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2/23/2016

1

Brain Tumor Rehabilitation Across the

Continuum of Care: Adult Perspectives

Meghan Moore PT, DPT, STAR/C

Cynthia Barbe PT, DPT, MS, STAR/C

Gabrielle Steinhorn PT, DPT, NCS

Department of Physical Medicine and Rehabilitation

Johns Hopkins Hospital CSM 2016

Brain Tumor Care at

The Johns Hopkins Hospital

• The Johns Hopkins Comprehensive Brain Tumor Center is one of the largest brain tumor treatment and research centers in the world.

• Rehabilitation occurs across the continuum from the Neuro Critical Care Unit and Oncology Critical Care Unit, step down acute care floors, inpatient acute rehab, home therapy and outpatient rehabilitation.

DISCLAIMER All speakers have nothing to disclose.

All equipment described in the presentation are what is available at

our facilities, and speakers have no financial gain from discussing

them.

All photos and videos used in this presentation have been granted

consent from the patients and/or their families. Consent forms have

been signed. And are property of The Johns Hopkins Hospital for

educational purposes only.

Objectives

1. Describe the types and classification of brain

tumors most common in the adult population.

2. Explain staging and grading of adult brain

tumors.

3. Identify types of interventions for primary

brain tumors and implications these have for

successful rehabilitation.

4. Discuss strategies to implement outcome

measures for the brain tumor population across

the continuum.

Tumor Classification

Primary Brain/CNS Tumor Metastatic tumor

Arise in CNS Cancer cells begin in lung,

breast, colon, skin

Malignant or non-malignant Spread to brain via

bloodstream

Named for cells in which

they originiate

Life- threatening

Examples- Gliomas from

glial cells, astrocytoma from

astrocytes

By definition- all are

malignant

Tumor Classification

Malignant Benign (non malignant)

Usually rapid growing Slow growing

Invasive Distinct borders

Life-threatening- can spread

within brain and spine

Rarely spreads

Examples - Glioma,

astrocytoma, glioblastoma

Examples - Vestibular

schwannoma, meningioma,

pituitary adenoma

2/23/2016

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WHO Grading System

• Slow growing cells

• Almost normal in appearance under microscope

• Least malignant and usually associated with long term survival

Grade I

• Relatively slow growing cells

• Slightly abnormal appearance under a microscope

• Can invade adjacent normal tissue Grade II

• Actively reproducing abnormal cells

• Infiltrate adjacent normal brain tissue

• Tend to recur, often at a higher grade Grade III

• Abnormal cells that reproduce rapidly

• Form new blood vessels to maintain rapid growth

• Areas of dead cells in the center Grade IV

Epidemiology – Incident Rate

• Incidence rate of all primary malignant and non-malignant

brain and CNS tumors is 21.42 cases per 100,000.

– Malignant tumors 7.25 per 100,000

– Non-malignant tumors 14.17 per 100,000

• An estimated 68,480 new cases of primary brain and

CNS tumors are expected to be diagnosed in the US in

2015.

– An estimated 23,180 primary malignant diagnosed

– An estimated 45,300 non-malignant diagnosed

• From birth, an American has 0.62% chance of being

diagnosed with a primary malignant brain/CNS tumor and

a 0.46% chance of dying from a primary malignant

brain/CNS tumor.

(Ostrom, et al. 2014)

Distribution of Primary Brain and CNS Tumors

by Behavior (N = 343,175), CBTRUS Statistical

Report: NPCR and SEER, 2007–2011.

Quinn T. Ostrom et al. Neuro Oncol 2014;16:iv1-iv63

© The Centers for Disease Control. Published by Oxford University Press on behalf of the Society for Neuro-Oncology in cooperation with the

Central Brain Tumor Registry 2014.

Distribution of All Primary Brain and CNS

Tumors by Site (N = 343,175), CBTRUS

Statistical Report: NPCR and SEER, 2007–2011.

