曹昭懿

臺大物理治療學系

Exercise of Cancer Patient:

Prevention, Survival & End of Life

2007 Male

Incidence Mortality

7210 5650

6040 2558

5898 5458

5006 2152

3367 1003

Incidence Mortality

7502 1552

4417 1912

3161 2535

2900 2159

1749 833

2007 Female

BHP, 2010/2

Goals of Oncology Rehabilitation

Preventive: to preclude or mitigate functional morbidity

Restorative: to return patients to their premorbid functional status

Supportive: to maximize function after permanent impairments

Palliative: to reduce the dependence and provide comfort and emotional support

Cancer Care Trajectory

4

Cancer Rehabilitation

System specific problems

Activity restrictions ADL Ambulation Mobility Transfer

Psychological problems

Immobility syndrome

Fatigue

Sexuality

Quality of life

Prevention Detection Buffering Coping Rehabilitation Palliation Health

Promotion

Survival

Prescreening Screening Pre-

treatment Treatment Survivorship End of life

PRE-DIAGNOSIS POST-DIAGNOSIS

DIAGNOSIS

PEACE: Physical Exercise Across the Cancer Experience

PACC: Physical Exercise & Cancer Control

Courneya et al, 2001, 2007

Prevention (I)

Friedenreich et al, 2002

Prevention (II)

Convincing evidence Colon cancer（ ↓ 40-50％）

Breast cancer（ ↓ 30-40％）

Probable evidence Prostate cancer（ ↓ 10-30％）

Possible evidence Endometrium cancer（ ↓ 30-40％）

Lung cancer（ ↓ 30-40％）

Detection

1. A 3-fold increase in prostate specific antigen

concentration after 15-min cycle ergometer exercise

(Oremek et al, Clin Chem 1996;42:691-5)

2. None after treadmill (Leventhal et al, J Urology 1993;150:893-4)

3. Exercise reduced the anxiety from screening and dx

(Streggles et al, Cancer Prev & Control 1998;2:213-20)

4. PA associated with compliance to cancer screening

(Larsen et al, BMC Gastroenterol 2006;6:5)

Buffering (Coping)

Cope with disease physically & emotionally while

awaiting treatment

Improving health/fitness to allow treatment

Delaying the need for treatment by managing the

disease and its symptoms

20 patients with lung cancer, structured exercise

training till resection, VO2peak, 6-min walk increased

significantly (Jones et al. Cancer 2007;110:590-8)

Common long-term and late effects of cancer treatment

Surgery Radiation Systemic therapy

• Cosmetic effects

• Functional disability from

removal of a limb or organ

• Damage to an organ (bowel,

bladder, sexual organ)

• Pain

• Scarring/adhesions

• Incisional hernia

• Lymphedema

• Systemic effects (removal of

endocrine organs, infection

risk post-splenectomy)

• Second malignancies

• Neurocognitive deficits

• Xerophalmia, cataracts

• Xerostomia, dental caries

• Pneumonitis, pulmonary

fibrosis

• Coronary artery, valvular,

conduction, cardiomyopathic,

and pericardial disase

• Bowel stricture

• Radiation procicits

• Bladder scariring

• Infertility, importence,

premature menopause

• Lymphedema

• Bone fracture

• Second malignancies

(myelodysplasia and leukemia)

• “chemo brain”

• Cardiomyopathy

• Renal toxicity

• Premature menopause

• Infertility

• Osteoporosis

• neuropathy

Coping

Managing side effects & toxicities

Maintaining physical functioning

Preventing muscle loss and fat gain

Improving mood states and QOL

Facilitating the completion of treatment

Potentiating the efficacy of cancer treatment

Moderate positive effects on: fitness, physical functioning, strength, fatigue, QOL

Courneya et al, Seminars in Oncology Nursing 2007;23(4):242-52

Rehabilitation

Spence et al, Cancer Treatment Review 2010;36:185-94.

