1. 癌症病人術後物理治療
1
臺大醫院物理治療師
蕭淑芳

2. Goal of surgery
2
 Debulking a tumor:表示腫瘤已無法完全切除，因此開
刀時只將較大，較易切除的腫塊拿掉
 Diagnosing a tumor(biopsy)
 Removing precancerous(癌前期) lesions
 Resecting a tumor
 Correction of life-threatening conditions caused by
cancer
 Palliation

3. Theme for postsurgery physical therapy
3
 Early mobilization
 Prevention of complications: pneumonia, ileus, DVT, loss of lean
body mass
 Lung hygiene
 Splinting cough, diaphragm/deep breathing exercise, posture
education
 Gait training
 Weight bearing restriction? pain?
 ADL training

4. Management of some common cancer
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 Breast cancer
 Head and neck cancer
 Lung cancer
 Colorectal cancer
 Gastrointestinal cancer

5. Breast cancer
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 Introduction of surgery type
 Post op programs

6. 前哨淋巴切除檢驗(sentinel node dissection)
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 優點：若哨兵淋巴結沒
有癌細胞，則不做腋下
淋巴清除，則減少淋巴
水腫的問題。
 缺點：有10﹪的僞陰性
率
 建議用在腫瘤2公分以
內及原位癌的患者

7. Lumpectomy or partial mastectomy
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 removal of the breast tumor
(the "lump") and some of
the normal tissue
 Lumpectomy : Tumor size<4
cm

8. Mastectomy
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 Removal of the whole breast
 Simple/ total mastectomy
 Modified radical mastectomy
 Radical mastectomy
 Partial mastectomy
 Subcutaneous (nipple-sparing) mastectomy.

9. Simple Mastectomy
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 removes the entire
breast, skin, nipple
 No muscles are
removed from
beneath the breast

10. Modified Radical Mastectomy
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 removal of both breast
tissue and lymph nodes:
 優點：維持胸部肌肉及
手臂肌肉的張力，
 手臂腫脹的情形較施行
乳房根除術輕微
 乳房重建較易。

11. Radical Mastectomy
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 Most extensive type of mastectomy
 Removes :
 the entire breast,
 Levels I, II, and III of the
underarm lymph (B, C, and D in
illustration),
 chest wall muscles under the
breast.
 缺點：會留下很長的疤痕，胸部也
會凹陷，可能導致淋巴水腫、手臂
無力、痲痹、疼痛、肩膀活動受限
制等，

12. Post op programs
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 Progressive shoulder ROM exercise:
 Begin after removal of the drains
 http://www.breastcf.org.tw/bloom/personal.php
 Postural exercise
 Lymphedema education

13. Head and neck cancer
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 Site: Lip, tongue, floor of mouth, gum, salivary gland,
oropharynx, nasopharynx, larynx, nose and sinuses,
ear, thyroid
 Surgery type
 Radical neck dissection:
 Modified radical neck dissection
 Selective neck dissection

14. Head and neck cancer
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 Reconstruction: TMJ dysfunction
 Pectoralis flap:
 Fibular flap:
 reconstruct the mandible bone; non-weight bearing for 4-7 days
 Vascular integrity, peroneal nerve function
 Transfer skill, bed mobility
 Radical forearm flap:
 no weight bearing activity on donor site,
 ROM limited to 90 degree before drains removed

15. Head and neck cancer
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 Post op care in acute phase
 Maintain airway, Lung hygiene and tracheotomy care
 Monitor circulation
 Prevent infection
 Control pain
 Postural training
 Cervical and shoulder ROM exercise

16. Airway management and tracheostomy care
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 Aim of care
 Ensure a patent airway
 Maintain comfort
 Ensure regular breathing rhythm, depth, and pattern
 Complication
 Bleeding
 Tracheoesophageal fistula
 Infection
 Obstruction or displacement of tracheostomy tube
 PT programs
 Breathing exercise, cleaning of tracheostomy q2-3h(suction),
humidification

17. Lung cancer
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 Small cell lung cancer
 High growth rate
 Worse progonosis
 Non small cell lung cancer
 Squamous cell carcinoma
 Adenocarcinoma
 Large-cell carcinoma

18. 18
epgonline.org

19. Reduced respiratory capacity after lung surgery
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 ↓25-30%functioning lung tissue after lobectomy or
bilobetomy
 ↓40% after left pneumonectomy
 ↓60% after right pneumonectomy
 Indicators for post-op lung function
 %FEV1
 Diffusion capacity of the lung for carbon monoxide
 Maximal oxygen uptake during exercise
 Provide oxygen

20. Lung cancer
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 Pre-op assessment: ADL, PFT
 Risk factor: obesity, smoking
 Review blood counts

