- 學位論文
腫瘤切除及淋巴廓清術後頭頸癌患者接受肩頸伸展與張口運動之成效
Effects of Shoulder and Neck Stretching and Mouth Opening Exercises on Post-Surgery Head and Neck Cancer Patients with Neck Dissection
摘要
背景 頭頸癌患者手術合併頸部淋巴廓清，是常見之術式，部分病人進一步合併放射線治療或同步化學放射線治療，會對頭頸部功能有更多的衝擊，雖然放射線治療的頭頸癌患者均會接受常規衛教，但過去研究發現成效不佳，多數患者可能未執行，往往造成立即或遲發性肩頸與張口功能受損及生活品質低落。 研究目的 本研究目的為：(1) 探討接受頭頸癌手術及頸部淋巴廓清術，或術後合併放射線治療及化學治療在肩頸功能（握力、肩部肌肉力量、及頸部關節活動度）、張口大小、憂鬱及生活品質在常規照護與肩頸伸展與張口運動介入組6個月內的變化；及 (2) 探討常規照護及接受肩頸伸展與張口運動介入對以上變項之成效。 研究方法 本研究為避免控制組與實驗組間的干擾，採前後研究設計 (pre- and post- study design)，由2016年01月至2020年1月於北部某醫學中心病房及門診進行收案。以接受頭頸腫瘤切除加上頸部淋巴廓清術患者為收案必要條件，在2018年1月前先收常規照護組；於2018年1月後會按照常規照護組中接受淋巴廓清術（改良式或選擇式淋巴廓清術）與性別（男或女）的比例進行收案。結果以握力（慣用手與非慣用手握力）、肩部肌肉力量（左右手肩屈曲及肩水平外展肌力）、頸部關節活動度（前彎、後仰、左右側彎、及左右轉）、張口大小、憂鬱及生活品質進行評估。本研究所有參與者皆追蹤3次，分別為：術後1個月內（T0，有放射線治療者則為治療前）、術後第3個月（T1，有放射線治療者則為該治療結束後約1-2星期左右） 及第6個月（T2，有放射線治療者則為該治療完成3個月）；運動介入效果運用廣義估計方程式進行，預估收案人數每組至少為87人。 研究結果 本研究先收常規照護組，共有89位接受頸部淋巴廓清術的頭頸癌患者同意參與，運動介入組，按常規照護組中接受頸部淋巴廓清術式與男女的比例進行收案，共87位同意參與；於術後第6個月追蹤完成者，常規照護組有69位及運動介入組66位，共135位納入最後的分析。 研究結果顯示，常規照護組，在所有時間點慣用手握力皆顯著較差，於術後第6個月 (T2) 頸部關節活動度改善（後仰、右側彎及右轉），其餘未顯著改變；運動介入組術後第3個月 (T1) 即有顯著較佳的肩頸功能（左右肩屈曲肌力、左肩水平外展肌力、左右側彎及左右轉），於術後第6個月 (T2)，除了右肩水平外展肌力與頸部前彎外，其餘握力、肩屈曲、左右側彎、左右轉、張口大小、憂鬱及生活品質皆顯著改善。 運動介入之病人術後第3個月 (T1) 有較佳的肩頸功能（慣用手與非慣用手握力、左右肩屈曲肌力、左肩水平外展肌力、左右側彎、左轉）優於常規照護組；於術後第6個月 (T2)，除了左右肩水平外展肌力（P值為0.077及0.069）與頸部前彎後仰外，其他皆優於常規照護組。 結果與結論 運動介入有效改善肩頸功能、張口大小、生活品質及舒緩憂鬱，尤其是在術後第6個月效果最為明顯，即運動對遲發之肩頸肌肉及張口功能成效明顯，本研究之發現能提供頭頸部癌症患者在家運動介入執行的可行性及有效性，建議納入門診治療照護之一環。
並列摘要
Background Surgery and concurrent chemoradiation therapy (CCRT) are the major treatments for head and neck cancer (HNC). Patients undergoing tumor excision with neck dissection (ND) might impact their physical function, especially impairments related to cervical range of motion (CROM), head and neck and shoulder function, and physical strengths. Purpose The aims of this study were to (1) assess the changes of shoulder and neck function, including handgrip strength, shoulder-muscle strength, and cervical range of motion (CROM) and mouth opening, and depression and QOL in HNC across the first half year post-surgery; and (2) compare the effects of 20-week “shoulder and neck stretching and mouth opening exercise” intervention on the above function, depression and quality of life (QOL) while compared to the control usual care group. Methods A pre- and post- study design was used to recruit HNC patients from one Otolaryngology Outpatient clinic in a medical center in Northern Taiwan. Eligible subjects were HNC who received tumor resection and ND with or without CCRT. Subjects in control as usual care group (control group) were recruited first. The exercise (intervention) group was recruited after completion of data collection in control group. The above-mentioned functions, depression and QOL were assessed. Patients were assessed at baseline (3-4 weeks post-operation before CCRT)/(T0) and 3- and 6-month post-operation (T1 and T2, respectively). An upper limb muscle and CROM related exercise training with 20-week telephone follow-up was design and implemented in intervention group. The Generalized Estimating Equation (GEE) was applied to compare the differences between groups. The estimated subject number would be 87 patients in each group. Results There were 89 and 87 eligible subjects recruited into control and intervention group respectively. There were 69 (control) and 66 (intervention) participants completed the 6 months assessment/ intervention. Generally, for control group, the hand grip strength and depression decreased and CROM increased at T2 (6 month) comparing to T0. Mouth opening and QOL remained similar at T2 comparing to T0. For exercise/intervention group, except neck forward flexion and shoulder horizontal abduction muscle strength, all other measured physical function, depression and QOL all improved at T2 comparing with the measure at T0. Compared to the usual care group, exercise group had significant improvement in most indicators except right shoulder horizontal abduction, neck forward flexion and extension, right neck rotation, mouth opening and QOL at T1 (three month after surgery). At T2 (6-month after surgery), except bilateral shoulder horizontal abduction muscle strength, neck forward flexion and extension, intervention group demonstrated a significantly improved than control group. Conclusion The results of this study provide the evidence-based information related to the changes of the impairments across the first 6 months in HNC post-surgery. Upper body exercise training with 20 weeks follow up demonstrated the powerful effects to improve these functions, particularly in 6th month after surgery. Systematical implementation of the assessment and intervention are strongly suggested to apply into clinical care to enhance HNC patients’ physical function, depression and quality of life.
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