癌症病人術後物理治療 賴忠駿
description
Transcript of 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
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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
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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
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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)
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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
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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
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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
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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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Stubblefield MD, O’Dell MW, editors. Cancer rehabilitation:
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Frownfelter D, Dean E. Cardiovascular and pulmonary physical
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Raven RW, editors. A practical guide to rehabilitation oncology.
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