Rehabilitation after brain tumor resection: A national study of postacute care service use through insurance claims data.

OBJECTIVE: To assess postacute rehabilitation service use and length of stay among a national sample of patients with brain tumors after surgery. DESIGN: A retrospective review was conducted of health care claims data of a national sample of patients via The Optum Clinformatics DataMart. SETTING AND PARTICIPANTS: This study included adult individuals (≥18 years of age) who were diagnosed with a brain tumor between 2015 and 2019 and underwent a craniotomy or craniectomy within 180 days of diagnosis. METHODS: Descriptive statistics were used to characterize patients by tumor type. Multivariate models assessed factors associated with discharge setting and length of stay. RESULTS: Of the 10,275 individuals identified, 69% had malignant tumors. Over two thirds of patients were discharged directly home (with or without home health care) and 9.3% and 9.5% were discharged to acute rehabilitation facilities (inpatient rehabilitation facilities [IRF]) and skilled nursing facilities (SNF/ICF), respectively. About 13.5% were discharged to other settings. The average length of stay during the episode of care was 8.6 (SD = 9.6) days. After adjusting for confounders, individuals with benign brain tumors were more likely to be discharged to either IRF or SNF/ICF than return home after acute care stay, as were those with greater comorbidities, older age, fee-for-service and health maintenance organization insurance. Wealthier patients were less likely to be discharged to a SNF/ICF than home, although income was not a factor affecting discharge to an IRF. Patients with benign tumors, the oldest old (80+), those with more comorbidities as well as Black and Hispanic patients had a longer length of stay during the acute hospitalization. CONCLUSIONS: Individuals with brain tumors have deficits amenable to rehabilitation; however, this study finds that service use differs by tumor type and demographic and socioeconomic factors. Further study is needed to identify if there are barriers to access and use of rehabilitation services in this population.

Feasibility of performance-based functional assessment in brain tumour survivors.

INTRODUCTION: Rehabilitation and exercise interventions are beneficial for the physical and psychological health of cancer survivors. Current clinic-based performance status measures do not accurately capture the survivor's functioning, or rehabilitation and exercise needs. Our primary objective was to explore the feasibility of performing a performance-based functional assessment with brain tumour survivors as a means to inform needs for rehabilitation and exercise. METHODS: A feasibility study was conducted with survivors of brain and other neurological cancers attending new patient or follow-up clinics. Survivors were assessed using the Short Physical Performance Battery (SPPB), grip strength and Rosow-Breslau Physical Activity Self-Assessment (RSB). RESULTS: We approached 40 survivors with brain tumours, and 30 agreed to participate in the study. The SPPB was inversely correlated with Eastern Cooperative Oncology Group (ECOG) scores (r = -.73; p < .01), but scores on the SPPB for individuals classified as ECOG 1 ranged from 5 to 12 out of 12, indicating a large variability in functional scores within this ECOG grade. CONCLUSION: Implementation of objective functional testing is feasible in the neuro-oncology outpatient clinic. The SPPB appears to best inform the functional status of survivors with brain tumours, facilitating more individualised exercise and rehabilitation referrals.

Rehabilitación de las funciones ejecutivas en un caso de oligoastrocitoma frontal derecho / Rehabilitation of executive functions in a case of right frontal oligoastrocytoma

El desarrollo tecnológico y científico en salud de los últimos años ha permitido mejoras en el diagnóstico y mayor eficacia en el tratamiento de pacientes con tumores cerebrales, generado un aumento no solo en la supervivencia, sino también una mayor demanda de los servicios de neuropsicología y rehabilitación, debido a las alteraciones cognitivas asociadas y dificultades en cuanto a la funcionalidad e independencia, disminuyendo significativamente la calidad de vida de estos pacientes. La presente investigación documenta el caso de un paciente masculino de 43 años, remitido al servicio de neuropsicología tras la resección de oligoastrocitoma frontal derecho, en la evaluación neuropsicológica se evidenció alteraciones en funciones ejecutivas, fluidez de lenguaje discursivo y dificultad en habilidades instrumentales. La investigación se realizó bajo el diseño cuasi experimental de caso único, donde se aplicó en repetidas ocasiones a lo largo del tratamiento el Inventario de Adaptabilidad Mayo-Portland (MPAI-4) para determinar las dificultades funcionales del paciente. El objetivo de la rehabilitación neuropsicológica se centró en implementar estrategias de autoinstrucciones y automonitoreo, que pudieran ser aplicadas en contextos cotidianos y en intereses específicos del paciente. Los resultados indican que el proceso de rehabilitación neuropsicológica demostró tener un efecto positivo en la funcionalidad del paciente y las estrategias aprendidas pueden ser trasladadas a su vida cotidiana

