C.3 Oefentherapie

Zie ook noot 15 - Uit de literatuur blijkt dat oefentherapie een belangrijke fysiotherapeutische interventie is, ook bij patiënten met borstkanker. Oefentherapie zoals die in de verschillende onderzoeken werd gehanteerd, kende verschillende uitvoeringsvarianten met betrekking tot aanvang, aard, frequentie en duur van de behandeling. Dit maakte het geven van concrete aanbevelingen soms lastig. Daarnaast wordt tegenwoordig steeds meer het belang ingezien van een actieve participatie van de patiënt, wat de fysiotherapeut vaak meer tot coach dan tot behandelaar maakt. 

Tijdens radio- en systeemtherapie bestaat er een risico op conditieverlies en toename van vermoeidheid. Omdat fysiotherapeutische interventies hierbij zijn gericht op het verbeteren van de conditie zijn aanbevelingen hieromtrent terug te vinden in de Standaard Beweeginterventie Oncologie.
De wetenschappelijke bevindingen ten aanzien van oefentherapie zijn opgenomen in noot 15.

 


Aanbevelingen oefentherapie

  • Aanbevolen wordt, als er nog een drain aanwezig is, niet verder dan 90 graden te bewegen en daarna langzaam op geleide van de pijn de mobiliteit van de arm/schouder op te bouwen.

  • Aanbevolen wordt patiënten 5-7 dagen postoperatief na een okselklierdissectie naar een fysiotherapeut te verwijzen. Als er geen extra comorbiditeit of risicofactoren aanwezig zijn, zijn 9-12 behandelingen over het algemeen voldoende om mobiliteitsbeperkingen en adl-beperkingen op te heffen.

  • Aanbevolen wordt om bij een axillary web syndroom (AWS), zeker als de patiënt nog radiotherapie krijgt, te behandelen met mobiliserende oefentherapie.

  • Indien in een later stadium radiotherapie en/of systeemtherapie volgt, wordt de patiënt geadviseerd om bij functieklachten en of tekenen van lymfoedeem opnieuw contact op te nemen met de behandelend fysiotherapeut.

  • Het wordt aanbevolen om 1 week postoperatief de normale beweegactiviteiten weer op te pakken met inachtneming van het wondgenezingsproces. Bewegingsangst moet worden voorkomen.

  • Het verdient aanbeveling het armvolume te evalueren tijdens de oefeninterventie.

  • Tijdens de eindevaluatie van de fysiotherapeutische behandeling wordt aanbevolen met patiënten de risicofactoren te bespreken en hen te adviseren bij functieklachten en/of tekenen van lymfoedeem opnieuw contact op te nemen met de behandelend fysiotherapeut.


 

Noot 15 Oefentherapie

Noot 15 Er zijn een groot aantal studies gevonden die onderzoek naar oefentherapie beschrijven, namelijk 7 systematische reviews (McNeely et al., 2010; Cheema et al., 2008; Montazeri et al., 2008; Bicego et al., 2006; Shamley et al., 2005; Erickson et al., 2001; Kärki et al., 2001), 2 richtlijnen (Harris et al., 2001; Weiss & Domann, 2006), 16 RCT’s (Torres Lacomba et al., 2010; Hayes et al., 2009; Schmitz et al., 2009; Cheema et al., 2008; Cinar et al., 2008; Todd et al., 2008; Beurskens et al., 2007; Ahmed et al., 2006; Hutnick et al., 2005; Lauridsen et al., 2005; Yoo et al., 2005; Courneya et al., 2003; McKenzie & Kalda, 2003; Bendz et al., 2002; Box et al., 2002; Molassiotis et al., 2002) en 11 relevante cohortstudies (Torres Lacomba et al., 2009; Oldervol et al., 2006; Gordon et al., 2005; Hutnick et al., 2005; Josenhans, 2005; Lauridsen et al., 2005; Nedstrand et al., 2005; Leidenius et al., 2003 ; Blanchard et al., 2001; Johansson & Branje, 2001; Moskovitz et al., 2001).

De SR’s van McNeely et al. (2010) en Kärki et al. (2001) en studies van Cinar et al. (2008), Hutnick et al., (2005) en Courneya et al. (2003) toonden aan dat begeleid oefenen verbetering gaf van de mobiliteit van de arm/schouder, adl, conditie, de kwaliteit-van-leven en vermindering van pijn en vermoeidheid.

In de SR’s van McNeely et al. (2010), Bicego et al. (2006) en Shamley et al. (2005), de richtlijn van Harris et al. (2001) en de RCT’s van Hayes et al. (2009) en Cinar et al. (2008) werd geconcludeerd dat starten met oefentherapie op dag 5-7 postoperatief een positief effect had op het voorkomen van seroom. Na 9-12 behandelingen waren de meeste klachten met betrekking tot mobiliteitsbeperkingen verholpen en waren patiënten in staat hun adl te hervatten. Oefenen onder begeleiding van een fysiotherapeut gaf een significant betere schouderfunctie en een betere kwaliteit van leven dan zelfstandig oefenen.

