癌症病人之運動處方 曹昭懿
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Transcript of 癌症病人之運動處方 曹昭懿
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
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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
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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
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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!