癌症病人術後物理治療 賴忠駿

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 cancer

◦ Head & Neck cancer

◦ Lung cancer

◦ Gastrointestinal tumor

◦ Neurological tumor

◦ Musculoskeletal tumor

2013/1/2 2

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

Post-surgical complication

Cardiopulmonary complications

◦ Restriction of lung capacities

◦ Atelectasis

◦ Airway clearance ↓

◦ Infection

Other complications

◦ Muscle wasting

◦ Deconditioned status

◦ Malnutrition

2013/1/2 4

2013/1/2 5 (Frownfelter D. 2006)

Common rehabilitation themes

post surgical patients Early mobilization

Pulmonary hygiene

Gait training

Training in ADLs

2013/1/2 6

(Malone DJ, editors. Physical therapy in acute care:

A clinician’s guide 2006)

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

Gait & ADLs training

Specific indication

◦ Status post amputation

◦ Weight bearing restriction

◦ Pain → limiting functional mobility

◦ Fatigue→ impeding mobility

2013/1/2 8

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

2013/1/2 9

(Courneya KS, editors. Physical activity and cancer. 2011)

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

Physical sequelae of treatment

Shoulder mobility and strength ↓

◦ Cording

◦ Stiffness in the tissue

◦ Pain

Pain and numbness

◦ 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)

61% Internal rotation

41% Abduction

34% External rotation

33% Flexion

2013/1/2 11

(Joansson et al, 2001)

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

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

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

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

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

Complications after breast

reconstruction

2013/1/2 17

(McNeely ML, 2012)

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

Procedure and Restriction

2013/1/2 19

(Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009)

Exercise after surgery

2013/1/2 20

(Stubblefield MD, editors. Cancer rehabilitation: Principles and practice. 2009)

Exercise after surgery

2013/1/2 21

Delayed vs. immediate exercise

following surgery – seroma incidence

2013/1/2 22

(Shamley DR, 2005)

2013/1/2 23

Delayed vs. immediate exercise

following surgery – drainage volume and

hospital stay

(Shamley DR, 2005)

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

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

Common problems

Poor posture

◦ Forward head, round shoulders, neck rotation

due to pain,

◦ Tracheostomy, fear of damaging the surgical site

Alter the venous and lymphatic drainage

system

Head & neck lymphedema

Exacerbate any shoulder dysfunction

Decrease the ability to clear secretions

2013/1/2 26

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

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

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

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

Effect of deep breathing exercise on

POD 1

2013/1/2 31

(Genc A, 2008)

A patient with oropharyngeal cancer

s/p surgery and tracheostomy

2013/1/2 32

Oropharyngeal cancer s/p wide excision,

bilateral modified radical neck dissection and

tracheostomy

2013/1/2 33

A patient with left lower gingiva cancer s/p

wide excision and modified redical neck

dissection

2013/1/2 34

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

Remove spinal accessory nerve

2013/1/2 36

(Malone DJ, editors.

Physical therapy in acute

care. 2006)

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

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

Intervention after reconstruction Pectoralis flap Fibular flap Radial forearm flap

Acute Postural training

Cervical ROM

•non-weightbearing

4~7 days

•Transfer technique

•Bed mobility

•Pulmonary hygiene

•Avoid weight

bearing through the

donor site during

transfers and ADLs

•Shoulder ROM <90° until drains removed

Long-

term

Wound healing

achieved:

Scapular retraction

and latissimus

strengthening for

posterior stability

Weight bearing

advanced:

•Household/

community

ambulation

•Verbal feedback to

avoid compensatory

gait deviation 2013/1/2 39

Progressive resistance training

improve shoulder dysfunction

2013/1/2 40 (Carvalho APV, 2012)

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

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

Surgery of lung cancer

Types of surgery (early stage: I~IIIA)