10 studies: post treatment 3-6 months

Feasible and may provide physiological and psychological benefits on Physical functioning

Fatigue & QOL

Immune

Body composition

Survival

Nurses’ Health Study (NHS, N=121700):

exercise & cancer recurrence & mortality

Holmes et al. 2005, JAMA

Meyerhardt et al. 2006, J Clin Oncol

JAMA 2005;293:2479-86

93％

97％

86％

89％

92％

Post Dx PA & Mortality: CC

Meyerhardt et al, 2006

Post Dx PA & Mortality: CC

Health Promotion

Optimizing QOL & physical functioning

Managing the chronic and/or late appearing effects

Reducing the likelihood of cancer recurring

Reducing the likelihood of developing of other

chronic diseases

Palliation (I)

Specific symptoms in terminal cancer patients

Pain 80%

Cachexia（惡病質）-anorexia（厭食） syndrome

Chronic nausea

Asthenia 無力

Dyspnea

癌症末期療護最常見症狀

疼痛 70%

口乾 68%

缺乏食慾 61%

無力 47%

便秘 45%

呼吸困難 42%

噁心、嘔吐 36%

失眠 34%

盜汗 25%

吞嚥問題 23%

泌尿問題 21%

神經精神症狀 20%

皮膚問題 16%

消化不良 11%

腹瀉 70%

Palliation (II)

Managing symptoms

Improving mobility

Slowing functional decline

Maintaining QOL

6-week structured PA : significant decrease in

fatigue & increase in physical performance &

emotional functioning (Oldervoll et al, 2005, 2006 )

50 patients, home-based PA, walking (Lowe, et al. Support Care Cancer 2010;18:1469-75)

癌因性疲倦 Cancer Related Fatigue

常伴隨癌症相關治療引起

休息不會降低疲倦感

常有睡眠障礙

處理原則

輕度適量運動

節省體能措施

心理支持與轉移注意力

睡眠衛生

治療相關症狀如貧血

美國癌症協會防癌指引

Achieve and maintain a healthy weight throughout life

Adopt a physically active lifestyle

成人:每周至少150分鐘中等程度運動或75分鐘劇烈運動，

或是相當的運動量，最好平均分配到每一天

兒童及青少年：每天至少60分鐘中至強度運動，每週至少3

天以上為劇烈運動量。

減少靜態生活，例如坐、躺著、看電視或其它對著螢幕

(screen-based )形式的娛樂。

除了日常生活外，多增加身體活動，對健康有很多益處。

Consume a healthy diet, with emphasis on plant food

If you drink alcoholic beverage, limit consumption

ACS guidelines on nutrition and physical activity for cancer prevention, 2012

27

Exercise Intolerance

Jones et al, Lancet Oncology 2009;10:598-605

Medical and Pre-exercise Evaluation

Comprehensive medical evaluation: medical

history, physical exam and physician clearance

Testing to exercise tolerance

Follow-up and re-evaluation at regular interval

癌症病人的評估

身體結構與功能(body structure and function)

心智

感覺功能與疼痛

神經肌骨系統與動作相關結構與功能

心血管、呼吸、血液、免疫

疲倦

Red flags and yellow flags

活動與參與(activity and participation)

Red Flags or Yellow Flags

Complete blood count

Anemia

Neutropenic

Thrombocytopenic

Neural impairments

Skeletal impairments

Cardiovascular or pulmonary system

中樞與周邊神經系統

顱內壓增加症狀

癲癇

動作與平衡

脊椎神經壓迫

感覺、疼痛

自主神經系統

骨骼轉移 60%的癌症復發會轉移到骨骼，其中一半轉移到脊椎骨

癌症對骨骼的影響

Loss of bone material (lytic tumor)

Invasion of bone (sclerotic tumor)

