3. 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
5. Cancer Rehabilitation
System specific problems
Activity restrictions
ADL
Ambulation
Mobility
Transfer
Psychological problems
Immobility syndrome
Fatigue
Sexuality
Quality of life
6. PEACE: Physical Exercise Across the Cancer Experience
PACC: Physical Exercise & Cancer Control
DIAGNOSIS
Health
Prevention Detection Buffering Coping Rehabilitation Palliation
Promotion
Survival
Prescreening Pre- Treatment
Screening Survivorship End of life
treatment
PRE-DIAGNOSIS POST-DIAGNOSIS
Courneya et al, 2001, 2007
9. 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)
10. 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)
11. Common long-term and late effects of cancer treatment
Surgery Radiation Systemic therapy
• Cosmetic effects • Second malignancies • Second malignancies
• Functional disability from • Neurocognitive deficits (myelodysplasia and leukemia)
removal of a limb or organ • Xerophalmia, cataracts • “chemo brain”
• Damage to an organ (bowel, • Xerostomia, dental caries • Cardiomyopathy
bladder, sexual organ) • Pneumonitis, pulmonary • Renal toxicity
• Pain fibrosis • Premature menopause
• Scarring/adhesions • Coronary artery, valvular, • Infertility
• Incisional hernia conduction, cardiomyopathic, • Osteoporosis
• Lymphedema and pericardial disase • neuropathy
• Systemic effects (removal of • Bowel stricture
endocrine organs, infection • Radiation procicits
risk post-splenectomy) • Bladder scariring
• Infertility, importence,
premature menopause
• Lymphedema
• Bone fracture
12. 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
13. Rehabilitation
10 studies: post treatment 3-6 months
Feasible and may provide physiological and
psychological benefits on
Physical functioning
Fatigue & QOL
Immune
Body composition
Spence et al, Cancer Treatment Review 2010;36:185-94.
14. Survival
Nurses’ Health Study (NHS, N=121700):
exercise & cancer recurrence & mortality
Holmes et al. 2005, JAMA
Meyerhardt et al. 2006, J Clin Oncol
18. 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
19. Palliation (I)
Specific symptoms in terminal cancer patients
Pain 80%
Cachexia(惡病質)-anorexia(厭食) syndrome
Chronic nausea
Asthenia 無力
Dyspnea
21. 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)
22. 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
23. 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
28. 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
29. 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)
30.
31. Red Flags or Yellow Flags
Complete blood count
Anemia
Neutropenic
Thrombocytopenic
Neural impairments
Skeletal impairments
Cardiovascular or pulmonary system
33. 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
34. 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
36. 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
37. KPS scale
Able to carry on normal 100 Normal no complaints; no evidence of disease.
activity and to work; no special
care needed. 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 70 Cares for self; unable to carry on normal activity or to do
home and care for most active work.
personal needs; varying
amount of assistance needed. 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; 40 Disabled; requires special care and assistance.
requires equivalent of
institutional or hospital care; 30 Severely disabled; hospital admission is indicated although
disease may be progressing death not imminent.
rapidly.
20 Very sick; hospital admission necessary; active supportive
treatment necessary.
10 Moribund; fatal processes progressing rapidly.
0 Dead
38. Health-related Quality of Life
Generic
SF 36
WHOQOL-BREF
Cancer-specific
EORTC
FACT
FLIC
CARES
39. 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 Avoid testing and PA that require balance and coordination
peripheral neuropathy
Poor functional capacity Avoid maximal testing; exercise intensity should be low with extremely
conservative increases made in intensity and duration
56. Exercise for Oncology Patients: aerobic
component Aerobic
Frequency 3-7 x/week
40%-60% of HR reserve or Oxygen uptake reserve, or
Intensity 60%-80% of max HR, or
RPE of 12-15
Mode Start with walking or recumbent bike
Start with 5-20 minutes depending on exercise tolerance, including warm-up and
Duration cool-down.
Goal is 20-60 minutes of continuous exercise
Progression Duration > frequency> intensity > mode
HR, BP, O2 sat, RPE, and pain
Patient monitor Avoid group exercise during periods of neutropenia
consideration Avoid training with presence of a new migrating central line
Avoid aquatics if neutropenic or with central line
57. 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
8-10 dynamic exercises involving, functional task training, using weight machines or
free weights. Recommend caution with TheraBand resistance.
Mode
Target large, major muscle groups, performing concentric, and eccentric
contractions, in supine, sitting or standing positions
Start with 1 set of 8-12 reps;.
Duration
Goal is 1-3 sets of 8-15 reps
Frequency > intensity:
2-3 x/week with 48 hr recovery
Progression
Add TheraBand only if no additional hematologic or orthopedic precautions are
present
HR, BP, O2 sat, RPE, DOE and pain
Patient monitor Avoid group exercise during periods of neutropenia
consideration Avoid training with presence of a new migrating central line
Avoid aquatics if neutropenic or with central line
58. 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 HR, BP, O2 sat, RPE, DOE and pain
consideration Avoid group exercise during periods of neutropenia
59. Other Types
TaiChi
Yoga
Dancing
Pilates
Other outdoor activities (mountain
climbing, bike…)
61. 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
62. 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
63. 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
64. 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, …)