Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2.

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Neurochemical supplementation in patients with depressed levels of participation after brain tumor surgery: Rationale and preliminary results.

A unique challenge in some brain tumor patients is the fact that tumors arising in certain areas of the brain involve the neural structures of consciousness or alertness, limiting the patient's ability to participate in rehabilitation following surgery. A critical question is whether neurostimulant therapy can help patients participate in rehabilitation efforts. We performed a retrospective review of all patients undergoing brain tumor surgery by the senior author from 2012 to 2018. We limited this study to patients with tumors occupying critical structures related to consciousness, alertness, and motor initiation. A combination of methylphenidate and levodopa/carbidopa was used to monitor the progress of patients through neurorehabilitation efforts. We identified 101 patients who experienced an inability to participate in rehabilitation (ITPR) in the post-operative period. Of these, 86 patients (85%) were treated with methylphenidate and levodopa/carbidopa. Cases of ITPR were related to dysfunction of the brainstem (12/86 cases, 14%), thalamus (17/86 cases, 20%), hypothalamus (14/86 cases, 16%), basal ganglia (13/86 cases, 15%), and medial frontal lobe (30/86 cases, 35%). Of the 86 individuals treated, 47/86 patients (55%) showed early improvement in their ability to participate with rehabilitation. At three month follow-up, 58/86 patients (67%) had returned to living independently or were at least interactive and cooperative during follow-up examination. This feasibility report suggests that combined therapy with methylphenidate and levodopa/carbidopa may help patients participate in neurorehabilitation efforts in the immediate post-operative period following brain tumor surgery. Randomized, controlled clinical trials are needed to explore this concept more thoroughly.

Interventions for cognitive problems in adults with brain cancer: A narrative review.

INTRODUCTION: Many patients with brain cancer experience cognitive problems. In this narrative review, we comprehensively evaluated empirical studies on various intervention approaches for cognitive problems in these patients. METHODS: Intervention studies that reported effects on cognitive functioning (either objectively tested or subjectively reported) in adult patients with primary and/or secondary brain tumours were identified through online searches in PubMed (MEDLINE) and Web of Science up to 13 March 2019. RESULTS: Of the 364 identified records, 10 pharmacological (including five randomised placebo-controlled trials), 10 cognitive rehabilitation (including five [pilot] RCTs) and two multiple-group exercise studies matched the inclusion criteria. Seventeen of 22 studies had final sample sizes smaller than 40. Several cognitive rehabilitation studies and some pharmacological approaches (donepezil and memantine) showed (at least partial) benefits for cognitive problems in adults with brain cancer. The effects of other pharmacological and exercise interventions were inconclusive and/or preliminary. CONCLUSION: Overall, drawing firm conclusions is complicated due to various methodological shortcomings, including the absence of a (placebo) control group and small sample sizes. Promising effects have been reported for cognitive rehabilitation and some pharmacological approaches. Suggestions for more thorough research with respect to the various approaches are provided.

Research agenda for life-threatening cancer.

OBJECTIVES: The aim of this study was to identify future research agendas that reflect the concerns and unexplored areas of interest for patients with life-threatening cancer, their relatives and the clinical specialists during the cancer trajectory. METHODS: Six focus group discussions were conducted addressing two different cancer trajectories: primary malignant brain tumour and acute leukaemia. For each of the two cancer trajectories, separate FGIs were carried out with patients, relatives and clinical specialists to identify important concerns, challenges and uncertainties. The FGIs were video/audio-recorded, transcribed and thematically analysed within and across FGI groups to construct research topics. Finally, the literature was reviewed for existing evidence concerning the identified research topic(s) to strengthen the suggested research agendas. RESULTS: New research agendas related to high-grade glioma brain tumour and acute leukaemia with corresponding research questions were formulated within the topics of supportive care/palliation, education/information, rehabilitation, complementary and alternative therapy and organization of health care. CONCLUSION: User involvement in identifying research agendas has the potential to improve quality of care for patients and caregivers across the cancer trajectory, while minimizing the gap in research between the healthcare user and healthcare provider.

Visual perception and spatial transformation of the body in children and adolescents with brain tumor.