Osteonecrosis

Reduced bone mineral density

主要症狀

疼痛

脊髓神經症狀

病理性骨折

Health-related Physical Fitness

Testing and Interpretation

Body composition: BMI, circumference,

skinfold, DXA

Cardiorespiratory fitness: VO2max, HRmax, 6-

min walking, 3-min step

Muscular strength and muscular endurance

Flexibility ACSM’s guideline for exercise

testing and prescription

Physical Functioning

Eastern Cooperative Oncology Group (ECOG)

scale

Karnofsky Performance Status scale (KPS scale)

ECOG performance status

Grade ECOG

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out

work of a light or sedentary nature, e.g., light house work, office work

2 Ambulatory and capable of all selfcare but unable to carry out any work

activities. Up and about more than 50% of waking hours

3 Capable of only limited self care, confined to bed or chair more than 50% of

waking hours

4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or

chair

5 Dead

Oken, et al. Am J Clin Oncol 1982;5:649-655

KPS scale

Able to carry on normal

activity and to work; no special

care needed.

100 Normal no complaints; no evidence of disease.

90 Able to carry on normal activity; minor signs or symptoms of

disease.

80 Normal activity with effort; some signs or symptoms of

disease.

Unable to work; able to live at

home and care for most

personal needs; varying

amount of assistance needed.

70 Cares for self; unable to carry on normal activity or to do

active work.

60 Requires occasional assistance, but is able to care for most of

his personal needs.

50 Requires considerable assistance and frequent medical care.

Unable to care for self;

requires equivalent of

institutional or hospital care;

disease may be progressing

rapidly.

40 Disabled; requires special care and assistance.

30 Severely disabled; hospital admission is indicated although

death not imminent.

20 Very sick; hospital admission necessary; active supportive

treatment necessary.

10 Moribund; fatal processes progressing rapidly.

0 Dead

Health-related Quality of Life

Generic SF 36

WHOQOL-BREF

Cancer-specific EORTC

FACT

FLIC

CARES

運動測試的注意事項 Complication Recommendation

Anemia Avoid maximal testing or intense PA with significant aerobic demands

Low WBC count Avoid maximal test; avoid situation with an increased risk of infection( swimming, crowded areas)

Low platelet count Avoid tests or PA that increase the risk of trauma

Fever Avoid PA until the cause of fever is determined

Dyspnea Investigate cause; limit exercise intensity

Severe cachexia Exercise should be low intensity and extremely conservative

Extreme fatigue/weakness Initial exercise intensity should be low, but increase as tolerated; intermittent activities may be perferred to continuous exercise

Mouth sores/ulcerations Avoid tests that require a mouthpiece

Severe nausea/vomiting Avoid testing or PA until symptoms improve; initiate PA at a level that can be tolerated

Bone pain Avoid high-impact testing or PA; swimming may be ideal

CNS abnormality or peripheral neuropathy

Avoid testing and PA that require balance and coordination

Poor functional capacity Avoid maximal testing; exercise intensity should be low with extremely conservative increases made in intensity and duration

運動測試或訓練的禁忌症或特別注意事項： 系統性

禁忌

急性感染

發燒

全身不舒服

需要調整及/或醫師同意

最近有急性疾病或感染，應等症狀消失48小時再開始

Hematologic values and exercise modification

Platelet count 血小板

<10,000 此時病人通常需輸血，輸血後要再確認血小板值才能決定運動是否合適。病人有出血的危險，不建議運動。

<20,000 ADL’s, AAROM, AROM但不抗重力或阻力；須小心引導。

20,000-30,000 輕度運動( no PROM; light AROM permitted; walking as tolerated)

30,000-50,000 AROM, submaximal isometric, stationary bicycle, walking as tolerated,

水中運動; 不可長時間牽拉或阻力運動。

50,000-

150,000 允許輕到中度阻力運動；性生活；游泳、低的階梯運動、平地無坡度騎腳踏車。

>150,000 正常生活無限制。

Hematologic values and exercise modification

Hemoglobin (Hgb) 血紅素

<8g/dL 建議暫停運動* (必須與醫師討論，考量目前的醫療與身體狀況)

