1. 1
癌症病人常見症狀
（呼吸困難、疲倦、疼痛）之
物理治療
醫療財團法人辜公亮基金會和信治癌中心醫院
物理治療師 廖清彬 2012.09.02

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參考資料
1. Michael DS, Michael WO. editors. Cancer Rehabilitation
Principles and Practice. New York: Demos Medical Publishing 2009
2. Jane R, Karen R, Nicola M, Jill C, Sian L, editors. Rehabilitation in
Cancer Care. Wiley-Blackwell 2008
3. Hermann D. Rehabilitation and palliation of Cancer patients.
Springer-Verlag France, Paris 2007
4. Rehabilitation Oncology ( Oncology Section American Physical
Therapy Association )
5. Physiotherapy Research International
6. Physical Therapy
7. Palliative Medicine

3. 3
“Quality of Life”
This is part of Comprehensive Cancer Care
Rehab Goals Based on Many Factors
Prognosis
Treatment
Co-morbidity / Impairment
Pain
Psychosocial Distress
Socioeconomic Background
Personal “Re-prioritization”

4. 4
Continuous Redefining of Treatment
Success and Functional Goals
Prognosis:
relative to stage / type of static or dynamic lesion(s)
Concurrent anti-neoplastic treatment
Medical co-morbidity – functional impairments
Degree of pain and psychosocial distress
Socioeconomic background – domestic and financial
resources to facilitate participation in goals
Personal “re-prioritization” – Symptom versus Disease
Oriented Care

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Avoid functional morbidity resulting
from cancer and/or its treatment
Stretch irradiated soft tissue
Protect skin with chemotherapy-induced
neuropathies
Aggressive post-thoracotomy chest PT and
shoulder range of motion
Prevent pathologic fractures with braces

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Restore pre-morbid level of function when
long-term impairment anticipated
Post-axillary dissection -- preserve ROM and
strength of shoulder; prevent extremities-edema
Post-BMT – aerobic reconditioning
Post-XRT of bone – prevent pathologic fracture
with mobility / ADL retraining

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Maximize function when long-term
impairment, disability, and/or handicap
result from cancer and its treatment
– Gait retraining after limb salvage
– Cognitive remediation after brain tumor
resection / irradiation
– Optimization of shoulder function after
Spinal Accessory Nerve sacrifice

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持續進行
• Staging work-up repeated
• Further treatment based on, age, stage, type of malignancy, prior
treatment response, patient interest in anti-neoplastic therapy,
potential for cure
• Aggressive high-dose CTX/XRT with high incidence of cumulative
toxicity (cardiac, neurological, wound healing, etc.)
• Preserve: mobility, community integration, and autonomous self-care:
– W/C or scooter, assistive devices
– Resistive exercise
– Energy conservation / Compensatory strategies
– Environmental control devices

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持續進行 (ㄧ)
• Selection factors
Severity of disability, extent and activity of disease,
family physical and emotional capability to participate
in care, prognosis
Benefits of continued rehab balanced against
progressive nature of disease
Flexible goals/duration due to evolving needs of the
patient and family
Emotional, functional, and spiritual support

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持續進行 (二)
• Integrated program based on preventive, restorative, supportive,
and palliative needs: 80% of treated patients demonstrated
measurable benefits and 68% showed moderate or marked
improvement or became fully independent
• Goal: Predict & properly treat those at greatest risk for
functional decline ….. To add ‘life to years’, not just ‘years’
• Increase aerobic condition, strength, flexibility, and mechanical
efficiency effect immune status and/or cytokine regulation

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Breathlessness
A subjective experience of breathing discomfort …interaction
physiological, psychological, social and environmental factors, induce
secondary physiological and behavioral responses. ( American Thoracic Society )
Cancer-related breathlessness
the cancer itself
cancer treatment
concurrent conditions: COPD, heart failure and
systemic illness
individual perception: anxiety, behavioral response

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Causes of breathlessness
Pulmonary : loss of functional lung tissue / M
obstruction of airway / M
loss of lung elasticity / M
Non-pulmonary : weakness of respiratory muscles / M
elevation of the diaphragm / M
defects of the circulatory system / M,C
anemia / C
metabolic disorders and renal
disease / C
anxiety or fear / E
＊ M: mechanical, C: chemical, E: emotional factors

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Assessment of breathlessness
• Medical and physical, social and occupational,
spiritual and psychological assessment
• Observation skills: respiratory function
breathing rate, chest wall movement, breath sounds, posture
( kyphosis and scoliosis ), frequency of sighing / yawning,
surgery
• Visual analogue scale ( VAS )
• Modified Borg scale ( MBS )
• Numeric rating scale ( NRS )

