Fagpressenytt

Vi vil her presentere det nye pasientforløpet «Prehabilitering av pasienter med colorectal cancer (CRC)» med hovedfokus på fysioterapioppfølgingen og gi et innblikk i hvordan prehabiliteringen gjennomføres, samt dele våre tanker og erfaringer.

Bakgrunn
Colorectal cancer (CRC) er den nest vanligste krefttypen i verden, og Norge er ett av landene med høyets forekomst (1, 2). I 2020 fikk 4494 nordmenn diagnosen og 268 av disse ble operert på Ahus (1). Eneste kurative behandlingen for denne krefttypen er kirurgisk fjerning av svulsten (3). Det oppstår komplikasjoner hos opptil 1/3 av pasientene (4). De vanligste komplikasjonene ved magekirurgi er anastomoselekkasje, sårruptur, ileus, lungebetennelse, blodpropp, urinveisinfeksjon og brokk (5). Det er vist at frekvens og alvorlighetsgrad av komplikasjoner er relatert til preoperativ funksjonell kapasitet, ernæringsstatus, røyking og mentalt velvære (6).
Selv uten komplikasjoner medfører store kirurgiske inngrep 20 til 40 % reduksjon i postoperativ fysisk funksjon og funksjonell kapasitet (7). De fleste pasienter er ikke tilbake på preoperativ funksjonell kapasitet selv åtte uker postoperativt (6). Funksjonell kapasitet defineres som en persons mulighet til å utføre aktiviteter i dagliglivet [[{"text":"dividuelle timer hos KEF og fysioterapeut, med LMS-kurs påfølgende mandag som vist i tabell 1. Pasienter som skal ha eller med stor sannsynlighet får stomi, tilbys individuell konsultasjon med stomisykepleier.nnKlinisk ernæringsfysiolog (KEF)nKEF gjør en ernæringskartlegging bestående av kostanamnese, eventuelle fordøyelsesplager og gjennomgang av blodprøver. Det blir gjennomført en antropometri for å se på kroppssammensetning ved hjelp av bioimpedansmåler (Seca mBCA 515), vekt, høyde, kroppsmasseindeks og vektutvikling. Det blir gitt individuelle kostråd og KEF følger opp pasienten på sengepost postoperativt etter behov.nnFysioterapinI den individuelle fysioterapikonsultasjonen informeres pasientene om hvorfor og hvordan de bør være fysisk aktiv og trene i den preoperative perioden, basert på Helsedirektoratet sine anbefalinger om fysisk aktivitet. Trening under neoadjuvant behandling gjennomgås for de det er aktuelt for. Pasientenes funksjons- og aktivitetsnivå kartlegges gjennom observasjon, anamnese og to fysiske tester. Testene som benyttes er 30 sekunder sit-to-stand (STS) og 30 sekunder Arm curl test fra Senior Fitness Test (15). Pasientene får individuelle råd om hjemmetrening. Trening av utholdenhet kan gjennomføres som kontinuerlig- og/ eller intervallarbeid. I tillegg gjennomgås et styrketreningsprogram for store muskelgrupper med ekstra fokus på mage- og ryggmuskulatur. Programmet finnes på tre nivåer og består av øvelser som kan gjøres hjemme uten behov for ekstra utstyr. Det deles ut en postoperativ informasjonsbrosjyre om aktivitet under innleggelsen, øvelser, restriksjoner etter operasjon samt tips om hjelp til opptrening etter utskrivelse.nPasientene oppfordres til å delta på trening i gruppe på Ahus, veiledet av fysioterapeut, med varighet på en time to ganger per uke frem til operasjonen. Treningen tilpasses individuelt med cirka 30 minutter utholdenhetstrening og 30 minutter styrketrening. Utholdenhetstreningen gjennomføres enten som kontinuerlig arbeid eller intervaller på 1-4 minutter på ergometersykkel eller tredemølle, med pauser på 1-3 minutter. Motstand på ergometersykkelen, helning og tempo på mølla, «Borg skår» samt lengden på intervallene og pauser registreres for å dokumentere progresjon. Det er anbefalt å ligge på Borg skår mellom 1517 på slutten av intervallene (3). Styrketreningen består av ulike øvelser for store muskelgrupper med spesielt fokus på mage- og ryggmusklene. Repetisjoner og antall sett tilpasses individuelt, men en etterstreber 10-15 repetisjoner i to serier (16). På Ahus foregår prehabiliteringstreningen på Pusterommet, som er et treningssenter for kreftpasienter før, under og etter kreftbehandling. De som ikke har anledning til å delta i prehabiliteringsgruppen får mulighet til å delta på egentrening eller andre gruppetimer i regi av Pusterommet. Etter endt postoperativ restriksjonsperiode kan alle ta kontakt for hjelp med opptrening av magemuskulaturen eller generell trening i regi av Pusterommet.nnLærings- og mestringskurs 1nLMS-kurset avholdes første mandagen etter diagnosetidspunkt (se tabell 1), og varer i 2,5 time. Forløpskoordinatorene er ansvarlig for kurset, men alle profesjonene holder innlegg. Forløpskoordinatorene forteller