PT在癌症病人的角色

Introduction

According to the American Cancer Society, it is estimated that about 1.4 million new cases of cancer will be diagnosed in 2008. Cancers of the prostate and breast will be the #1 diagnosed cancers in men and women, respectively, followed by lung and colorectal cancers in both men and in women. With the advancement of medicine and chemotherapy treatments, cancer patients are surviving longer. It is estimated the decrease in overall cancer death rate is 2.1% per year from 2002 through 2004, nearly twice the annual decrease of 1.1% per year from 1993 through 2002 in the United State. Some types of cancer can now be considered chronic illnesses. According to WHO’s definition, health is a condition of complete physical, mental and social well-being and not merely the absence of disease. Therefore in order to help patients achieve good health, the question of improving the quality of life for cancer survivors must be addressed. (Espey)

Some of the most common disabling complaints that all cancer patients have is fatigue and deconditioning. A study done by Lehman et al screened cancer patients for need for rehabilitation, and 45% of cancer patients would benefit from rehabilitation. Physical therapy helps patients restore their prior level of function, increase strength, therefore improve quality of life. However, the role of physical therapy in cancer rehabilitation still remain unclear, yet the benefits are evident. Of the many physical therapy interventions, exercise prescription, functional training, lymphedema management, and pulmonary rehabilitation have been researched extensively and shown beneficial results. Less data exists for other important physical therapy interventions such as physical modalities for pain control and family training. A major limitation to the evidence for physical therapy is a paucity of research on other types of cancer since most exercise and lymphoma studies were done on breast cancer patients. Regardless of the type of cancer patients, the goal of cancer rehabilitation should include proper assessment, prescription, program guidelines for cancer patients before, during, and after cancer treatment. (Schneider). Current review of evidence show outpatient physical therapy interventions improve cardiovascular endurance, strength, and pain reduction. Other physical therapy interventions such as lymphoma management which is specific to cancer patients undoubtedly are beneficial for these patients.

Exercise

The topic of exercise prescription for cancer patients have been an interest of many health care providers. Exercise is proven to help with weight control, physical conditioning, and paradoxically, help decrease cancer fatigue. The effects of exercise is studied extensively in patients with breast cancer. One physiological change seen with breast cancer patients on adjuvant chemotherapy is weight gain and body mass change of increase fat mass and decreased fat-free mass from overeating and lack of physical activity as well as menopausal changes. From the preliminary data, a combination of aerobic and resistance exercises seem to improve body mass composition(Ingram). However, due to lack of consistency in the exercise programs and outcome measurement, further research is required.

According to recently published systematic review on treatment and management of chronic fatigue syndrome, behavioral therapy and graded exercise therapy showed the most promising results. (Whiting et al) Results from the review of 12 randomized trials with breast cancer patients undergone two interventions: aerobic exercises (10 studies) and resistance exercises (2 studies) showed promising improvements in the quality of life, fatigue, physical function, and physical capacity and/or muscular fitness, during and after cancer treatment. Treatment outcomes were measured using the health-related quality of life (HRQOL) and VO2max. Even though the conclusion of studies show a general trend in improvement of quality and physical function, there is a wide variety of exercise program with varying duration and intensity. This finding needs to be validated in a more well-defined patient population with a standard exercise protocol. Another issue that physical therapists frequently encounter is the problem of patient adherence and frequent cancellations due to the chronicity of cancer related illnesses.

According to recently published systematic review on treatment and management of chronic fatigue syndrome, behavioral therapy and graded exercise therapy showed the most promising results. (Whiting et al) Results from the review of 12 randomized trials with breast cancer patients undergone two interventions: aerobic exercises (10 studies) and resistance exercises (2 studies) showed promising improvements in the quality of life, fatigue, physical function, and physical capacity and/or muscular fitness, during and after cancer treatment. Treatment outcomes were measured using the health-related quality of life (HRQOL) and VO2max. Even though the conclusion of studies show a general trend in improvement of quality and physical function, there is a wide variety of exercise program with varying duration and intensity. This finding needs to be validated in a more well-defined patient population with a standard exercise protocol. Another issue that physical therapists frequently encounter is the problem of patient adherence and frequent cancellations due to the chronicity of cancer related illnesses.

TABLE I. American Heart Association (AHA) Risk Stratification Criteria

 

 

AHA classification	NYHA class	Exercise capacity	Angina/ischemia and clinical characteristics	ECG monitoring
A: Apparently healthy			Less than 40 years of age, without symptoms, no major risk factors,and normal GXT	No supervision or monitoring required
B: Known stable CAD, low risk for vigorous exercise	1 or 2	5–6 METS	Free of ischemia or angina at rest or on the GXT, EF 40%–60%	Monitored and supervised only during prescribed sessions (6–12 sessions), light resistance training may be included in comprehensive rehabilitation programs
C: Stable CV disease with low risk for vigorous exercise but unable to self-regulate activity	1 or 2	5–6 METS	Same disease states and clinical characteristics as class B but without the ability to self-monitor exercise	Medical supervision and ECG monitoring during prescribed sessions, nonmedical supervision of other exercise sessions
D: Moderate to high risk for cardiac complications during exercise	< or equal to 3	>6 METS	Ischemia (_4.0 mm ST depression) or angina during exercise, two or more previous Mis, EF <30%	Continuous ECG monitoring during rehabilitation until safety is established, medical supervision during all exercise sessions until safety is established

