癌症病人常見症狀之物理治療王儷穎

癌症病人常見症狀

（呼吸困難、疲倦、疼痛）之

物理治療

FATIGUE

癌症病人常見症狀（呼吸困難、疲倦、疼痛）之物理治療

Definition of Cancer-Related

Fatigue

NCCN 2012

• Cancer-related fatigue is a distressing

persistent, subjective sense of

physical, emotional and/or cognitive

tiredness or exhaustion related to

cancer or cancer treatment that is not

proportional to recent activity and

interferes with usual functioning

CTCAE: Fatigue

• Grade 1:

– Fatigue relieved by rest

• Grade 2:

– Fatigue not relieved by rest; limiting

instrumental ADL

• Grade 3:

– Fatigue not relieved by rest, limiting self

care ADL

Screening

• Screen every patient for fatigue at

regular intervals Severity: 0-10

Scale

• None to mild (0-3)

– Education + general strategies to manage

fatigue

– Ongoing re-evaluation

• Moderate to severe 4-10

– Education + primary evaluation of fatigue

(history, assessment of treatable

contributing factors)

– Active treatment, follow-up, end of life

Treatable contributing factors

• Medications/Side effects

• Pain

• Emotional distress

• Anemia

• Sleep disturbance

• Nutritional deficit / Imbalance

• Decreased functional status

• Comorbidities

Functional Status Query

• Changes in exercise or activity patterns

• Influence of deconditioning

• Can patients accomplish normal ADL?

• Can they participate in formal or

informal exercise programs?

Impacts of Current Medications

• Narcotics, antidepressants,

antiemetics, and antihistamines:

Contribute to excessive drowsiness

and increasing fatigue

• Certain cardiac medications: e.g., beta-

blocker: bradycardia and subsequent

fatigue

• General Strategies for Management of

Fatigue

– Self-monitoring of fatigue levels

– Energy conservation techniques

– Use distraction

Energy conservation techniques

• Set priorities

• Pace

• Delegate

• Schedule activities at times of peak energy

• Labor saving devices

• Limit naps to < 1 hr to not interfere with night-

time sleep quality

• Structured daily routine

• Attend to one activity at a time

• Interventions for CRF

– Nonpharmacologic

– Pharmacologic

FOR PATIENTS ON ACTIVE

TREATMENT AND POST-TREATMENT

Non-pharmacologic Interventions

• Activity enhancement

• Physically based therapies

• Psychosocial interventions

• Nutrition consultation

• Cognitive behavioral therapy for sleep

Activity Enhancement

(active or post-treatment)

• Maintain optimal level of activity

• Starting and maintaining an exercise

program

– Endurance + Resistance

• Red and Yellow Flags

Some Facts

• Cancer-related fatigue interfered with all ADLs in the majority of patients

• Interference

– Moderate

– Higher in women, non-whites and patients with metastatic disease

• 3-5 hours of moderate activity per week may experience better outcomes and have fewer side effects of therapy

Physical Therapy Referral

(Active Treatment)

• Patients with comorbidities (e.g.,

COPD, cardiovascular disease)

• Recent major surgery

• Specific functional or anatomical

deficits (e.g., decreased neck ROM due

to surgery for head and neck cancer)

• Substantial deconditioning

Exercise Prescriptions

(Active Treatment)

• Individualized

– Age, gender, type of cancer, physical

fitness level

• Begin at a low level of intensity and

duration

• Progress slowly

• Modified accordingly with the patient’s

condition changes

Evidence - 1

• 17 RCTs

• Improvement in fatigue

– 35%

– Weighted pooled mean effect size: -0.42 (95% CI: -

0.599 to -0.231)

• Improvement in vigor/vitality

– 30%

– Weighted pooled mean effect size: -0.69 (95% CI: -0.43

to -0.949)

• Effect: administered during therapy > after therapy

was completed

Kangas and colleagues, 2008

Evidence - 2

• 28 RCTs

• Overall result:

– Exercise is effective in relieving fatigue

• SMD: -0.23; 95% CI: -0.33 to -0.13

– Effective both during and after therapy

– Patient population: breast and prostate

cancer

2008 Cochrane

Physically-based Therapies

(Active Treatment)

• Acupuncture

– ?