The technological and scientific development on health in recent years has allowed improvements in diagnosis and treatment on brain tumor patients, have increase not only their survivor rate but also their need of neuropsychology and rehabilitation services due to cognitive alterations associated and the subsequent struggling with independence and functionality that reduces significantly their life quality. The present research documents the case of a male patient, 43 years old, referred to the service after resection of right frontal oligoastrocytoma, in the neuropsychologic evaluation evidenced executive functions, discursive language fluency alterations and difficulties in instrumental skills. The research was carried out under the quasi experimental design of a single case where there will be applied repeatedly during the course of treatment the Mayo-Portland Adaptability Inventory (MPAI-4) to identify functional difficulties on the patient. The objective of the neuropsychological rehabilitation focuses on implementing self-instruction and self-observance strategies in order to apply them on an ordinary context and the patient's specific areas of interest. The results indicate that the neuropsychological rehabilitation treatment has shown a positive effect on the patient's functionality and an improvement on his ability to apply the learned strategies to his day to day life.

Don't need help, don't want help, can't get help: How patients with brain tumors account for not using rehabilitation, psychosocial and community services.

OBJECTIVE: To understand why some adults with primary brain tumors do not use support services despite indications of a need for help. METHODS: Nineteen adults recently diagnosed with primary brain tumors participated in semi-structured interviews. Thematic analysis was used to identify recurrent ways participants explained their non-use of support services. RESULTS: Some patients indicated that they did not use support services as they did not need help, in particular reporting positive experiences relative to their expectations or to others, that their needs were met, or difficulties recognizing their needs. Some patients reported not wanting help, citing preferences to self-manage, other priorities, or negative perceptions of the services available. Many patients identified barriers to support service utilization, particularly problems recognizing that services could address their needs and that their needs were valid concerns. CONCLUSION: The gap between patients' needs and their service use may result from patients' expectations from the medical system, shifting of standards for well-being, cognitive changes, and access issues. PRACTICE IMPLICATIONS: Addressing knowledge barriers and perceptions relating to help-seeking, as well as recognizing the challenges specific to this patient group in terms of need recognition and access issues, may assist in improving patients' physical, psychological and social well-being.

Evaluation of the Cost of Comprehensive Outpatient Therapies in Patients with Malignant Brain Tumors.

OBJECTIVE: The aim of this study was to compare the cost of comprehensive outpatient therapy (day rehabilitation) in individuals with malignant brain tumors to those with stroke and traumatic brain injury. DESIGN: This was a prospective, nonrandomized, longitudinal study of 49 consecutive adults with malignant brain tumors enrolled in the 6 day rehabilitation sites of 1 institution over 35 months. The control group was composed of 50 patients with brain injury and 50 patients with stroke, who were also enrolled in the day rehabilitation program during the same period. A comparison was made of the total Medicare cost and the cost per day of day rehabilitation in patients with malignant brain tumors compared with the control group. RESULTS: The patients with malignant brain tumors had lower total cost and cost per day than did the combined traumatic brain injury and stroke group during day rehabilitation (F2,143 = 3.056 [P = 0.05] and F2,142 = 5.046 [P = 0.008], respectively). CONCLUSIONS: The cost of comprehensive outpatient rehabilitation in patients with malignant brain tumors is less expensive than that of patients with traumatic brain injury or stroke, which are neurological diagnoses commonly seen in day rehabilitation. This study shows that cost should not be a barrier to providing outpatient therapies to this patient population.

Prognostic value of health-related quality of life for death risk stratification in patients with unresectable glioblastoma.

