Recovery in glioblastoma multiforme during inpatient rehabilitation is equivalent in first versus repeat resection: A 10-year retrospective analysis.

BACKGROUND: Inpatient rehabilitation improves function in people with brain tumors, including glioblastoma multiforme (GBM) but there are limited data on the impact of multiple resections on outcomes. We hypothesize that outcomes will be more favorable for those patients with a single resection when compared to those with more than one resection. OBJECTIVE: To examine functional outcomes in inpatient rehabilitation for people with GBM who underwent one or more resections prior to admission. DESIGN: Retrospective analysis. SETTING: Inpatient rehabilitation unit within a large, urban, academic medical center. PARTICIPANTS: Patients who were admitted to our institution for the treatment of initial GBM or GBM recurrence necessitating surgical resection or repeat resection. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Total FIM Change, Total Functional Independence Measure (FIM) Efficiency, Motor and Cognitive FIM efficiency, and proportion discharged home. RESULTS: From 2006 to 2016, 94 persons with GBM were admitted. Eight were readmissions classified as "repeat" and another seven transferred to the medical floor and excluded. Of the 79 patients included, 56 were first and 23 second resections, with a group mean age of 62.7 + 12.2 years and were 51% male. On analysis of covariance, change in FIM score from admission to discharge was insignificant between groups, adjusted for age and acute care length of stay (17.1 vs. 17.4, F[1, 75] = 0.027, P = .871). Likewise, the proportion of home discharge was not significant between groups (chi-square, 75.0% vs. 78.3%, P = .758). CONCLUSIONS: Patients who have undergone second resections for GBM are reasonable candidates for admission to the inpatient rehabilitation units despite carrying a poor prognosis and having multiple exposures to surgical morbidity. Factors to take into account are that candidates considered for a second resection may be relatively younger or healthier and therefore may perform better from a functional standpoint. In addition, postoperative steroid administration may play a role in the similarities the authors noted. A larger, multicenter study should validate our findings (limited by sample size and a single location) and identify factors predicting a successful outcome.

Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial.

BACKGROUND: Long-term loss of arm function after ischaemic stroke is common and might be improved by vagus nerve stimulation paired with rehabilitation. We aimed to determine whether this strategy is a safe and effective treatment for improving arm function after stroke. METHODS: In this pivotal, randomised, triple-blind, sham-controlled trial, done in 19 stroke rehabilitation services in the UK and the USA, participants with moderate-to-severe arm weakness, at least 9 months after ischaemic stroke, were randomly assigned (1:1) to either rehabilitation paired with active vagus nerve stimulation (VNS group) or rehabilitation paired with sham stimulation (control group). Randomisation was done by ResearchPoint Global (Austin, TX, USA) using SAS PROC PLAN (SAS Institute Software, Cary, NC, USA), with stratification by region (USA vs UK), age (≤30 years vs >30 years), and baseline Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score (20-35 vs 36-50). Participants, outcomes assessors, and treating therapists were masked to group assignment. All participants were implanted with a vagus nerve stimulation device. The VNS group received 0·8 mA, 100 µs, 30 Hz stimulation pulses, lasting 0·5 s. The control group received 0 mA pulses. Participants received 6 weeks of in-clinic therapy (three times per week; total of 18 sessions) followed by a home exercise programme. The primary outcome was the change in impairment measured by the FMA-UE score on the first day after completion of in-clinic therapy. FMA-UE response rates were also assessed at 90 days after in-clinic therapy (secondary endpoint). All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT03131960. FINDINGS: Between Oct 2, 2017, and Sept 12, 2019, 108 participants were randomly assigned to treatment (53 to the VNS group and 55 to the control group). 106 completed the study (one patient for each group did not complete the study). On the first day after completion of in-clinic therapy, the mean FMA-UE score increased by 5·0 points (SD 4·4) in the VNS group and by 2·4 points (3·8) in the control group (between group difference 2·6, 95% CI 1·0-4·2, p=0·0014). 90 days after in-clinic therapy, a clinically meaningful response on the FMA-UE score was achieved in 23 (47%) of 53 patients in the VNS group versus 13 (24%) of 55 patients in the control group (between group difference 24%, 6-41; p=0·0098). There was one serious adverse event related to surgery (vocal cord paresis) in the control group. INTERPRETATION: Vagus nerve stimulation paired with rehabilitation is a novel potential treatment option for people with long-term moderate-to-severe arm impairment after ischaemic stroke. FUNDING: MicroTransponder.