McNeely et al. (2010) concludeerde uit sommige onderzoeken dat vroeg (1-3 dagen postoperatief) starten met oefentherapie, op de korte termijn een snellere verbetering (niet-significant) gaf van de bewegingsomvang, dan starten na 1 week. Het verschil in bewegingsomvang was na 1 maand teniet gedaan. Seroom kwam echter meer voor bij vroeg starten. In de eerste week postoperatief werden anteflexie en abductie tot 90 graden uitgevoerd. In de tweede week werd de bewegingsomvang op geleide van de pijn uitgebreid, met als uiteindelijk doel het behalen van de preoperatieve mobiliteit van de arm en de schouder. Blanchard et al. (2001) beschreven in hun cohortstudie dat vroeg starten met oefentherapie een vermindering van bewegingsangst gaf bij patiënten met hoge angstscores.

Een belangrijke bevinding uit studies van McNeely et al. (2010), Hayes et al. (2008), Schmitz et al. (2009), Cheema et al. (2008), Ahmed et al. (2006) en Bicego et al. (2006) was dat oefentherapie (waaronder ook weerstandsoefeningen) geen exacerbatie van lymfoedeem liet zien en dat oefentherapie zelfs de lymfatische afvoer stimuleerde. Box et al. (2002a, b) toonde zelfs aan dat er 2 jaar postoperatief, in de experimentele groep met als interventie oefentherapie, significant minder lymfoedeem voorkwam. Ook Torres Lacomba et al. (2010) en Todd et al. (2008) zagen minder lymfoedeem ontstaan bij patiënten die fysiotherapie in een vroege postoperatieve fase kregen, in tegenstelling tot de patiënten die alleen voorlichting kregen van de mammacareverpleegkundige.

Gordon et al. (2005) beschreven dat er aanwijzingen waren dat oefentherapie, in tegenstelling tot een psychologische interventie, bij 20-40% van de patiënten een betere armfunctie en een betere fysieke kwaliteit-van-leven gaf.
In diverse cohortstudies (Torres Lacomba et al., 2009; Josenhans et al., 2005; Lauridsen et al., 2005; Leidenius et al., 2003; Johansson et al., 2001; Moskovitz et al., 2001) werd onderzoek gedaan naar de invloed van oefentherapie op axillary web syndroom (AWS). Het bleek dat het AWS door oefentherapie eerder (na ongeveer 1 maand) verdwenen was in vergelijking met afwachten van het spontaan herstel (3-6 maanden). Het resultaat van de behandeling bij AWS werd in de meeste studies behaald met een kortdurende interventie.

Onderzoeken naar de effecten van ontspanningsoefeningen tijdens systeemtherapie door Weis & Domann (2006), Nedstrand et al. (2005), Yoo et al. (2005) en Molassiotis et al.(2002) toonden aan dat door ontspanningsoefeningen angst, misselijkheid en het aantal opvliegers verminderden. In de RCT van Headly et al. (2004) en de cohortstudie van Oldervol et al.(2006) werd geconcludeerd dat oefentherapie in de palliatieve fase significant minder fysieke achteruitgang en vermoeidheid gaf dan geen behandeling en dat het emotioneel functioneren en het algemeen welzijn door de interventie verbeterde.

 

Niveaus van bewijs

Niveau 1. Het is aangetoond dat begeleid oefenen verbetering geeft van de mobiliteit arm/schouder, de conditie, adl en kwaliteit van leven. Daarnaast geeft begeleid oefenen vermindering van pijn, bewegingsangst en vermoeidheid. (A1: McNeely et al., 2010; Kärki et al., 2001. A2 : Cinar et al., 2008; Courneya et al., 2003; Hutnick et al., 2005. B: Blanchard et al., 2001.) Het is aangetoond dat het beperkt uitvoeren van schouderbewegingen in de eerste week postoperatief minder seroom geeft. Na 9-12 behandelingen, startend 1 week postoperatief, kunnen bewegingsbeperkingen verholpen zijn en is de patiënt in staat zijn adl uit te voeren. (A1: McNeely et al., 2010; Bicego et al., 2006; Shamley et al., 2005. A2: Hayes et al., 2009; Cinar et al., 2008; Harris et al., 2001.) Het is aangetoond dat oefentherapie geen negatieve gevolgen heeft voor het ontstaan, dan wel verergeren van lymfoedeem. (A1: McNeely et al., 2010. A2: Torres Lacomba et al., 2010; Schmitz et al., 2009; Todd et al., 2008; Ahmed et al., 2006; Bicego et al., 2006.) Het is aangetoond dat ontspanningsoefeningen tijdens systeemtherapie de angst, misselijkheid en het aantal opvliegers verminderen. (A2: Weis & Domann, 2006; Nedstrand et al., 2005; Yoo et al., 2005; Molassiotis et al., 2002.)

Niveau 2. Het is aannemelijk dat het risico op het ontstaan van lymfoedeem verminderd door oefentherapie. (A2: Torres Lacomba et al., 2010; Todd et al., 2008; Box et al., 2002a, b. B: Hayes et al., 2008.) Het is aannemelijk dat door oefentherapie het AWS eerder verdwenen is dan bij afwachten van het spontaan herstel. (B: Torres Lacomba et al., 2009; Lauridsen et al., 2005 ; Leidenius et al., 2003 ; Johansson et al., 2001; Moskovitz et al., 2001. C: Josenhans, 2005.) Het is aannemelijk dat oefentherapie in de palliatieve fase minder achteruitgang van het fysiek welbevinden geeft en minder vermoeidheid dan geen oefentherapie. (A2: Headly, 2004; B: Oldervol, 2006.) 

Niveau 3. Er zijn aanwijzingen dat fysiotherapie in tegenstelling tot een psychologische interventie een betere armfunctie en fysieke kwaliteit van leven geeft. (B: Gordon et al., 2005.)

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