Representations of own and others' body play a crucial role in social interaction. While extensive knowledge has been gathered on the neuropsychological deficits affecting body representation in adult brain lesion patients, little is known on how acquired damage to a developing brain may affect this process. We tested it on pediatric brain tumor survivors, comparing the abilities of 30 children and adolescents (aged 8-16 years) surviving from a supratentorial tumor (STT) or an infratentorial tumor (ITT) in two different tasks of body representation. Thirty children with typical development (TD) served as control group. In the first task, we tested configural (body inversion effect) and holistic (composite illusion effect) processing of others' bodies. In the second task, we tested the ability to perform first-person and object-based mental spatial transformations of own body and external objects, respectively. Configural processing was spared in all patients. Conversely, ITT, but not STT patients, were impaired in the holistic processing of body stimuli. STT patients performed overall worse than both controls and ITT patients at mental spatial transformations of both own body and external objects. ITT children presented selective alteration in using the first-person transformation strategies with body stimuli. Results suggest that body-representation abilities may be heavily affected in pediatric brain tumor survivors. STTs may be associated to greater difficulties in mental visuo-spatial transformation abilities, likely reflecting damage to fronto-parietal circuits. Conversely, ITTs may be associated to specific disturbances of visual body perception abilities that require motor simulation processes, reflecting direct or indirect damage to cerebellar areas.

A novel neuromodulation technique for the rehabilitation of balance and gait: A case study.

Cranial-nerve non-invasive neuromodulation (CN-NINM) through the tongue has been proposed as an adjuvant intervention to improve efficacy of rehabilitation. However, CN-NINM effects have only been explored in multiple sclerosis and stroke populations. In this report we used CN-NINM during a 2-week (2 × 1.5 h sessions daily) physiotherapy program for the rehabilitation of a 57 y/o woman presenting with balance and gait impairments after a surgical resection of a fourth ventricular ependymoma. Clinical and instrumented balance and gait assessments showed improved performance in all tests and without adverse effects This study shows the beneficial effects and feasibility of combined physiotherapy and CN-NINM in this patient.

Challenging the Myth of Right Nondominant Hemisphere: Lessons from Corticosubcortical Stimulation Mapping in Awake Surgery and Surgical Implications.

For many years, the right hemisphere (RH) was considered as nondominant, especially in right-handers. In neurosurgical practice, this dogma resulted in the selection of awake procedure with language mapping only for lesions of the left dominant hemisphere. Conversely, surgery under general anesthesia (possibly with motor mapping) was usually proposed for right lesions. However, when objective neuropsychological assessments were performed, they frequently showed cognitive and behavioral deficits after brain surgery, even in the RH. Therefore, to preserve an optimal quality of life, especially in patients with a long survival expectancy (as in low-grade gliomas), awake surgery with cortical and axonal electrostimulation mapping has recently been proposed for resection of right tumors. Here, we review new insights gained from intraoperative stimulation into the pivotal role of the RH in movement execution and control, visual processes and spatial cognition, language and nonverbal semantic processing, executive functions (e.g., attention), and social cognition (mentalizing and emotion recognition). These original findings, which break with the myth of a nondominant RH, may have important implications in cognitive neurosciences, by improving our knowledge of the functional connectivity of the RH, as well as for the clinical management of patients with a right lesion. In brain surgery, awake mapping should be considered more systematically in the RH. Moreover, neuropsychological examination must be achieved in a more systematic manner before and after surgery within the RH, to optimize care by predicting the likelihood of functional recovery and by elaborating specific programs of rehabilitation.

Two assessments to evaluate imagery ability: translation, test-retest reliability and concurrent validity of the German KVIQ and Imaprax.