om normale følelser og reaksjoner på en kreftdiagnose, krise/mestring, «hva er viktig for deg», familie/nettverk, barn som pårørende og en oppmerksomhetsøvelse med fokus på pust. Stomisykepleier snakker om det å leve med stomi samt gir en kort innføring i stomistell. KEF informerer om kostråd før og etter operasjonen. Fysioterapeuten repeterer og gjennomgår hvorfor og hvordan en skal trene i perioden frem til operasjon, trening under stråling -og cellegiftbehandling, aktivitet og mobilisering under innleggelsen, restriksjoner for å forebygge brokk og tiltak for å unngå lungekomplikasjoner. Avslutningsvis informeres det kort om trening etter utskrivelse. I tillegg legges det til rette for utveksling av tanker- og erfaringer.nnOppfølging av fysioterapeut på sengepostnDet tilstrebes at fysioterapeuten som hadde den individuelle konsultasjonen med pasienten preoperativt tilser pasienten på sengepost første postoperative dag. Behovet for oppfølging vurderes fortløpende. Pasienten skal i utgangspunktet være tilstrekkelig informert preoperativt til selv å starte mobilisering, uavhengig av når fysioterapeuten kommer. På sengepost er det utarbeidet en dagbok der det blant annet angis anbefalt tid ute av sengen og gjennomføring av respirasjonsøvelser. Ved utreise repeteres restriksjoner samt informasjon om gradvis økende aktivitetsnivå og tips om opptrening.nnLærings- og mestringskurs 2nPasientene tilbys LMS-kurs 4-6 uker postoperativt. Dette holdes en gang per måned med 10 til 15 pasienter. Alle profesjonene holder også her innlegg og temaene er ernæring, matlyst, fordøyelse, energiøkonomisering, fysisk aktivitet, trening under adjuvant behandling, opptrening av magemuskulatur, trening med stomi, kroppsbilde og seksualitet.nErfaringer og tanker om fysioterapi i prehabilitering på AhusnPakkeforløpsfristene setter en ramme for hvor lang tid vi har til å prehabilitere pasientene. Forskning har vist at det krever 3-4 uker med trening for å øke den funksjonelle kapasiteten med 5-10% (17). I praksis ser vi at det i noen tilfeller blir kortere tid til prehabilitering enn 3-4 uker, både på grunn av ventetid til undersøkelser og at noen opereres raskere enn fristen på 35 dager. For pasienter med god funksjonell kapasitet er det fint med rask operasjon, men for de resterende ville det vært gunstig å utsette operasjonen noen uker for å ha tid til å øke den preoperative funksjonelle kapasiteten. Siden prehabilitering inngår i et pakkeforløp med tidsfrister, og det fra sykehusets side er ønskelig at de fleste opereres innenfor 35 dager, vil ikke dette i praksis alltid la seg gjennomføre selv om det ville vært til det beste for pasientene.nPrehabilitering er en tids- og ressurskrevende prosess, og det er tidligere vist at det brukes for mye tid på prehabilitering av de som trenger det minst (13). I Canada ble pasientene kartlagt før inkludering. Pasienter som gikk under 400 meter på 6-minutter-gangtest (6MWT), lå under 4 på self-reported METs og over 1 på Revised Cardiac Risk Index fikk tilbud om prehabilitering. De som ikke oppfylte kriteriene ble operert innen kort tid (13). På Ahus har vi sett på testresultatene fra 6MWT fra piloten i 2019, at de færreste pasientene med CRC oppfyller de canadiske kriteriene for prehabilitering. Hos oss er derfor ikke dette inklusjonskriterier. I midlertidig ser vi at mange av pasientene ikke oppfyller Helsedirektoratets anbefalinger for fysisk aktivitet, og vi har derfor foreløpig valgt å tilby prehabiltering til alle.nI prehabiliteringsprogrammet på Ahus har vi tatt utgangspunkt i pilotprosjektet fra Nederland. Dette prosjektet hadde et testbatteri bestående av seks tester; 6MWT, Håndstyrke, STS og 1RM test, Cardio Pulmonary Exercise Test (CPET) og Stair climb test. I pilotperioden gjennomførte vi de fire førstnevnte testene i tillegg til Armcurl test. CPET og Stair climb test var av praktiske årsaker ikke mulig å gjennomføre på Ahus. Vi erfarte i 2019 at mange pasienter lå innenfor normalområdet på testene, oppnådde takeffekt, i tillegg til at testene var tids- og plasskrevende. Vi besluttet derfor å kun benytte STS og Armcurl test da resultatene fra disse testene og observasjon ved gjennomføring gir oss informasjon om pasientene. Resultatene vurderes opp mot persentilene i Senior Fitness Test. Vi får dermed et inntrykk av pasientens funksjonelle kapasitet og gjennomføringsevne ved baseline. Testresultatene ligger til grunn for individuelle treningsråd. Den registrerte 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