Glioblastoma is the most common malignant brain tumor in adults. Baseline health-related quality of life (HRQoL) is a major subject of concern for these patients. We aimed to assess the independent prognostic value of HRQoL in unresectable glioblastoma (UGB) patients for death risk stratification. One hundred and thirty-four patients with UGB were enrolled from the TEMAVIR trial. HRQoL was evaluated at baseline using the EORTC QLQ-C30 and BN20 brain cancer module. Clinical and HRQoL parameters were evaluated in univariable and multivariable Cox analysis as prognostic factors for overall survival (OS). Performance assessment and internal validation of the final model were evaluated with Harrel's C-index, calibration plot, and bootstrap sample procedure. Two OS independent predictors were identified: future uncertainty and sensitivity deficit. The final model exhibited good calibration and acceptable discrimination (C statistic = 0.63). The internal validity of the model was verified with robust uncertainties around the hazard ratio. The prognostic score identified three groups of patients with distinctly different risk profiles with median OS estimated at 16.2, 9.2, and 4.5 months. We demonstrated the additional prognostic value of HRQoL in UGB for death risk stratification and provided a score that may help to guide clinical management and stratification in future clinical trials.

Primary brain tumor patients' supportive care needs and multidisciplinary rehabilitation, community and psychosocial support services: awareness, referral and utilization.

Primary brain tumors are associated with significant physical, cognitive and psychosocial changes. Although treatment guidelines recommend offering multidisciplinary rehabilitation and support services to address patients' residual deficits, the extent to which patients access such services is unclear. This study aimed to assess patients' supportive care needs early after diagnosis, and quantify service awareness, referral and utilization. A population-based sample of 40 adults recently diagnosed with primary brain tumors was recruited through the Queensland Cancer Registry, representing 18.9 % of the eligible population of 203 patients. Patients or carer proxies completed surveys of supportive care needs at baseline (approximately 3 months after diagnosis) and 3 months later. Descriptive statistics summarized needs and service utilization, and linear regression identified predictors of service use. Unmet supportive care needs were highest at baseline for all domains, and highest for the physical and psychological needs domains at each time point. At follow-up, participants reported awareness of, referral to, and use of 32 informational, support, health professional or practical services. All or almost all participants were aware of at least one informational (100 %), health professional (100 %), support (97 %) or practical service (94 %). Participants were most commonly aware of speech therapists (97 %), physiotherapists (94 %) and diagnostic information from the internet (88 %). Clinician referrals were most commonly made to physiotherapists (53 %), speech therapists (50 %) and diagnostic information booklets (44 %), and accordingly, participants most commonly used physiotherapists (56 %), diagnostic information booklets (47 %), diagnostic information from the internet (47 %), and speech therapists (43 %). Comparatively low referral to and use of psychosocial services may limit patients' abilities to cope with their condition and the changes they experience.

Daily Life Experiences of Patients With a High-Grade Glioma and Their Caregivers: A Longitudinal Exploration of Rehabilitation and Supportive Care Needs.

BACKGROUND: There is a lack of knowledge regarding the breadth of needs for rehabilitation and supportive care across the disease and treatment trajectory for patients with a high-grade glioma (HGG) and their caregivers. OBJECTIVE: The aim of this study was to elucidate the experiences and needs for rehabilitation and supportive care in patients with HGG and their caregivers. METHODS: Patients with malignant glioma (N = 30) and their caregivers (N = 33) were interviewed five times during the first year of the HGG trajectory. A thematic analysis of interviews at five time points revealed five main themes describing the experiences related to the illness trajectory and needs for rehabilitation and supportive care. RESULTS: The five main themes identified were (a) individual strategy for acquiring prognostic information, (b) shared hope, (c) engagement in health promotion activities, (d) adjustment to symptom limitations, and (e) role transition from family member to caregiver. CONCLUSION: The individual and sometimes opposing preferences among patients and their caregivers for prognostic information is a chosen strategy that supports individual needs in managing the HGG trajectory. Patients and caregivers experience a feeling of solidarity, from which shared hope arises; however, this hope needs to be supported by healthcare professionals. Driven by hope, they seek to optimize the therapeutic effect of the oncological treatments by being engaged together in health promoting activities. As symptoms progressed, the need for information and guidance regarding symptoms and supportive care interventions became evident. Caregivers play a significant supporting role for the patients and need special support themselves and practical assistance especially when symptoms progress. Finally, there is a need for rehabilitation programs that target the cognitive ability of the patients to participate actively.