BACKGROUND: A combination of physical practice and motor imagery (MI) can improve motor function. It is essential to assess MI vividness in patients with sensorimotor impairments before implementing MI interventions. The study's aims were to translate the Canadian Kinaesthetic and Visual Imagery Questionnaire (KVIQ) and the French Imaprax, and to examine reliability and validity of the German versions. METHODS: Questionnaires were translated according to guidelines. With examiner's help patients (diagnosis: stroke: subacute/chronic, brain tumour, Multiple Sclerosis, Parkinson's disease) were tested twice within seven days (T0, T1). KVIQ-G: Patients were shown a movement by the examiner, before executing and imagining the movement. They rated vividness of the image and intensity of the sensations on a five-point Likert-scale. Imaprax required a 3-step procedure: imagination of one of six gestures; evaluation of gesture understanding, vividness, and imagery perspective. Questionnaire data were analysed overall and for each group. Reliability parameters were calculated: intraclass correlation coefficient (ICC), Cronbach's alpha, standard error of measurement, minimal detectable change. Validity parameters included Spearman's rank correlation coefficient and factor analysis of the KVIQ-G-20. RESULTS: Patients (N = 73, 28 females, age: 63 ± 13) showed the following at T0: KVIQ-G-20(vis) 41.7 ± 9, KVIQ-G-10(vis) 21.1 ± 5. ICC for KVIQ-G-20(vis) and KVIQ-G-10(vis) was 0.77; KVIQ-G-20(kin) 36.4 ± 12, KVIQ-G-10(kin) 18.3 ± 6. ICCs for KVIQ-G-20(kin) and KVIQ-G-10(kin) were 0.83/0.85; Imaprax(vis) 32.7 ± 4 and ICC 0.51. Internal consistency was estimated for KVIQ-G-20 α(vis) = 0.94/α(kin) = 0.92, KVIQ-G-10 α(vis) = 0.88/α(kin) = 0.96, Imaprax-G α(vis) = 0.70. Validity testing was performed with 19 of 73 patients, who chose an internal perspective: r(s) = 0.36 (p = 0.13). Factor analysis revealed two factors correlating with r = 0.36. Both explain 69.7% of total variance. CONCLUSIONS: KVIQ-G and Imaprax-G are reliable instruments to assess MI in patients with sensorimotor impairments confirmed by a KVIQ-G-factor analysis. KVIQ-G visual values were higher than kinaesthetic values. Patients with Multiple Sclerosis showed the lowest, subacute stroke patients the highest values. Hemiparetic patients scored lower in both KVIQ-G subscales on affected side compared to non-affected side. It is suggested to administer the Imaprax-G before the KVIQ-G to test patient's ability to distinguish between external and internal MI perspective. Duration of both questionnaires lead to an educational effect. Imaprax validity testing should be repeated.

Two case study evaluations of an arts-based social skills intervention for adolescents with childhood brain disorder.

OBJECTIVE: Arts-based programmes have been shown to be useful for individuals with disturbances in cognitive and behavioural functioning. The current case studies examined the feasibility and effectiveness of a theatre skills training programme to facilitate social skills and participation for adolescents with childhood brain disorder. METHODS: A case study approach was used with two adolescent participants. Focus groups were conducted immediately post-intervention, while a battery of quantitative measures were administered pre- and post-treatment, as well as 8 months post-treatment. RESULTS: Perceived and documented improvements in social skills and participation were observed from pre- to post-intervention and at follow-up. CONCLUSION: Results support the use of an arts-based intervention for youth with brain injuries to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for youth with childhood brain disorder, who may have impaired awareness of their abilities and/or impairments in memory and language comprehension.

Rehabilitation in neuro-oncology: a meta-analysis of published data and a mono-institutional experience.

BACKGROUND: Rehabilitation for cancer patients with central nervous system (CNS) involvement is rarely considered and data on its use are limited. The purpose of the present study is to collect all available published data on neuro-oncology rehabilitation and perform a meta-analysis where results were presented in a comparable manner. Moreover, the authors report results on cancer patients with neurological disabilities undergoing rehabilitation at their unit. STUDY DESIGN: A PubMed search was performed to identify studies regarding cancer patients with CNS involvement undergoing inpatient physical rehabilitation. Studies with a complete functional evaluation at admission and discharge were selected. As the most common evaluation scales were Functional Independence Measure (FIM) and Barthel Index (BI), only articles with complete FIM and/or BI data were selected for the meta-analysis. Moreover, 23 cancer patients suffering from diverse neurological disabilities underwent standard rehabilitation program between April 2005 and December 2007 at the San Raffaele Pisana Rehabilitation Center. Patient demographics and relevant clinical data were collected. Motricity Index, Trunk Control Test score, and BI were monitored during rehabilitation to assess patient progresses. BI results of patients in this study were included in the meta-analysis. RESULTS: The meta-analysis included results of a total of 994 patients. A statistically significant (P < .05) improvement of both BI and FIM scores was demonstrated after rehabilitation (standardized mean difference = 0.60 and 0.75, respectively). Functional status determined by either FIM or BI improved on average by 36%. CONCLUSION: Published data demonstrate that patients with brain tumors undergoing inpatient rehabilitation appear to make functional gains in line with those seen in similar patients with nonneoplastic conditions.

IgE, allergy, and risk of glioma: update from the San Francisco Bay Area Adult Glioma Study in the temozolomide era.