• Massage therapy

– One RCT and one retrospective review

– Positive effects of massage therapy on

fatigue during active therapy

Gilchrist et al., 2009

• Nervous tissue

– MRI

– Compression of neurologic tissue, (ie,

spinal cord, nerve roots, or nerve plexus)

by tumor or unstable vertebral fractures

– Patients with vertebral metastases or

spinal cord compression

Red and Yellow Flags

• Skeletal system

– Dual-energy x-ray absorptiometry

• Diagnostic test for osteopenia and osteoporosis

– Radiography or computed tomography scan

• If 25%–50% of the cortex of bone is degraded, then

partial weight bearing precautions should be

instituted. If greater than 50% bone degradation,

then touch-down or non–weight-bearing

precautions are recommended

• Multiple myeloma


Karavatas et al., 2006


• Hematologic system functions

– Might alter during anticancer treatment

– Complete blood count (ie, hemoglobin,

hematocrit, white blood count, platelet

count)

• Diagnostic test to detect anemia, neutropenia,

and thrombocytopenia

• These values also are useful in exercise

prescription, particularly in choosing safe

mode and intensity of exercise



• Cardiovascular system functions

– Might be affected due to anticancer treatment

– Echocardiogram

• Assesses ventricular function, including ejection

fraction, wall movement, and cardiac output

– Treatment related cardiotoxicity

• Hodgkin’s disease treated with ABVD or BEACOPP

• Breast cancer treated with doxorubicin and

cyclophosphamide


Risk factors for fatigue in post-

treatment, disease-free patients

• Many….

• Pretreatment fatigue, depression,

anxiety, comorbidities, cytokines, etc.


(Post Treatment)

• Post-treatment, disease-free

• Patients to survivors transition

• Regular exercise

– Improving strength, energy, and fitness

– Decreased anxiety and depression

– Improve body image

– Increase tolerance for physical activity

Physical Therapy Referral

(Post Treatment)

• Specific issues that should trigger a

referral of PT if the patient

– Is significantly deconditioned, weak

– Have relevant late effects of treatment

(such as cardiopulmonary limitations)

Evidence

• 44 Studies, 3,254 cancer survivors

– Exercise reduced fatigue

– Moderate-intensity, resistance exercise

– Older cancer survivors

Brown and colleagues, 2011

Interventions for Patients at the

End of Life

• In palliative care unit: 100% reported

fatigue

• General Strategies for Management of

Fatigue

– Energy conservation

– Use distraction

Energy conservation techniques

(end-of-life)

• Set priorities

• Pace

• Delegate

• Schedule activities at times of peak energy

• Labor saving devices and assistive devices

• Eliminate nonessential activities

• Structured daily routine

• Attend to one activity at a time

• Conserve energy for valued activities


(end-of-life)

• Optimize level of activity with careful consideration of the following constraints:

– Bone metastases

– Thrombocytopenia

– Anemia

– Fever or active infection

– Assessment of safety issues (risk of falls, stability)

Evidence

• Pilot

• Small sample size

• But promising results

– Better activity level

– Increased QoL

– Less anxiety

Porock and colleagues, 2000

Activities

(End of Life)

• Walking

• Arm exercises with resistance

• Marching in place

• Dancing

PAIN


Definition of Pain

• Pain is defined by the International

Association for the Study of Pain

(IASP) as an unpleasant

multidimensional, sensory and

emotional experience associated with

actual or potential tissue damage, or

described in relation to such damage

Merskey and Bugduk 1994; NCCN 2012

• Screen for pain

– Pain present or not

– Anticipated painful events and procedures

If pain present

• Quantify pain intensity and characterize

quality

• Severe uncontrolled pain is a medical

emergency and should be responded to

promptly

Pain Intensity Rating

• Minimum assessment

– In the past 24 hours: Current pain, Worst

pain, Usual pain, Least pain

• Comprehensive assessment

– Worst pain in past week, pain at rest pain

with movement

Numerical Rating Scale

• Numerical rating scale (0 to 10: no pain

to worst pain you can imagine)

– Verbal

– Written

• Categorical scale:

– None (0); Mild (1-3); Moderate (4-6); Severe

(7-10)

Top: Faces Pain Scale (Bieri et al., 1990), scored 0 to 6

Bottom: Faces Pain Scale-Revised, scored 0-2-4-6-8-10 (or 0-1-2-3-4-5).