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Breathlessness management
• Medical intervention: bronchodilators, corticosteroids,
benzodiazepine, morphine,O2, nebulized saline
• Non-pharmacological intervention: individual patient’s
needs ( such as breathing retaining, positioning and
carefully graded exercise ),
cognitive-behavioral approaches ( education, relaxation
and improving symptom awareness ),
alter environments ( energy conservation / modification
ADL )

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Breathlessness management (1)
Breathing retraining: step-by-step approach
Positioning: high side lying, sitting with support, standing relaxed
Exercise: aerobic exercise ( walking, stair climbing, static cycle,
treadmill ), carefully gradually increase ( frequency, duration,
intensity ), avoid distress and set achievable goals
Cognitive-behavioral approaches: fear, anxiety, overbreathing,
hyperventilation syndrome ( dizziness, headaches,
paraesthesia, chest pain, palpitations, blurred vision ), simple
breathing exercise, relaxation techniques, passive
neuromuscular relaxation
Alter environments: task simplification, reduce energy
consumption, individual patient’s needs

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Cancer-Related Fatigue
Distress persistent, subjective sense of tiredness or exhaustion
related to cancer or cancer treatment ( NCCN, National Comprehensive Cancer Network, 2006 )
CRF: physical, psychological and cognitive components
No energy, tired, exhausted, poor concentration, memory loss,
irritable, ….
Direct effects of the tumor, treatment side effects,
anaemia, pain or deconditioning, psychosocial factors such as
anxiety and depression

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CRF- assessment
International Classification of Diseases-10
ICD-10, proposing 11 symptoms of CRF ( Cella et.al.1998 )
＊Significant fatigue, diminished energy or increased need to
rest, disproportionate to any recent change in activity level
• Complains of generalised weakness or limb heaviness
• Diminished concentration or attention
• Decreased motivation or interest in usual activities
• Insomnia or hypersomnia
• Experience of sleep as unrefresing or non-restoratives

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CRF- assessment ( 1 )
International Classification of Diseases-10
ICD-10, proposing 11 symptoms of CRF ( Cella et.al.1998 )
• Perceived need to struggle to overcome inactivity
• Marked emotional reactivity ( e.g. sadness, frustration and
irritability ) to feeling fatigued
• Difficulty in completing daily tasks attributed to feeling fatigued
• Perceived problems with short-term memory
• Post-exertional malaised lasting several hours
• 6/11, 2wks/month,＊, usual function, ca/ca t’x, not psychiatric

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The role of physiotherapy in the
management of CRF
• Muscle atrophy and decreased stamina are marked
components of CRF.( NCCN,2006;Mock,2004;Tomkins Stricker et al.,2004)
• Exercise has the strongest evidence base and is reported
as the most effective non-pharmacological intervention.
• Exercise program begins when the patients start
adjuvant therapy and lasts throughout the treatment.
• Low-to-moderate intensity ( 50-70%HRmax,11-13RPE )
• Progressive, Aerobic 15-30mins/day, 3-5days/week
• Exercise diary, session mode, intensity, duration, target
heart rate, symptoms experienced.

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CRF Clinical Practice Guidelines
Three main stages / physiotherapy & exercise ( NCCN,2006 )
During active treatment
high levels of fatigue / chemotherapy first 72 hours / radiotherapy course
recovery time (should be monitored) ≦30mins
swimming＊
When active treatment if completed and long-term follow-up
CRF can be at its peak post-treatment / especially no exercise during t’x
short- / long-term goals 3- / 6-month, low-to-moderate intensity, aerobic / resistive,
targeting weakened areas, gradually ↑ frequency、duration、intensity, motivation /
group therapy
At end of life
progression of disease, pain, medication, depression, anemia, poor nutrition, sleep
disturbance, PT aim maintain mobility and independence /close consultation

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Cancer Pain
• Pain “ an unpleasant sensory and emotional experience
associated with actual or potential tissue damage” IASP
( international association for the study of pain )
• Cancer pain “ ..... Composed of acute pain, chronic pain, tumor-
specific pain, treatment-related pain, …psychological
responses of distress and suffering, …”
1. pain directly due to the cancer, e.g. bony metastatic disease
2. pain indirectly due to the cancer, e.g. spinal nerve root compression
by a tumor
3. pain secondary to cancer treatment, e.g. peripheral neuropathy
secondary to chemotherapy
4. pain not related to cancer or its treatment but which coexists e.g.
painful OA joint

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Cancer Pain ( 1 )
• Patients with cancer often have multiple pains and
multiple causes of pain.
• Coexist with other symptoms :
fatigue
nausea and vomiting
breathlessness
deconditioning (↓ social activity / support )
anxiety ( hopelessness, negative perception )
fear and depression ( pain experience, indicate
further damage / worse of disease )