The consistently observed inverse relationship of allergic conditions with glioma risk and our previous demonstration that immunoglobulin E (IgE) levels also were lower in glioma patients than controls suggest that atopic allergy may be related to a mechanism that inhibits or prevents glioma. We sought to extend these results with a new and larger series of patients (n = 535 with questionnaire data; 393 with IgE measures) and controls (n = 532 with questionnaire data; 470 with IgE measures). As expected, glioma cases were less likely than controls to report history of allergies [among self-reported cases, Odds ratios (OR) = 0.59, 95% confidence interval (CI): 0.41-0.85]. IgE levels also were lower in glioma cases versus controls (OR per unit log IgE = 0.89, 95% CI (0.82-0.98). However, this inverse relationship was only apparent among cases receiving temozolomide, a treatment which became part of the "standard of care" for glioblastoma patients during the study period. Among patients receiving temozolomide, IgE levels in cases whose blood samples were obtained within 30 days of diagnosis were slightly higher than controls, whereas IgE levels in cases whose blood sample was obtained >60 days after diagnosis were significantly lower than controls (OR = 0.80; 95% CI: 0.71-0.89). Thus, although our results robustly confirm the inverse association between allergy and glioma, the results for IgE are affected by temozolomide treatments which may have influenced IgE levels. These results have implications for the study of immunologic factors in glioma as well as for immunotherapy protocols for treating glioma.

Complementary and alternative medicine use and quality of life in patients with primary brain tumors.

This study explored the use of complementary and alternative medicine (CAM) approaches and their relationship with demographic and disease characteristics and quality of life (QOL) in the primary brain tumor (PBT) population. One hundred one PBT patients were enrolled in this study. The results showed that 34% of patients reported using CAM. Forty-one percent reported using more than one type of CAM. The average cost of each CAM used per month was 69 dollars, with 20% of patients spending more than 100 dollars per month. The majority (74%) reported that their physicians were unaware of their use of CAM. Data analysis found a higher performance status to be the only factor significantly related to use of CAM therapy (P < 0.005). There was no difference in patient report of QOL between users and nonusers of CAM therapies. The high number of patients who do not report CAM use has potential implications for evaluation of symptoms and response to therapy in this population. This may be especially relevant in those patients with higher functional status participating in clinical trials.

[Use of biological vicarious biofeedback in the rehabilitation of patients with brain damage]. / Zastosowanie biologicznego zastepczego sprzezenia zwrotnego w rehabilitacji chorych z uszkodzeniami mózgu.

The mechanisms of feedback not controlled by our consciousness play an essential role in the functions of the central nervous system in the process of programming of activities, behaviour and control of these functions. In case of deviations or errors of activities the possibility of their immediate correction exists. Brain damage after trauma or caused by tumour disturbs these normal feedback mechanisms producing very varying symptom complexes. In such cases it is advantageous to introduce vicarious feedback based mainly on visual and auditory afferentation. The authors present own original methods used in the rehabilitation of such patients using vicarious feedback with elbow crutch with light and sound signalling in walk learning, and platform for attitude stability exercises. The earlier obtained results of rehabilitation by this method in a large group of patients after stroke, and preliminary observations of patients after trauma and after tumour operations justify recommendation of the method.

[Functions and tasks of the psychological rehabilitation of patients with malignant brain tumors]. / Funktionen und Aufgaben der psychischen Rehabilitation von Patienten mit maligner Hirntumorerkrankung.

Based on a holistic understanding of rehabilitation, overall objectives in rehabilitating patients with malignant brain tumour are outlined. On the background of demands to orient rehabilitational efforts more than hitherto on the specific needs of those affected, results obtained from interviewing 36 brain tumour patients are set out, regarding their anxieties as well as factors that were experienced as helpful in the process of coping with the disease. The rank of assistance in adjusting to impending death in rehabilitative work with patients who have malignant brain tumours is discussed. Also, possible reasons are outlined for patients hardly ever talking about their condition's life-threatening nature on their own initiative. A patient-centered approach is advocated for the psychoemotional support of this patient group, implications for training and further education of hospital workers are discussed briefly.

[Compensatory capabilities of the symmetrical regions of the dominant and subdominant hemispheres of the human brain]. / O kompensatornykh vozmozhnostiakh simmetrichnykh oblastei dominantnogo i subdominantnogo polusharii golovnogo mozga cheloveka

A comparison was made between the EEG characteristics and spectral power of EEG frequencies in symmetrical parts of both cerebral hemispheres in order to elucidate the involvement of these areas in compensatory processes in patients with tumours localized in one of the cerebral hemispheres, before and after the removal of the tumour. Before the operation, the presence of a focus of pathological activity causing inactivation of adjacent cortical cells, is attended with activation of cells in the symmetrical areas of the intact hemisphere. Elimination of the pathological focus results in the fluctuation of interhemispheric asymmetry; for certain time periods inactivation in the sick hemisphere is replaced by activation, while in the intact hemisphere activation changes over to inactivation. The revealed properties are termed by the authors as interhemispheric compensatory conjugation of reactions. They probably reflect the potential possibilities of different areas in the process of compensation.