乳癌手術後的早期物理治療可能預防淋巴水腫
作者：Zosia Chustecka
出處：WebMD醫學新聞
January 22, 2010 — 根據一項發表於1月12日英國醫學期刊（BMJ）的隨機分派、單盲、控制組研究結果，乳房手術後的早期物理治療可能預防淋巴水腫。
來自西班牙馬德里Alcala de Henares大學Maria Torres Lacomba與其同事們寫到，乳癌手術或放射線治療後對腋下淋巴系統的損傷或阻斷會導致組織間隙淋巴液體局部或整體堆積，稱為繼發性淋巴水腫。透過術前與術後諮詢、教育以及早期偵測，可能降低繼發性淋巴水腫風險。
這項研究目的在於評估乳癌手術後，早期物理治療降低繼發性淋巴水腫風險的效果。在西班牙馬德里一間大學醫院，120位於2005年5月到2007年6月之間接受腋下淋巴結切除手術的女性被隨機分派到早期物理治療組或是控制組。
被分派到早期物理治療組的病患，接受物理治療師進行自我淋巴引流、疤痕組織按摩、漸進式主動與輔助肩部運動以及衛教，而控制組只接受衛教。主要試驗終點是臨床顯著繼發性淋巴水腫的發生率，以兩個相鄰位置超過臂圍相較於另一未受影響手臂增加超過2公分定義。
在116位完成一年後續追蹤的女性中，18位（16%）發生繼發性淋巴水腫，包括控制組的14位（25%）、物理治療組的4位（7%；P=0.01；風險比值為0.28；95%信賴區間[CI]為0.10-0.79）。存活分析發現控制組相較於物理治療組，診斷出繼發性淋巴水腫的時間早了4倍（介入組/控制組，危險比值為0.26；95% CI為0.09-0.79）。
研究作者們寫到，對腋下淋巴結切除乳癌女性而言，在手術後至少一年，接受早期物理治療是預防繼發性淋巴水腫一個有效的介入。這些結果強調了物理治療在認識、預防、早期診斷與治療繼發性淋巴水腫上的角色。
這項研究的限制包括，僅由受訓過的物理治療師提供物理治療、有限的應用性；使用診斷淋巴水腫的特定條件；以及可能的評估誤差。
在隨後的主編評論中，來自明尼蘇達州羅徹斯特梅約診所的Andrea Cheville博士指出，物理治療在特定女性身上是有潛力的。
Cheville博士寫到，有限、但非常多證據支持物理治療在手術切除腋下淋巴結後疼痛控制、肩部功能與活動範圍、以及降低女性發生淋巴水腫風險的效果。臨床醫師應該考慮轉介病患給受過淋巴水腫訓練的物理治療師。未來的研究需要評估特定治療方式，例如衛教與自我淋巴引流的效果。
西班牙衛生部門可洛斯三世健康機構贊助這項研究。研究作者們與Cheville博士表示已無相關資金上的往來。
Early Physiotherapy May Help Prevent Lymphedema After Breast Cancer Surgery
By Zosia Chustecka
Medscape Medical News
January 22, 2010 — Early physiotherapy may help prevent and reduce lymphedema after breast cancer surgery, according to the results of a randomized, single blinded, controlled trial reported in the January 12 issue of the BMJ.
"Acquired interruption or damage to the axillary lymphatic system after surgery or radiotherapy for breast cancer can lead to regional or generalised accumulation of lymph fluid in the interstitial space, known as secondary lymphoedema," write Maria Torres Lacomba, from Alcala de Henares University in Madrid, Spain, and colleagues. "Efforts have been made to reduce the risk of secondary lymphoedema by preoperative and postoperative counselling and education and by early detection."
The goal of this study was to assess the efficacy of early physiotherapy in reducing the risk for secondary lymphedema after surgery for breast cancer. At a university hospital in Madrid, Spain, 120 women who had breast surgery involving dissection of axillary lymph nodes between May 2005 and June 2007 were randomly assigned to an early physiotherapy group or to a control group.
Patients in the early physiotherapy group were treated by a physiotherapist with a program involving manual lymph drainage, massage of scar tissue, and progressive active and action-assisted shoulder exercises, as well as an educational strategy, whereas the control group received only the educational strategy. The primary study endpoint was the incidence of clinically significant secondary lymphedema, defined as more than a 2-cm increase vs the nonaffected side in arm circumference measured at 2 adjacent points.
Of 116 women who completed 1-year follow-up, 18 (16%) developed secondary lymphedema, including 14 in the control group (25%) and 4 in the physiotherapy group (7%; P?= .01; risk ratio, 0.28; 95% confidence interval [CI], 0.10 - 0.79). Survival analysis showed that secondary lymphedema was diagnosed 4 times earlier in the control group vs the physiotherapy group (intervention/control, hazard ratio, 0.26; 95% CI, 0.09 - 0.79).
"Early physiotherapy could be an effective intervention in the prevention of secondary lymphoedema in women for at least one year after surgery for breast cancer involving dissection of axillary lymph nodes," the study authors write. "This result emphasises the role of physiotherapy in the awareness, prevention, early diagnosis, and treatment of secondary lymphoedema."
Limitations of this study include physiotherapy provided by trained physiotherapists, limiting generalizability; use of a particular criterion for diagnosing lymphedema; and possible measurement errors.
In an accompanying editorial, Dr. Andrea Cheville, from Mayo Clinic in Rochester, Minnesota, suggests that physiotherapy shows promise in a selected group of women.
"Limited but compelling evidence supports the usefulness of physiotherapy after surgical clearance of the axillary lymph nodes to control pain, enhance shoulder functionality and range of motion, and reduce a woman's risk of developing lymphoedema," Dr. Cheville writes. "Clinicians should therefore consider referring patients to physiotherapists who are trained in treating lymphoedema. Future research is needed to assess the efficacy of specific treatment modalities such as education and manual lymphatic draining."
The Health Institute Carlos III of the Spanish Health Ministry supported this study. The study authors and Dr. Cheville have disclosed no relevant financial relationships.
BMJ. 2010;340:b5396.
