乳癌病人的照護需求與物理治療服務方案

Abstract

癌症治療技術的長足進步，使癌症病人存活率大幅提高，早期(early stage) 乳癌患者有超過九成可以存活五年以上，因此在存活期間，緩解因治療產生的後遺症所帶來的影響，以及促進或維持乳癌存活者達到最佳的健康狀態與生活品質，是健康照護者提供後續服務的重要課題。 乳癌婦女有九成接受手術治療，除了因為治療產生之上半身機能損傷與功能障礙比其他癌症病人更需要物理治療服務外，相關研究也顯示癌症病人在體能訓練的需求。物理治療師是動作科學與運動訓練的專家，在乳癌病患的照護上可以擔任的角色除了治療局部的後遺症、改善系統性治療衍生之神經肌肉骨骼系統後遺症之外，尚可在預防的角度上，能透過早期偵測與預防性介入，避免或延緩進一步後遺症發生；以及在健康促進的角色上，對於在特殊需求族之群體能訓練，亦可提供專業服務。 本論文的目的為探討合乎乳癌病人需求的物理治療服務方案，包括三個研究。 第一個研究探討乳癌婦女肩頸手臂症狀盛行率與對於上肢功能與生活品質的衝擊，並且了解其身體復健的需求。採用橫斷式問卷調查，問卷內容包括疾病與治療資料、肩頸手臂的症狀、上肢功能障礙及生活品質以及復健服務需求問卷，共回收249份有效問卷，初步分析結果發現在上肢常見的12種肩頸手臂症狀，有81.5%病友至少有其中一種症狀，平均有4.5±3.6個症狀，顯示上半身肩頸手臂症狀普遍存在。其中至少有一處疼痛佔72.7%，有6成至少有一種動作受限的症狀，有38%自覺手臂無力，近三成受訪者自覺有手臂或腋下腫脹症狀。其中以疼痛、無力及肩關節活動受限症狀對上肢功能及生活品質影響較大。在復健服務需求問卷部份，分別為身體復健需求調查及需求的滿足狀況。分析結果有關身體復健資訊主要來自醫院提供的衛教資料與醫護人員指導，主要指導者近七成為護理師，物理治療師指導只有近二成；但各有五成左右受訪者希望由護理師或物理治療師指導手術後復健指導。乳癌病友對於物理治療的需求包括術後衛教指導與症狀處理，並且有一半受訪者勾選有體能訓練服務的需要，且大部分希望提供的時機是定期回診時。另外，有12%受訪者採用網路資源收集資料，顯示在此高教育程度族群中，網路是值得重視的一個管道。 第二個研究為隨機分配試驗，目的一為觀察乳癌病人在手術後功能恢復的狀況，與不同時期出現身體機能問題；目的二為建立癌症病人持續性照護模式的先例，探討定期監測與照護對於預防後期發生功能障礙之成效。招募新診斷之乳癌病人，在接受手術後第一次回診時收案，受試者在收案時隨機分成兩組，一組為一般照護組，另一組為監測照護組，監測照護組受試者由資深物理治療師依需要給予物理治療諮詢，定期給予追蹤，有需要則直接做衛教指導。定期於手術後3個月、6個月、12個月，安排物理治療檢查與填寫上肢功能障礙、生活品質問卷。主要成效評量指標為上肢功能障礙，以及上身機能損傷如關節肌肉活動度不足、疼痛類型、水腫與肌力不足等，次要成效評量指標為生活品質。共有155位受試者接受持續追蹤，分配到監測照護組與一般照護組分別有76及79位。結果顯示乳癌病人在手術後三個月在上肢功能、肩關節活動度及生活品質多有顯著恢復，但仍有一成受試者在手術後一年在上肢功能障礙仍有輕度障礙以及肩關節活動度未到正常角度。不良姿勢(圓肩)、胸小肌柔軟度不足、筋肌膜疼痛隨著時間出現的比例有增加趨勢。 第三個研究為探討阻力訓練對於台灣乳癌病人的合適性，此為一個隨機分配研究，探討為期3個月，在物理治療師指導下做阻力運動訓練對乳癌存活者在體適能、上肢功能與生活品質的效果。共有34位完成佐藥治療的乳癌存活者隨機分配分成控制組與運動訓練組，運動訓練組參加每周兩次，為期12週的阻力運動訓練，並且追蹤一年，結果兩組之間並無顯著差異，部分身體功能相關評量項目有時間效應(time effect)。 結論：乳癌病人因治療相關的上肢後遺症普遍存在，在以問卷調查主觀感受症狀的盛行率比客觀臨床評量的高，其中以疼痛、肩活動受限及自覺無力對上肢功能影響較大。手術組織破壞範圍較大，患者主觀感受腫脹、疤痕緊張及肩關節活動受限影響較多。以長期追蹤客觀檢查乳癌病人的姿勢、肌筋膜柔軟度、疼痛類型，發現術式的影響多為短期，在姿勢、肌肉柔軟度及筋肌膜疼痛之間的關聯，值得進一步探討。同時在持續監測服務時應注意患者姿勢、筋肌膜問題的評估與介入，但介入效果需要後續研究。乳癌病人普遍教育程度較高，對於網路資源利用與資訊需求高，建議可以在定期回診，利用網路與電腦科技提供相關資訊，並可利用資訊科技或是問卷做上肢症狀與功能篩檢，以為轉介進一步物理治療諮詢的指標。

