The comparison of two different physiotherapy methods in treatment of lymphedema in advance breast cancer patients

淋巴水腫是乳癌晚期病人常見的困擾之一，腫脹的肢體常會影響病人的舒適與身體心像，進而降低生活品質。「完整淋巴水腫治療」（Complex lymphedema therapy）是目前公認針對淋巴水腫有效的物理治療，主要是合併徒手淋巴按摩、壓縮治療、運動及皮膚照護，能夠減少18.7-66%的水腫。壓縮治療所使用的短縮性繃帶造成病人緊繃等不舒服的感受，是否適用於晚期病人則不得而知。本研究目的即探討簡易及完整淋巴水腫治療對於晚期病人之成效，並運用主客觀的成效指標進行比較，選擇最終最適合此病人群之治療方式。研究採隨機的實驗設計，自民國九十六年六月於北部某醫學中心納入二十名有單側淋巴水腫的晚期乳癌婦女，隨機分派至簡易淋巴水腫治療組11名及完整淋巴水腫治療組9名，進行每週5次，為期3週的治療。兩組分別於第1次治療前及第15次治療後接受主觀的問卷測量(淋巴水腫症狀感受量表、生活品質量表、身體心像量表)。肢體的體積則於每次進行治療之前測量。研究結果顯示，(1)水腫程度方面，完整淋巴水腫治療組的水腫程度較簡易淋巴水腫治療組低，達統計上顯著差異（p<0.05）；(2)症狀感受方面，兩組治療前後對於重、堅硬、緊繃、不舒服、疼痛、脹、麻、無力皆有顯著差異（p<0.05），但兩組的改變量未達顯著差異。(3)生活品質方面，無論是簡易淋巴水腫治療組或是完整淋巴水腫治療組，都提升病人的生活品質(p<0.05），但兩組的改變量未達顯著差異。雖然兩組都可提升生活品質，但所針對的範疇不相同。簡易淋巴水腫治療組的心理情緒範疇改善程度優於完整淋巴水腫治療組(p<0.05)；完整淋巴水腫治療組的身體症狀範疇改善程度優於簡易淋巴腫治療組(p<0.05)。另外，為了解變項間的關係，將治療前的成效指標進行相關性分析，結果發現，水腫程度與症狀感受呈負相關(p<0.05)，由此可見，如果病人在一開始對於淋巴水腫的症狀感受越嚴重，生活品質即越差。(4)身體心像方面，簡易淋巴水腫治療組在治療後有顯著差異，但兩組的改變量則無顯著差異。根據以上結果，本研究建議為：完整淋巴水腫治療雖能夠有效的減少肢體的腫脹，但對於以生活品質為優先考量的癌症晚期病人而言，肢體腫脹減輕的多或少相對較不重要。簡易淋巴水腫治療除了能夠減輕腫脹及不適的症狀感受外，對心理情緒狀態也有正向的影響。建議未來的研究應該針對其他的措施(例如簡易徒手淋巴引流)進行多方比較，以提供臨床實務的治療照護指引。Lymphedema is a common complication among patients with advance breast cancer.t results in poor quality of life because extremity swelling would affect patients’ comfort and body image. Complex lymphedema therapy, including manual lymph drainage, compression therapy, exercise and skin care, is the most effective physical therapy to reduce 18.7~66% lymphedema in these patients. For this reason, we conduct a randomized study to compare simple lymphedema therapy and complex lymphedema therapy in advance breast cancer patients with lymphedema. im: To compare degree of lymphedema improvement, symptomatic relief, body image and quality of life between these two treatment modalities. ethods: Twenty breast cancer patients with unilateral lymphedema were enrolled into this study. Eleven patients served as the complex lymphedema therapy and were treated with manual lymphatic drainage, short stretch bandage ,skin care and exercise. Nine patients in the simple lymphedema therapy were treated with manual lymphatic drainage, skin care and exercise. These treatments were performed 5 times a week for 3 weeks. The volume of the affected extremity is measured each time before treatment. Questionnaires including : Lymphedema related symptoms scale、McGill Quality of Life questionnaire、body image scale , were done before the first and after fifteenth treatment. esults: We use generalized estimating equation method to evaluate extremity volumes and Mann-Whitney U test to compare difference between these two treatment arms. Complex lymphedema therapy had a significantly reduce extremity swelling than simple lymphedema therapy (P<0.05). These two methods have also improved lymphedema symptoms before and after treatments (P<0.05), but there is no significant different between groups. These two methods improvement quality of life before and after treatment (P<0.05) in different dimensions. Complex lymphedema therapy improved physical dimension, and simple lymphedema therapy improved psychological dimension. However, there is no difference between these two treatments. As body image scale, simple lymphedema arm improved after therapy(P<0.05), but there is no significant different between groups.onclusion: Although simple lymphedema treatment can not reduce more extremity than complex lymphedema therapy, it can result in improvement of symptomatic relief, life quality and improvement of body image. To improve symptom and quality of life is more important then reduce arm volume for advance breast cancer patients.口試委員會審定書......................................I謝.................................................II文摘要............................................III文摘要..............................................V 錄...............................................VII目錄................................................X目錄...............................................XI一章 緒論...........................................1一節 研究動機與重要性...............................1二節 研究目的.......................................3三節 研究問題與假設.................................4四節 名詞界定.......................................5二章 文獻查證.......................................6一節 淋巴系統的解剖及生理病理機轉...................6二節 淋巴水腫的評估................................ 12三節 淋巴水腫的治療................................ 15四節 晚期乳癌的治療目標............................18五節 淋巴水腫系統性文獻查證........................19三章 研究方法......................................27一節 研究設計......................................27二節 受試者........................................29三節 研究工具......................................30四節 資料收集流程..................................33五節 介入措施......................................35六節 資料處理與分析................................38七節 研究倫理考量..................................39四章 研究結果......................................40一節 研究對象之基本屬性............................40二節 兩組對水腫程度之成效..........................42三節 兩組對於症狀感受之成效........................48三節 兩組對於生活品質之成效........................52三節 兩組對於身體心像改變之成效....................58五章 討論..........................................62一節 患肢體積的改善效果...........................62二節 症狀感受的改善效果...........................65三節 生活品質的改善效果...........................66四節 身體心像的改善效果...........................68六章 結論與建議....................................69一節 研究限制與建議...............................69二節 結論.........................................70考文獻.............................................73文部份.............................................73文部分.............................................74錄..................................................1錄 一、淋巴水腫物理治療的系統性文獻查證.............1錄 二、基本資料及疾病特性...........................5錄 三、淋巴水腫症狀感受.............................6錄 四、生活品質量表（MQOL-台灣版）..................7錄 五、身體心像量表.................................8錄 六、病人對於繃帶治療的感受.......................9錄 七、受試者說明及同意書..........................10錄 八、淋巴水腫皮膚照護守則........................15錄 九、短縮性繃帶..................................17錄 十、運動治療....................................18錄 十一、臺大醫院研究倫理委員會審查公文............2