21. Lung cancer
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 Post op care
 Symmetrical movement of the thoracic cage
 ROM of shoulder
 Breathing training: pursed lip and diaphragmatic
breathing
 Drainage of secretions/ percussion, use of
nebulizers
 Splinting cough
 Reconditioning: early ambulation, functional
independent

22. Symptoms and signs of Radiation pneumonitis
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 Dyspnea
 Non-productive cough
 Tachypnea
 Low grade fever
 Fullness in the chest
 ↑ESR
Treatment: corticosteroids,

23. Cardiovascular complications after pneumonectomy
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 Arrhytmias: 20-25%
 Atrial fibrillation, supraventricular tachycardia, artial flutter
 ↑mortality
 Myocardial infarction
 Acute heart failure
 Pulmonary emboli
 stroke

24. Possible organ displacement after right
pneumonectomy
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 Displacement of the tracheal to the right side
 Displacement of esophagus
 Mediastinal displacement to the empty pleural space
 Elevation of diaphragm and liver
 Deviation of the vertebral column

25. Superior vena cava obstruction
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 Tumor compress
 Neck swelling
 Distended veins over chest
 Swelling of one or both arms
 Dyspnea
 Hoarse voice
 Stridor
 Headache

26. 26
http://www.aboutcancer.com/svco_cuases_nejm_507.gif

27. PT intervention for SVCO
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 Elevate the patient‘s head
 Oxygen therapy
 Modified chest care skill
 Avoid compression therapy

28. Colon cancer
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 Ileostomy: after removal of colon and rectum,
externalized ileum
 Colostomy: rectum removed, distal colon attached to
abdominal
 Ileo-anal reservoir surgery

29. Somatic rehabilitation requirements after
hemilectomy
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 Hernias
 Diarrhea/constipation
 Adhesions
 Anemia
 Diet/obesity

30. Precautionary measures to prevent abdominal wall
hernia
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 Caution in lifting and carrying heavy loads
 Loads should never lifted suddenly
 Excess weight should be avoided
 Abdominal bandage

31. Example of physical therapeutic interventions for
abdominal surgery
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 Breathing exercise
 Deep breathing/ inspiratory holds
 Incentive spirometry
 Huffing/ directed cough
 Chest percussion/vibration
 Early mobilization
 Log-rolling /bracing with pillow
 Transfer/ gait training
 Progressive ambulation

32. Gastrointestinal surgery
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 Thoracoscopy
 Laparoscopy
 Esophagectomy
 Esophagus reconstruction

33. Pre/post upper abdominal and thoracic surgery
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 Pre op assessment: FEV1
 Post op increased risk of respiratory complication:50%
 Disruption of abdominal and diaphragmatic muscles
↓30%FRC for days
 Impaired mucociliary function
 PT programs
 Breathing exercise, Deep breathing, Incentive spirometry,
Huffing, Chest percussion/vibration
 Early mobilization

34. Precaution for PT programs after upper abdominal
and thoracic surgery
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 Avoid head down postural drainage:
 Suction ??
 Drips and drains
 Shoulder ROM

35. The environment and patient support/non-
intravenous equipment after GI sugery
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 IV fluid
 TPN
 Enteral nutrition: PEG (percutaneous enteral
gastrostomy), J-tube (jejonostomy), NG
 PRBC (paced red blood cell): ↑the O2 carrying
capacity of blood
 FFP(fresh frozen plasma): ↑blood volume
Stop PT
 JP (Jackson-Pratt) drain
 Sump drain
 Foley

36. Breathlessness management
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 Breathing exercise
 Positions
 High side lying
 Sitting upright in a chair with feet, back, and arm support
 Forward lean sitting with arm resting on pillows on a table

37. Bone metastasis
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 Location of metastatic bone disease
 Vertebrae 69%
 Pelvis 40%
 Femur 25%
 Ribs 25%
 Humerus 20%

38. Pain characteristics that may indicate fracture
or impending fracture
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 Pain with weightbearing
 Pain in the groin
 Pain with hip external rotation and abduction
 Pain with deep breathing
 Pain in a ban around the chest wall
 Increased pain with supine
 Increased pain with valsava

39. Goal of Surgery for pathological fracture
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 Excision of tumor
 Cure
 Stabilization of bone
 Prevention sequela from bed rest
 Palliation

40. Reference
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 Physical therapy in acute care : a clinician's guide .
Edited by Daniel Malone Thorofare, NJ : Slack, 2006.
 Rehabilitation in cancer care. edited by Jane Rankin
Chichester, UK ; Ames, Iowa : Wiley-Blackwell, 2008.