Comparative assessment of neuro-cognitive impairments among patients with brain tumor and healthy adults.

AIM: Most brain tumor patients encounter cognitive impairments. Coping with such challenges is intolerable for them. OBJECTIVE: This study tries to determine the diagnostic role of cognitive tests, CPT, Stroop and TOL, in assessing neuro-cognitive impairments among patients with brain tumor and healthy participants. MATERIAL AND METHODS: A cross-sectional study was done on a sample of 15 to 65 years old of 84 brain tumor patients and 84 healthy Iranians. Participants of both groups were physically and mentally examined and approved by neurosurgeons, neurologists and psychiatrists. By completing the questionnaires, they all entered the study and were referred to the neuroscientist for performing the tests. RESULTS: According to CPT, Stroop and TOL tests, the performance of both groups was significantly regarding about age, sex and education variables (P < 0.05). CONCLUSION: Brain tumor patients in comparison to healthy participants met more cognitive changes on sustained, selective attention and planning. Therefore, diagnosis and assessment of these cognitive changes before and after the surgery can help rehabilitating patients' brains and improve their lives quality.

Fatigue assessment and rehabilitation outcomes in patients with brain tumors.

OBJECTIVES: This study seeks to investigate the fatigue severity and the relationship among fatigue and other associated factors in patients with brain tumors, and to evaluate the rehabilitation outcome on fatigue. DESIGN: We assessed 25 patients in whom brain tumors had been resected and transferred to the rehabilitation department of our hospital. Patients were evaluated for fatigue severity using the Piper Fatigue Scale (PFS) and the Brief Fatigue Inventory (BFI), for mood using the Beck Depression Inventory, for motor function using the Motricity Index (MI), for functional status using the Karnofsky Performance Status (KPS) scale and the Modified Barthel Index (MBI), and for quality-of-life using the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30). We also measured the levels of serum hemoglobin, C-reactive protein, albumin, and creatine kinase; and anthropometric variables before and 4 weeks after rehabilitation. RESULTS: Of the 25 patients, 21 (84.0%) reported fatigue during the previous week. The average PFS score was 4.6 ± 1.8 and the average BFI score 5.2 ± 2.2, indicating the moderate level of fatigue. Patients with recurrent tumors had significantly higher PFS scores than did those with initial tumors. Fatigue correlated significantly with the KPS, MBI, and EORTC QLQ-C30 physical functioning and insomnia scales. In addition, insomnia was a significant predictor of fatigue before rehabilitation, and the baseline fatigue scales, MBI, MI, and EORTC QLQ-C30 physical functioning scale were the important independent predictors of fatigue after rehabilitation. During rehabilitation, the KPS, MBI, and MI scores improved significantly, whereas total PFS and BFI scores did not change. CONCLUSIONS: These findings suggest that patients with brain tumors commonly complain of moderate level of fatigue, which may reduce daily functioning and quality of life, with sleep disturbance being a significant predictor of fatigue. During rehabilitation, functional outcomes and motor power showed improvements in those patients, not aggravating fatigue.

Exploring access to rehabilitation services from allied health professionals for patients with primary high-grade brain tumours.

Primary brain tumours account for less than 2% of cancer diagnoses in the UK but more people under 40 die from a brain tumour than from any other cancer. Despite developments in some treatment options, survival remains poor and patients suffer with considerable functional and cognitive deficits. Rehabilitation for patients with primary brain tumours produces statistically and clinically significant improvements in function. When compared, similar functional gains are made following rehabilitation for brain tumour patients and for those following stroke and traumatic brain injury. There have been very few studies looking at access to rehabilitation for this group of patients as a primary objective. However, existing studies and clinical experience suggest that patients with brain tumours do not access rehabilitation services frequently or easily, either locally or nationally. Therefore, this qualitative study addressed the reasons for this through semi-structured interviews of healthcare professionals, investigating their experiences of rehabilitation for this patient group and describing commonly identified barriers under key themes. The interviews gauged the views of eight healthcare professionals representing three professions in different settings, including hospital and community based. The resultant barriers fell under the following themes: professional knowledge and behaviours; services and systems; and the disease and its effects. Suggested solutions were wide ranging and included education, multidisciplinary meetings and specialist clinicians to co-ordinate care. The barriers to accessing rehabilitation for this group of patients are complex, but some of the solutions could be reached through education and co-ordination of services. Further research into the benefits of, and access to, rehabilitation for this group of patients is essential to ensure that patients with brain tumours are given opportunity to gain from the benefits of rehabilitation in the same way as other diagnoses, both cancer and non-cancer.