Instructions: “These faces show how much something can hurt. This face

[point to left-most face] shows no pain. The faces show more and more pain

[point to each from left to right] up to this one [point to right-most face] - it

shows very much pain. Point to the face that shows how much you hurt

[right now]. Hicks et al., 2001

Comprehensive Pain

Assessment

• In order to identify

– Etiology

– Pathophysiology

– Specific cancer pain syndrome

– Determine patient goals for comfort,

function

Red Flag

• Pain related to an oncologic emergency

– Bone fracture or impending fracture of

weight bearing bone

– Brain metastases

– Epidural metastases

– Leptomeningeal metastases

– Pain related to infection

– Obstructed or perforated viscus

CTCAE: Pain

• Grade 1

– Mild pain

• Grade 2

– Moderate pain; limiting instrumental ADL

• Grade 3

– Severe pain; limiting self care ADL

Classification of pain management

strategies in cancer patients

• By cause – tumor-induced pain, iatrogenic pain, unspecific pain

• By quality – nociceptive pain, neuropathic pain

• By duration – acute pain, chronic pain, breakthrough pain

• By severity – weak, moderate, strong

• By site of origin – visceral pain, bone pain, soft tissue pain

• By psychosocial status

Cancer-induces pain:

mechanisms

• Cancer tissue infiltrating nerves

• Cancer tissue blocking or destroying nerves

• Peritumoural edema compressing nerves

• Cancer tissue secreting substances that irritate the nerves or lower the pain threshold

• Pathologic fractures inducing functional instability Mechanisms

Anticancer treatment-induced

pain

• Pain syndromes due to loss of organs

• Post radiation pain syndromes

• Chemotherapy-induced polyneuropathy

Pain of unknown origin….

Classification by site of origin

• Periosteal and/or bone pain

– dull, boring, deep, but may also be sharp and lancinating. lt

is usually easy to locate and tends worsen during motion.

• Pain of soft tissue and muscles

– often permanent and is usually dull, boring, continuous and

diffuse in terms of location. It occurs independently of

motion.

• Visceral pain

– mainly due to infiltration, ulceration or compression in the

gastrointestinal, respiratory or urogenital tract. Visceral pain

is typically dull, deep, hard to localize, and may be colicky.

Therapeutic measures

• Causal (anti-tumor therapies)

• Symptomatic (therapies influencing the

pain sensitivity)

• Co-analgesic interventions (therapies

influencing the biopsychosocial

environment)

Anticancer therapies for pain

relief

• Surgery

• Chemotherapy

• Hormone therapy

• Radiotherapy

Symptomatic pain management

strategies

• Most used approach

• Systemic pharmaceutical approach

– Non-opioid analgesics

– Opioids

– Antidepressants

– Co-analgesics

WHO step system for cancer

pain management

NON-PHARMACOLOGIC

TREATMENTS

Physical therapy in pain

management for patients with

cancer

• Higher awareness of motion patterns

• Relaxation of painfully tense muscles

• Relaxation of fibrotic subcutaneous tissue

• Patient is taught behaviors calculated to

relieve pain

• Patient learns relaxation techniques

• Patient learns postures designed to

reduce pain

Postural re-education

• For patients who have altered posture or movement secondary

to pain

– Breast cancer

• Correct protective posture

– Head and neck

• Shoulder dysfunction

Physical Modalities

• Bed, bath, and walking supports

• Positioning instruction

• Energy conservation, pacing of activities

• Massage

• Heat and/or ice

• TENS

• Acupuncture or acupressure

• Ultrasonic stimulation

Massage and warm baths

• Mechanisms:

– Resolve painful tension

– Rebound vasodilation

– Mentally soothing and relaxing effects on the

limbic system

• Most beneficial to patients with high levels of

psychological distress

• Contraindications:

– Tumor regions, thrombocytopenia, high BP,

severe heart failure, etc.

(Soden et al., 2004)

Massage and soft tissue

mobilization

• Scar mobilization/massage, myofascial

techniques and connective tissue

massage

(Hunter, 1994; Mannheim, 2001).