Significant progress in breast cancer treatment made prolonging survival of patients with breast cancer. Many cancer survivors experience lasting, adverse effects caused by cancer and cancer treatment. Survivorship issues and quality of life of patients related to breast cancer treatment has recently drawn significant attention. Breast cancer survivors deserve the best possible care to manage the complications of breast cancer treatment and restore optimal function. Physical therapists are members of the multi-professional team to prevent and to decrease physical sequelae. In addition to traditional rehabilitation, physical therapy has important role on surveillance for early identification and intervention of upper extremity morbidities caused by breast cancer surgery and related treatment. Physical training for the sake of health promotion is also needed and may be provided by physical therapist. The purpose of this dissertation was to find a possible need-met and functioning based service model of physical therapy for women with breast cancer during their cancer trajectory. This dissertation included three studies. Study I was a cross-sectional questionnaire survey investigating common breast cancer treatment related upper body morbidities, upper body function and quality of life as well as physical rehabilitation needs. A total 249 valid questionnaires were analyzed. The results revealed that 81.5% of participants reported having at least one, with average 4.5±3.6 symptoms, of a total 12 common arm symptoms listed. Pain at least one site was reported by 73.7% of the subjects. Motion restriction was reported among 60% of subjects. Weakness was reported among 38% of subjects. And about 30% reported arm or axillary swelling. Pain, weakness and shoulder range of motion limitation related to upper extremity dysfunction and quality of life. In the second part of the questionnaire survey about physical rehabilitation needs, participants reported that post-surgical rehabilitation instruction was mostly given by nurse. Only 20% of participants reported had received post-surgical rehabilitation instruction by a physical therapist, which was much lower than expectation. Besides need of PT for post-surgical education and symptom management, high need of physical training was also found in this study In the second study, a longitudinal surveillance care model was provided in order to observe functional recovery trajectory of breast cancer patient after surgery, and to examine the effect of PT surveillance care model in preventing further functional impairment by early detection and intervention. Newly diagnosed unilateral breast cancer patients are recruited after surgery. Physical therapy evaluations and questionnaire survey including upper extremity disability and quality of life were assessed at 3, 6, 12, months post-surgery. Self-management instruction and counselling will be given if needed after evaluation. Total 155 participants were included and attended follow-up assessment and they were randomized into surveillance group (76 participants) or usual care group (79 participants). The primary outcomes including upper extremity disability, upper body morbidities such as insufficient shoulder range of motion or muscle flexibility, pain, edema and weakness. The secondary outcome was quality of life. The results revealed no significant difference between the two groups. Most upper body symptoms; disability and quality of life were recovered 3 months after surgery. However, presence of shoulder ROM limitation and mild upper extremity disability were found among near 10% of participants. A trend of prevalence increase over time among such as round shoulder, pectoralis minor tightness, and myofascial pain were found. Study III examined the effect of progressive resistance training for breast cancer survivors which conducted by a randomized controlled trial. A total 34 breast cancer survivors were recruited in this study. Participant assigned to exercise group received a 12 -week, twice weekly progressive resistant training programs instructed by a physical therapist. There was no significant difference between groups on physical fitness, function, and quality of life, which may be due to small sample size, insufficient training intensity or ceiling effect. In summary, breast cancer treatment related upper body morbidities were prevalent and found higher in subjective symptom survey than objective physical examination. Pain, shoulder range of motion limitation and feeling weakness were found having negative impact on upper extremity function. Higher prevalence of reporting edema, scar tightness and shoulder range of motion limitation were found among subjects underwent more extensive surgery. However, surgical type only influenced muscle flexibility and AWS for short term according to the longitudinal observation. Further research on the association between posture, muscle flexibility and myofascial pain was needed. In the surveillance of upper extremity function, physical therapist must pay attention to the evaluation and intervention of posture change and myofascial conditions, although research on the effect of intervention is still lacking. Our participants were highly educated, with high information need and internet user. Information and screening by using web and computer system is suggested.