Quality of life following surgery for intracranial meningiomas at Brigham and Women's Hospital: a study of 164 patients using a modification of the functional assessment of cancer therapy-brain questionnaire.

The objective of this study was to determine the subjectively reported quality of life (QOL) of patients with meningiomas surgically treated. Demographic, medical and outcomes data on 164 patients were retrospectively analyzed with the use of the Brain Tumor Center database at the Brigham and Women's Hospital, Boston, MA. The patients were contacted via a telephone survey and were asked 26 standardized QOL questions based on a modification of the validated Functional Assessment of Cancer Therapy-Brain (FACT-BR) Study, which used only questions adjuvant to brain tumor patients. The patients' ages ranged from 23 to 87 years. The mean follow-up time after intracranial surgery was 33 months and median follow-up time was 28 months, with a range of 0 to 165 months. Of those 164 patients still living, 95% (155) participated in the telephone survey. 80% reported being satisfied with their post-treatment quality of life; 86% reported that they could write, read, drive and return to work at their pre-morbid level of functioning; 87% described themselves as 'independent' and able to act on their own initiatives. Our study found a high level of satisfaction for QOL in patients who have undergone surgery for intracranial meningiomas. Patients, by their own report, are able to lead independent, personally satisfying, meaningful and productive lives. This provides useful information to share with patients in discussions regarding surgical treatment of these lesions.

Neuropsychological assessment of an 8-year-old child following excision of a right temporal lobe oligodendroglioma.

A case of right temporal lobe oligodendroglioma in an 8-year-old female is reported. This case is unusual, because of the rarity of this type of tumour in children, because it was accompanied by seizure activity which is atypical, and because it highlights the difficulties in diagnosis. Prior to diagnosis, the background had included normal early development, followed by gradual development of partial complex seizures with poor response to medication in the absence of clear findings on EEG or CT. Considered to have been present prior to 1 year of age, the tumour was purported to be the aetiological base for seizure activity, which ceased after surgical excision. Post-surgical difficulties with academic progress and behaviour resulted in referral for neuropsychological evaluation, which revealed lowered overall cognitive functioning with deficits in processing speed, abstract verbal reasoning, concept formation, visual perception, visual reasoning, scanning, attention, memory, academic attainment and learning, and clerical motor speed. Behavioural functioning revealed impairment in social skills, irritability, impulsivity, and mood changes. The relative contributions of medication (adverse reaction and toxicity), long term seizure activity, early age of onset, and presence/excision of tumour are difficult to ascertain specifically. Findings appear consistent with those of right temporal lobe brain injury.

Verbally administered Barthel Index as functional assessment in brain tumour patients.

OBJECTIVE: To investigate verbally administered Barthel Index as a measure of functional status in patients with high grade gliomas. BACKGROUND: Barthel Index (BI) is a performance score of activities of daily living which has been validated in patients with neurological disability. While any assessment of quality of life in brain tumour patients should include all the aspects of CNS function we concentrated on measurement of physical performance status and evaluated the role of BI as a measure of palliative effect of treatment in patients with high grade glioma undergoing radiotherapy. METHODS: BI was verbally administered on 504 occasions in 107 patients with high grade glioma. The BI scores were correlated with Karnofsky performance score (KPS), and neurological performance score (NPS) as a measure of inter-index reliability. The BI's prognostic value was assessed using actuarial survival data. RESULTS: BI was sensitive to change and reflected the degree of functional impairment. In patients with high grade glioma BI correlated with KPS, and NPS (R2 = 0.872 and 0.658 respectively). BI score was also of prognostic value in terms of survival. The median survival of patients with functional independence was 9 months with moderate disability 5 months and with severe disability 4 months. CONCLUSION: Verbally administered Barthel Index is easy to use, reliable and sensitive to change and is of prognostic value. It is a useful tool in the management of patients with gliomas, as an objective evaluation of palliative effectiveness of treatment in patients with functional disability.