8-10g/dL 可以做輕度運動；不做有氧運動。

10-12g/dL 可以做低衝擊及低強度有氧運動(如固定式腳踏車)，等長運動，

阻力運動。

>12g/dL 正常生活無限制。

Hematocrit (Hct) 血球容積

< 25% 不建議運動*。

25%-30% 可以做輕度運動；漸進的阻力運動。

>30% 正常生活無限制。

White blood count (WBC) 白血球

<5,000/mm3 有發

燒 不建議運動*。

>5,000/mm3 可以做輕度運動；漸進的阻力運動。

運動測試或訓練的禁忌症或特別注意事項： 神經系統

禁忌

認知功能明顯降低

頭暈或頭重腳輕

Disorientation

視力模糊

ataxia

注意

輕到中度認知障礙：確認可以聽從指令

平衡不佳、周邊感覺障礙：預防跌倒

運動測試或訓練的禁忌症或特別注意事項： 肌肉骨骼系統

禁忌

最近新生的骨頭、背部、頸部疼痛

異常肌肉無力

嚴重惡病質

異常/非常疲累

KPS小於65%不做運動測試

需要調整及/或醫師同意

有疼痛或抽筋現象

骨質疏鬆

類固醇引起的肌肉病變

惡病質

輕到中度疲累

運動測試或訓練的禁忌症或特別注意事項： 腸胃系統

禁忌

嚴重噁心

過去24-36小時有嘔吐或腹瀉，

脫水

營養不良：體液或/及食物攝取不足

需要調整及/或醫師同意

水分或食物攝取有問題：多專業照護，照會營養師

運動測試或訓練的禁忌症或特別注意事項： 心血管系統

禁忌

胸痛

休息心跳 >100 bpm或 <50bpm

休息血壓

SBP > 145 mmHg

DBP > 95 mmHg

DPB <50 mmHg

心率不整

腳踝水腫

需要調整及/或醫師同意

有心臟血管疾病

有用降血壓藥物或調整心率藥物

有淋巴水腫

運動測試或訓練的禁忌症或特別注意事項： 呼吸系統

禁忌

呼吸急促

咳嗽、哮喘

深呼吸時有胸痛

需要調整及/或醫師同意

輕到中度呼吸急促：避免maximal tests

Principles of Exercise

Overload

Adaptation

Specificity

Reversibility

Modification: for cancer setting and during

adjuvant therapy

運動處方

運動方式 有氧運動訓練：心肺適能

肌力與肌耐力訓練

柔軟度：關節活動與牽拉運動

劑量 強度

頻率

時間

Home-based VS supervised group

癌症治療中運動原則

根據病人狀況與個別喜好給予個別化運動計畫

本來已有運動者可以降低強度及/或縮短時間，但主要目標要盡量維持活動

如果之前不太活動，先從輕度活動慢慢增加

小心有跌倒或受傷風險

最好有人在旁邊

如果病人在臥床，建議物理治療協助維持肌力與關節活動度，以及幫助抵抗疲倦與沮喪

癌症病人運動處方之特別考量

生命徵象

身上有傷口、管路

發燒

貧血、白血球、血小板低下

骨骼疼痛、轉移、骨質密度下降

神經系統損傷

嚴重疲累

有 氧 運 動

型態：走路、跑步機、固定式腳踏車、手搖腳踏車。

太極？瑜珈？氣功？（化療期間不建議游泳）

時間：15～30 分鐘（可增至40～50分鐘）

強度：低至中度（一點點喘，50％最大心跳MHR開

始或是40％之保留心跳HRR＋休息心跳）

MHR＝220-年齡

＝40％ *HRR（最大心跳－休息心跳）＋休息心跳

頻率：每週2～3次→3～5次

阻 力 運 動

型態：啞鈴（水瓶）、彈力帶、體重

體重：蹲站、坐站、爬樓梯、踮腳走、翹腳走、仰臥起坐、引體向上、伏地挺身

次數：5～15下/1～3次/天

強度：60％～80％之1RM，12-15 RM（中度）～8-12 RM（強度）

頻率：每週2～3次→3～4次

癌症治療後的運動建議

根據運動測試結果給予個人化運動計畫

根據個人需求、目標與喜好

影響運動的障礙、影響運動能力的長期副作用

考量運動處方的一般原則

運動處方的各參數

重新評估與調整運動處方

57

Exercise for Oncology Patients: aerobic component Aerobic

Frequency 3-7 x/week

Intensity

40%-60% of HR reserve or Oxygen uptake reserve, or

60%-80% of max HR, or

RPE of 12-15

Mode Start with walking or recumbent bike

Duration

Start with 5-20 minutes depending on exercise tolerance, including warm-up and

cool-down.

Goal is 20-60 minutes of continuous exercise

Progression Duration > frequency> intensity > mode

Patient monitor

consideration

HR, BP, O2 sat, RPE, and pain

Avoid group exercise during periods of neutropenia

Avoid training with presence of a new migrating central line

Avoid aquatics if neutropenic or with central line

Exercise for Oncology Patients: strength training

component Strength training

Frequency 2-3 x/week, 48 hour recovery between sessions

Intensity 40%-60% of 1 RM or 6-12 reps

Mode