Lymphatic drainage

• Mechanisms: reduces excess limb

volume and dermal thickness

• Effective for edema-related pain relief

• Methods:

– Manual

– Compression garments


Heat

• Mechanisms:

– relaxing effects

• Many concerns:

Ice

• Mechanisms:

– Reducing inflammation, swelling,

decelerates neurotransmission, etc.

– Less risk while applying to patients with

cancer

• Contraindication:

– Patients with peripheral arterial occlusive

disease (PAOD) history

Hydrotherapy

• Mechanisms:

– Mechanical + thermal stimulation

– Beneficial effects on muscle, circulation,

and immune system


Electrotherapy

• TENS

– for treatment induced pain

– No formal guideline

– Conventional TENS

– Applied on painful area or an adjacent

dermatome

– Intensity: “strong but comfortable”

– Duration: several minutes up to several hours


Therapeutic exercise

• Start cautiously, build up gradually and

be within the patient’s tolerance levels

• Graded and purposeful activity

Chronic pain syndromes: s/p

surgical intervention

• S/P

– mastectomy

– gastrectomy

– proctectomy

– thoracotomy

– amputation

• Phantom pain

• Lymphedema

Adverse effects of non-opioids

• Risk of ulceration

• Risk of bleeding

• Impaired renal function

• Cardiovascular risks?

Adverse effects of opioids

• Addition tendency

• Excessive sedation

• Respiratory depression

DYSPNEA


Definition of Dyspnea

• A subjective experience of breathing

discomfort that consists of qualitatively

distinct sensations that vary in

intensity

American Thoracic Society 1999

Causes of dyspnea in patients

with cancer

• Disease related

– Malignant pleural

effusion

• Treatment related

– RT related

pneumonitis

• Comorbidities

– Example: COPD

• Airway obstruction

• Hypoxemia

• Psychogenic

dyspnea

• Cardiovascular

failure

• Neurologic disorder

• Anemia

CTCAE: Dyspnea

• Grade 1 – Shortness of breath with moderate exertion

• Grade 2 – Shortness of breath with minimal exertion; limiting

instrumental ADL

• Grade 3 – Shortness of breath at rest; limiting self care ADL

• Grade 4 – Life-threatening

– consequences; urgent intervention indicated

• Grade 5 – Death

Interventions

• Assess symptom intensity

• Treat underlying causes/comorbid

conditions

• Relieve symptoms

Treat underlying

causes/comorbid conditions

• Radiation/Chemotherapy

• Therapeutic procedure for cardiac,

pleural, or abdominal fluid

• Bronchoscopic therapy

• Bronchodilators, diuretics, steroids,

antibiotics, or transfusions

Relieve symptoms

• O2 for hypoxia

• Educational, psychosocial, and emotional

support for the patient and family

• Nonpharmacologic therapies

• Morphine

• Benzodiazepines

• Temporary ventilator (CPAP, BiPAP)

– Non-invasive in nature

Non-pharmacological measures

to relieve dyspnea

• Positioning

– Forward lean sitting

• Elbows resting on knees or a table when seated,

or on a suitable surface, for example a

windowsill or wall, when standing

– Advise on passively fixing the shoulder

girdle for optimizing ventilatory muscle

efficiency and relief of breathlessness

• Hands/thumbs resting in/on pockets, belt loops,

waistband, or across the shoulder handbag

strap when ambulating


to relieve dyspnea

• Breathing techniques

– Breathing control

– Diaphragmatic

– Pursed lip

– Exhalation on effort (“blow as you go!”)

– Paced breathing

• Paced with activity


to relieve dyspnea

• Non-invasive ventilation

• Oxygen therapy

• Airway clearance techniques

– Active cycle of breathing techniques

– Positive expiratory pressure (PEP)


to relieve dyspnea

• Energy conservation techniques:

Reduction in the energy expenditure

• Combined of techniques

– Using a WC and portable O2 during

hygiene/toileting/outing


to relieve dyspnea

• Fans

• Cooler temperature

Oncology Rehabilitation

• To help patients stay physically strong

so they can tolerate conventional

cancer treatment and continue to

participate in everyday activities

• Continue services

before treatment

during treatment

after treatment

癌症病人常見症狀之物理治療王儷穎

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Transcript of 癌症病人常見症狀之物理治療 王儷穎

癌症病人常見症狀之物理治療王儷穎

Transcript of 癌症病人常見症狀之物理治療王儷穎