◦ Wedge resection

◦ Segmentectomy

◦ Lobectomy

◦ Bilobectomy

◦ Pneumonectomy

2013/1/2 43

Prior to surgical resection

Selection of the patient

◦ General and pulmonary-specific evaluation

◦ Symptom limited cardiopulmonary exercise test

Independent predictor of surgical complication rate

Pre-surgery exercise training

◦ VO2peak improve

◦ Lower perisurgical complication

◦ Improve postsurgical recovery

2013/1/2 44

(Courneya KS, editors. Physical activity and cancer. 2011)

Pre-surgical exercise training

2013/1/2 45

(Courneya KS, editors. Physical activity and cancer. 2011)

Pre-surgical exercise training

2013/1/2 46

(Jones at al, 2007)

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

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

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

Post-surgical exercise training

2013/1/2 50 (Courneya KS, editors. Physical activity and cancer. 2011)

Post-surgical exercise training

2013/1/2 51

(Jones et al, 2008)

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

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

Clinical presentation of GI cancers

Upper GI cancers

Lower GI cancers

2013/1/2 54 (Rankin J, editors. Rehabilitation in cancer care 2008.)

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

2013/1/2 55

Ileostomy,

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

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

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

Following an oseophagectomy

2013/1/2 59

(Rankin J, editors.

Rehabilitation in cancer care

2008.)

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

Post-surgical long term exercise

2013/1/2 61

(Courneya KS, editors. Physical activity and cancer. 2011)

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

Characteristics of brain tumor

2013/1/2 63

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

Common problem of brain tumors

2013/1/2 65 (Rankin J, editors. Rehabilitation in cancer care 2008.)

Intracranial neurosurgical

procedure 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

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

Early rehabilitation post surgery

2013/1/2 68

(Bartolo M, 2012)

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

Relative risk for MSCC

Metastatic compression lesion

◦ 70% thoracic spine

◦ 20% lumbar spine

◦ 10% cervical region

2013/1/2 70

(Rankin J editors. Rehabilitation in cancer care. 2008)

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

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

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

Physical intervention for MSCC patient

2013/1/2 74 (Rankin J editors. Rehabilitation in cancer care. 2008)

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

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

General protocols of osteosarcoma

Presurgical phase Acute

postsurgical phase

Subacute

postsurgical phase

Chronic

subsurgical phase

0~2 weeks 2~6 weeks >6 weeks

• Correct

limitations or

improve current

functions

• Identify needs

from other

members

• Identify realistic

postsurgical/

treatment goals

• Minimal

assistance to

modified

independence in

functional

transfer

• Maximum

protection of

affected joint/

limb

• Begin to wean off

assistive device

• Restore full range

of motion

• Progressive

resistance training

• Progressive gait

training

• Restoration of

joint stability and

functions

• Advancing

strength and

endurance

training

• Incoporating

sports-related

functional training

2013/1/2 77

(Punzalan M, 2009)

Physical therapy after LE surgery

2013/1/2 78

(Punzalan M, 2009)

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 brace

ROM exercise begin after

Post-op 1 week,

progress to 90° slowly.

Knee locked at 0° with

brace for 1 month

No ROM exercise!!

2013/1/2 79

Distal Femur Proximal Tibia

Brace Using for

1 year with

no restriction of

knee motion

Using for 6 months with

90° restriction, then,

6-12 months with no

restriction

Assisted

devise

6 months, depends on strength

ROM

Exercise

Post-op

3 month: 140° Post-op 6 month: 90° then, progress slowly

to 120° in 3months.

Strength

Training

1.SLR exercise with knee locked at 0° 2. Functional Electric Stimulation for

Quadriceps

Post-OP to 6 months

2013/1/2 80

Post-OP quadriceps setting

2013/1/2 81

Post-OP hip abduction/adduction

2013/1/2 82

Post-OP / OPD follow-up

4-phase straight-leg-raising

平躺抬腿 側躺抬腿

側躺夾腿

趴姿抬腿

2013/1/2 83

OPD follow-up

Active knee flexion

Passive 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 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

Reference

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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

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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

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