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Cancer Pain - Assessment
• Description of the pain
severity, irritability, nature
terminal disease and severe pain vs no evidence of
cancer but chronic cancer-treatment-related pain
• Responses to the pain
effective pain relief as quickly as possible
cognitive-behavioral therapy to improve function
• Impact of pain on the patient’s life

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Cancer Pain – Assessment ( 1 )
☆ Activity limitation / functional limitation
□ Physical impairments
Visual analogue scale ( VAS )
Numerical ratings scale ( NRS )
mild moderate severe pain
0 1 2 3 4 5 6 7 8 9 10
no pain worst pain

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Management of cancer-related pain
The majority of cancer pain is due to tumor effects.
bone metastases : 8 Gy / radiation fraction
Medical approaches
Pharmacological approaches
Non-opioids
Opioids
Adjuvants
Radiotherapy
Physical therapy interventions

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Management of cancer-related pain ( 1 )
• Physical therapy interventions
relieve pain
improve function
improve quality of life
physical, psychosocial, lifestyle adjustment
/ educational approaches

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Management of cancer-related pain ( 2 )
• Physical approaches
therapeutic exercise
graded and purposeful activity
postural re-education
massage and soft-tissue mobilization
transcutaneous electrical nerve stimulation ( TENS )
heat and cold

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Management of cancer-related pain ( 3 )
Resulting in
Causing increased
Reduces
Causing loss of
Activity
Stiffness
Function
Pain

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American Physical Therapy Association’s
Guide to Physical Therapist Practice
• A physical therapist may use physical agents
and modalities to
• decrease neural compression
• decrease pain and swelling
• decrease soft tissue and circulatory
disorders

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American Physical Therapy Association’s
Guide to Physical Therapist Practice
• A physical therapist may use physical agents
and modalities to
• enhance airway clearance
• enhance movement performance
• enhance or maintain physical performance

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American Physical Therapy Association’s
Guide to Physical Therapist Practice
• A physical therapist may use physical agents and
modalities to
• improve joint mobility
• improve tissue perfusion
• prevent or remediate impairments、 functional
limitations、disabilities to improve physical
functions
• reduce edema
• reduce risk factors and complications

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Physical agents and modalities
Physical agents
Increase
tissue extensibility
rate of wound healing
Modulate pain
Reduce
soft tissue swelling or inflammation
Remodel scar tissue
Treat skin conditions

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Physical agents and modalities ( 1 )
Physical agents
Cryotherapy
cold packs, ice massage, vapocoolant spray
Hydrotherapy
contrast baths, pools, whirlpool tanks
Light agents
infrared, laser, ultraviolet
Sound agents
ultrasound, phonophoresis
Thermotherapy
deep heat, hot packs, paraffin

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Physical agents and modalities ( 2 )
• Mechanical modalities
improve circulation
increase range of motion
modulate pain
decrease and control edema
stabilize an area that requires temporary
support

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Physical agents and modalities ( 3 )
• Mechanical modalities
Compression therapies ( compression
bandaging, compression garments, taping, )
Gravity-assisted compression ( standing
frame, tilt table )
Continuous passive motion devices ( CPM )
Traction devices ( intermittent, positional,
sustained )

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Physical agents and modalities ( 4 )
• Electrotherapeutic modalities
assist functional training
assist muscle force generation and contraction
increase the rate of healing
decrease unwanted muscular activity
modulate / decrease pain
reduce soft tissue swelling、inflammation、
restriction.

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Physical agents and modalities ( 5 )
• Electrotherapeutic modalities
Biofeedback
Electrical stimulation
electrical muscle stimulation EMS,
functional electrical stimulation FES,
neuromuscular electrical stimulation
NMES, transcutaneous electrical nerve
stimulation TENS

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Physical agents and modalities ( 6 )
• Indications
• Precautions
• Contraindications
General precautions and absolute contraindications
＊Each patient must be carefully considered on an
individual basis.＊

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Physical agents and modalities ( 7 )
• Contraindications
Patient-centered surveys
1.cryotherapy to reduce the severity of oral
mucositis (C/T)
2.TNES electrodes or an electrical stimulation
band placed acupuncture points to reduce the
incidence and severity of nausea and vomiting
(C/T)

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Therapeutic Exercise in Cancer
• Goals
• ↓risk, impairments, ↑function, fitness, well-
being
preventive
restorative
supportive
palliative

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Therapeutic Exercise in Cancer ( 1 )
• Strengthening Exercise
• Aerobic Exercise
• Range of Motion and Flexibility
• Coordination and Balance Training
• Chest Physical Therapy
• Considerations
Fatigue
Pain

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