Similar to the adult population, since 70% of all children diagnosed with malignant cancer become long-term survivors, the issue of improving quality of life in this young adult population must be addressed. Children and adolescents on anthracycline face the danger of developing the well-documented chemotherapy-induced cardiomyopathy and congestive heart failure (Bristow). After chemotherapy, these patients demonstrate a significant “spectrum of disuse” as a result of sedentary lifestyle and restricted physical activity from protective parents. Physical therapy prescribed exercises are critical for these young adult patients in preventing future heart attacks and improve physical condition. According to the study and guidelines made by the American Heart Association , symptomatic patients with anthracycline-induced cardiomyopathy should start with exercise intensity of 40%–60% of VO2 peak or Class C AHA Classification. Resistance training should consist of a single set of 8–12 repetitions with resistance 40%–60% of one repetition maximum performed on 8–10 machines two or three times per week.

Lymphedema management

Lymphedema management can be broadly categorized into intensive management which include decongestive therapy provided by trained healthcare professionals or limb maintenance therapy applied by the patients themselves. Current evidence recommendation is for 2-stage lympedema management. First stage consist of skin care, manual lymphedema treatment, low intensity exercises, and compression garment application. Second stage is to be initiated immediately after the first stage is completed and the goal is to maintain the results from the first stage. Treatment is consist of compression garment by low-stretching sleeves, skin care, exercise, and home manual lymphedema management program. (Moser)

Pain Reduction

The incidence of pain is extremely high in surgical cancer patients. To provide optimal therapy, it is important to know the type of pain the patient is experiencing. (Chang) 1) somatic pain. 2) visceral pain 3) neuropathic pain. These 3 types of pain may be due to tumor invasion into pain-sensitive structures, pain due to treatment, including surgical interventions, or pain that is unrelated to cancer or its treatment. Pain reducing modalities are not definitive at this time, however, modalities that have shown to be safe for reducing pain include cryotherapy, biofeedback, iontophoresis, transcutaneous electrical nerve stimulation. (TENS), and massage. (Watkins). Early ROM exercises can help surgical breast and head & neck patients mobilize the affected joints. In conclusion, the rehabilitation model for treating pain is a multidisciplinary approach that utilizes combination treatments including medications, physical modalities, exercise, CAM, injections, and surgical interventions. (Silver)

Functional Outcomes and Quality of Life

Quality of life can be categorized into four groups: physical, emotional, social, and cognitive. Cancer patients often have impairments in all four domains. Current research show patients with cancer who continue doing exercise have a higher quality of life outcomes. (Swartz). Physical therapists can undoubtedly improve the area of physical function. Cancer patients also often have emotional issues. Significant number of research have shown that by increase physical activity, patients will also show improved emotional status. (Labb) Women who have had primary treatment for breast cancer, those undergoing adjuvant therapy, and even some of those under treatment for metastatic disease, have an excellent employment record and seem to have encountered relatively few employment-related problems. The person who has been treated for head and neck cancer, particularly if his or her speech or appearance has been altered, faces employment problems quite different from those of the individual with breast cancer. It is interesting that 54 percent of the California blue-collar head and neck cancer patients indicated a need for mental health counseling, compared with less than 20 percent each of the breast and colorectal patients. (Mallette SJ)

Rehabilitation and palliative care have become increasingly important in cancer patients. There is a scarcity of evidence in this area, however, based on clinical experience, rehabilitation can help improve terminally ill patients improve their functional status. Areas of functional deficits that can be improved with physical therapy treatments include impaired transfers, decreased functional mobility, limited family education, and fatigue. Physical therapists can educate caregivers on safe transfers thus help reduce some burden and anxiety. (Santiago-Palmar)

Multidisciplinary Approach

Physical therapist should be an integral part of a multidisciplinary team caring for cancer patients. Cancer patients have challenges unlike any other diseases and for that reason, the success of their treatment outcome depends on a team of specialists. According to Crom Cancer rehabilitation involves helping a person with cancer to obtain maximum physical, social, psychological, and vocational functioning within the limits imposed by disease and its treatment. To be able to provide such care, an interdisciplinary team of oncologists, physiatrists, physical therapists, occupational therapists, nursing staff, and other disciplines is necessary. To demonstrate the complexity of cancer treatment, for example, cancer patients frequently experience symptoms of depression which may affect their activity level and in turn, result in loss of muscle mass, consequently may affect their ability to receive further chemotherapy treatments. In this case, an appropriate first step may be consult psychiatry along with physical therapy to help manage the depression and improve functional activity level to prepare the patient for chemotherapy.

Conclusion

New medical and surgical treatments are emerging for cancer patients. Current evidence points to the increasing importance of the role of physical therapy in the rehabilitation of cancer patients. Several modalities can help different types of cancer patients, thus an individualized program to cater to each patient’s functional goals is the most important. This further validates the clinical importance of physical therapists involvement in cancer patient’s overall recovery. To help cancer patient achieve good quality of life, physical therapy can play a significant role by improving strength, functional mobility, and decrease pain. Further research is needed to validate and quantify the benefits of physical therapy intervention in cancer patients.

(作者係廖文炫老師的女兒)