjuvant cancer treatment
  32. 32. PT for cancer-related fatigue •  Fatigue •  lower levels of fatigue in cancer patients who exercised compared to control or comparison groups •  home-based walking programs •  Aerobic exercise was particularly effective, with fatigue levels approximately 40-50% lower in exercising subjects  (Ganz  PA,  2007)     •  non-significant improvement in fatigue for breast cancer participants in the exercise intervention groups compared to control (Campbell  2005;  Drouin  2002;  Mock  1997;  Mock  2004;  Segal  2001    SD;Segal  2001SU)
  33. 33. PT for cancer-related fatigue •  Psychosocial interventions •  psycho-educational group intervention focusing on active coping strategies and physical activity is beneficial to cancer survivors after breast cancer treatments (Fillion,  2008)   •  self-administered form of stress management training, peer-modeling video
  34. 34. Exercise  for  cancer  patient   •  Cancer-related fatigue •  Body Composition •  sarcopenic  obesity  with  evidence  of  reduced  physical  ac3vity  supports  the  need  for  interven3ons  focused  on  exercise,  especially  resistance  training   •  non-­‐significant  reduc3on  in  weight  for  par3cipants  in  the  aerobic  exercise  (Cochrane, 2009) •  Nausea:  aerobic  exercise  may  serve  as  a  poten3al  interven3on        for  controlling  or  mi3ga3ng  chemotherapy  induced  nausea  (Winningham 1988)   •  Quality of life:  evidence  is  conflic3ng  as  to  whether  exercise  interven3ons  are  effec3ve  in  increasing  cancer-­‐and  cancer  site -­‐specific  quality  of  life   •  Psychological distress outcomes:  anxiety,  mood,  depression:  no  evidence

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