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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
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
Gilchrist et al., 2009
Karavatas et al., 2006
Red and Yellow Flags
• 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
Gilchrist et al., 2009
Red and Yellow Flags
• 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
Gilchrist et al., 2009
Risk factors for fatigue in post-
treatment, disease-free patients
• Many….
• Pretreatment fatigue, depression,
anxiety, comorbidities, cytokines, etc.
Activity Enhancement
(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
Activity Enhancement
(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
癌症病人常見症狀(呼吸困難、疲倦、疼痛)之物理治療
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
• Contraindications:
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
• Contraindications:
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
• Contraindications:
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
癌症病人常見症狀(呼吸困難、疲倦、疼痛)之物理治療
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
Non-pharmacological measures
to relieve dyspnea
• Breathing techniques
– Breathing control
– Diaphragmatic
– Pursed lip
– Exhalation on effort (“blow as you go!”)
– Paced breathing
• Paced with activity
Non-pharmacological measures
to relieve dyspnea
• Non-invasive ventilation
• Oxygen therapy
• Airway clearance techniques
– Active cycle of breathing techniques
– Positive expiratory pressure (PEP)
Non-pharmacological measures
to relieve dyspnea
• Energy conservation techniques:
Reduction in the energy expenditure
• Combined of techniques
– Using a WC and portable O2 during
hygiene/toileting/outing
Non-pharmacological measures
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