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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

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參考資料

1. Michael DS, Michael WO. editors. Cancer Rehabilitation

Principles and Practice. New York: Demos Medical Publishing 2009

2. Jane R, Karen R, Nicola M, Jill C, Sian L, editors. Rehabilitation in

Cancer Care. Wiley-Blackwell 2008

3. Hermann D. Rehabilitation and palliation of Cancer patients.

Springer-Verlag France, Paris 2007

4. Rehabilitation Oncology ( Oncology Section American Physical

Therapy Association )

5. Physiotherapy Research International

6. Physical Therapy

7. Palliative Medicine

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“Quality of Life”

This is part of Comprehensive Cancer Care

Rehab Goals Based on Many Factors Prognosis

Treatment

Co-morbidity / Impairment

Pain

Psychosocial Distress

Socioeconomic Background

Personal “Re-prioritization”

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Continuous Redefining of Treatment

Success and Functional Goals

Prognosis: relative to stage / type of static or dynamic lesion(s)

Concurrent anti-neoplastic treatment

Medical co-morbidity – functional impairments

Degree of pain and psychosocial distress

Socioeconomic background – domestic and financial resources to facilitate participation in goals

Personal “re-prioritization” – Symptom versus Disease Oriented Care

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Avoid functional morbidity resulting

from cancer and/or its treatment

Stretch irradiated soft tissue

Protect skin with chemotherapy-induced

neuropathies

Aggressive post-thoracotomy chest PT and

shoulder range of motion

Prevent pathologic fractures with braces

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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

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Maximize function when long-term

impairment, 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

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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

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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

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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

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Breathlessness

A subjective experience of breathing discomfort …interaction

physiological, psychological, social and environmental factors, induce

secondary 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

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Causes of breathlessness

Pulmonary : loss of functional lung tissue / M

obstruction of airway / M

loss of lung elasticity / M

Non-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

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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 )

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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 )

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Breathlessness management (1)

Breathing retraining: step-by-step approach

Positioning: high side lying, sitting with support, standing relaxed

Exercise: aerobic exercise ( walking, stair climbing, static cycle,

treadmill ), carefully gradually increase ( frequency, duration,

intensity ), avoid distress and set achievable goals

Cognitive-behavioral approaches: fear, anxiety, overbreathing,

hyperventilation syndrome ( dizziness, headaches,

paraesthesia, chest pain, palpitations, blurred vision ), simple

breathing exercise, relaxation techniques, passive

neuromuscular relaxation

Alter environments: task simplification, reduce energy

consumption, individual patient’s needs

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Cancer-Related Fatigue

Distress persistent, subjective sense of tiredness or exhaustion

related to cancer or cancer treatment ( NCCN, National Comprehensive Cancer Network, 2006 )

CRF: physical, psychological and cognitive components

No energy, tired, exhausted, poor concentration, memory loss,

irritable, ….

Direct effects of the tumor, treatment side effects,

anaemia, pain or deconditioning, psychosocial factors such as

anxiety and depression

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CRF- assessment

International Classification of Diseases-10

ICD-10, proposing 11 symptoms of CRF ( Cella et.al.1998 )

＊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

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CRF- assessment ( 1 )

International Classification of Diseases-10

ICD-10, proposing 11 symptoms of CRF ( Cella et.al.1998 )

• 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

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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.

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CRF Clinical Practice Guidelines

Three 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 therapy

At end of life

progression of disease, pain, medication, depression, anemia, poor nutrition, sleep disturbance, PT aim maintain mobility and independence /close consultation

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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

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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 )

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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

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Cancer Pain – Assessment ( 1 )

☆ Activity limitation / functional limitation

□ Physical impairments

Visual analogue scale ( VAS )

Numerical ratings scale ( NRS )

mild moderate severe pain

0 1 2 3 4 5 6 7 8 9 10

no pain worst pain

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Management of cancer-related pain

The majority of cancer pain is due to tumor effects.

bone metastases : 8 Gy / radiation fraction

Medical approaches

Pharmacological approaches

Non-opioids

Opioids

Adjuvants

Radiotherapy

Physical therapy interventions

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Management of cancer-related pain ( 1 )

• Physical therapy interventions

relieve pain

improve function

improve quality of life

physical, psychosocial, lifestyle adjustment

/ educational approaches

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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

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Management of cancer-related pain ( 3 )

Resulting in

Causing increased

Reduces

Causing loss of

Activity

Stiffness

Function

Pain

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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

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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

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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

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Physical agents and modalities

Physical agents

Increase

tissue extensibility

rate of wound healing

Modulate pain

Reduce

soft tissue swelling or inflammation

Remodel scar tissue

Treat skin conditions

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Physical agents and modalities ( 1 )

Physical agents

Cryotherapy cold packs, ice massage, vapocoolant spray

Hydrotherapy contrast baths, pools, whirlpool tanks

Light agents infrared, laser, ultraviolet

Sound agents ultrasound, phonophoresis

Thermotherapy deep heat, hot packs, paraffin

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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

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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 )

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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.

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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

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Physical agents and modalities ( 6 )

• Indications

• Precautions

• Contraindications

General precautions and absolute contraindications

＊Each patient must be carefully considered on an

individual basis.＊

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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)

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Therapeutic Exercise in Cancer

• Goals

• ↓risk, impairments, ↑function, fitness, well-

being

preventive

restorative

supportive

palliative

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Therapeutic Exercise in Cancer ( 1 )

• Strengthening Exercise

• Aerobic Exercise

• Range of Motion and Flexibility

• Coordination and Balance Training

• Chest Physical Therapy

• Considerations

Fatigue

Pain

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