8-10 dynamic exercises involving, functional task training, using weight machines or

free weights. Recommend caution with TheraBand resistance.

Target large, major muscle groups, performing concentric, and eccentric

contractions, in supine, sitting or standing positions

Duration Start with 1 set of 8-12 reps;.

Goal is 1-3 sets of 8-15 reps

Progression

Frequency > intensity:

2-3 x/week with 48 hr recovery

Add TheraBand only if no additional hematologic or orthopedic precautions are

present

Patient monitor

consideration

HR, BP, O2 sat, RPE, DOE and pain

Avoid group exercise during periods of neutropenia

Avoid training with presence of a new migrating central line

Avoid aquatics if neutropenic or with central line

Exercise for Oncology Patients: flexibility

component Flexibility training

Frequency 2-7 days/week

Intensity Slow static stretches only to the end range

Mode

Duration 4 reps of 10-60 seconds per stretch

Progression Duration > frequency > intensity >mode

Patient monitor

consideration

HR, BP, O2 sat, RPE, DOE and pain

Avoid group exercise during periods of neutropenia

Other Types

TaiChi

Yoga

Dancing

Pilates

Other outdoor activities (mountain

climbing, bike…)

Interventions: End of Life

Activity Enhancement (I)

Fatigue: **

during cancer treatment

following cancer treatment

Aerobic capacity:

11/22: significant difference between intervention and control

group

3/22: significant pre-post difference

8/22: non significant difference

Quality of life: --

Anxiety: --

Depression: -- Cramp et al, 2008

Activity Enhancement (II)

↑functional capacity so↓effort in activities

15~45min/session (no more than I hour)

1-5 sessions/week

3~32 weeks, average: 12 weeks

25~80% age-predicted HRmax (220-age)

walk, bicycle, ergometer, treadmill, yoga, tai-chi,

multidimensional (aerobic+stretching+resistance exercise)

group/individualized, supervised/home-based , mixture of

supervised and home-based

Psychosocial Interventions

Education:

energy conservation and activity management to balance rest

and activity

planning, delegating, prioritizing, pacing, resting

Support group

Individual counseling

Comprehensive coping strategy

Stress management training

Behavioral intervention

Sleep Therapy

Stimulus control

go to bed when sleepy, get out of bed after 20 min of wakefulness

Have a routine bedtime and rising time

Sleep restriction

avoidance of long or late day naps

Limiting total time in bed

Sleep hygiene

caffeine and exercise avoidance near bedtime

comfortable sleep surroundings (dark, relaxing…)

soothing activities at bedtime (music, …)

Thank You!