Quinn T. Ostrom et al. Neuro Oncol

2014;16:iv1-iv63

© The Centers for Disease Control. Published by Oxford University Press on behalf of the Society for Neuro-Oncology in cooperation with the

Central Brain Tumor Registry 2014.

Distribution of Malignant Primary Brain and CNS

Tumors by Site (N = 115,799), CBTRUS Statistical


Quinn T. Ostrom et al. Neuro Oncol

2014;16:iv1-iv63

© The Centers for Disease Control. Published by Oxford University Press on behalf of the Society

for Neuro-Oncology in cooperation with the Central Brain Tumor Registry 2014.

Distributions of All Primary Brain and CNS

Tumors by CBTRUS Histology Groupings and

Histology (N = 343,175), CBTRUS Statistical


Quinn T. Ostrom et al. Neuro Oncol 2014;16:iv1-iv63

© The Centers for Disease Control. Published by Oxford University Press on

behalf of the Society for Neuro-Oncology in cooperation with the Central Brain

Tumor Registry 2014.

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Epidemiology – Survival

Age of Diagnosis 5 year survival rate –

Primary Malignant

0-19 years

73.3%

20-44 years 58.5%

45-54 years 31.1%

55-64 years 17.7%

65-74 years 10.5%

75 years and older 5.9%

• 5 year survival rate

after diagnosis with a

non-malignant

tumor is 91.9% in the

US

• 5 year survival rate

after diagnosis of a

malignant tumor is

34.2% (overall)

(www.cbtrus.org/factsheet)

Causes and Risk Factors

• Environmental Factors – Exposure to ionizing radiation

• Genetic Factors – Few hereditary genetic syndromes (ex. Neurofibromatosis, Von

Hipple Lindau Syndrome)

– Genetic mutations

• Tumor suppressor genes - TP53 mutation plays a role in

causing low grade tumors develop into high grade tumors

• Growth factors – EGFR shown to be in high quantities in high

grade tumors

• Familial genetic links in gliomas

Symptoms leading to referrals

• Unrelenting headache

• Seizure

• Focal neurological deficits • Language impairment

• Unilateral weakness and/or sensory deficits

• Central vestibular signs

• Personality changes

www.webmd.com

Diagnostic Tests

• Imaging Studies

– CT scan (with and/or without contrast)

– MRI (with and/or without contrast)

– Functional MRI

– Angiography

– PET

• Laboratory Tests

– Lumbar puncture – CSF analysis

– Endocrine evaluation – for pituitary and

hypothalamic tumor

• Biopsy

PET scan

Traumaticbraininjury.net

Gliomas

• Three types of glial

cells

– Astrocytes

astrocytomas

– Oligodendrocyte

Oligodendrogliomas

– Ependymal

Ependymomas

• Primary malignant

tumors

• Grades I-IV

Illustration ©McGraw Hill

Gliomas - Astrocytomas

• Grade I- Pilocytic

Astrocytoma

• Grade II – Diffuse

Astrocytoma

• Grade III –

Anaplastic

Astrocytoma

• Grade IV –

Glioblastoma

Multiforme

Picture - http://www.nature.com/labinvest/journal/v84/n4/fig_tab/3700070f1.html

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Gliomas - Oligodendroglioma

• Grade II or Grade III

(anaplastic)

• Occur most frequently in young

and middle aged adults

• 50% of oligos occur in the

frontal lobe

• Surgery with possibility of

radiation

• Chemo may be used for grade

III

http://upload.wikimedia.org/wikipedia/commons/7/7f/Oligodendroglioma_006.jpg

Gliomas - Ependymomas

• Ependymal cells line the

ventricles of the brain and

center of the spinal cord.

• Rare – Account for 2-3% of

primary tumors, however in

children they account for

30% of primary tumors

• Typically slow growing and

often Grade I

• Surgical resection often

followed by radiation

http://www.virtualmedstudent.com/images/ependymoma_MRI_sagittal.jpg

Meningiomas

• The most common non-malignant tumor

• Accounts for 36% of all primary tumors

• Arise from the arachnoid layer of meninges

• Majority are benign, grade I, localized and non-infiltrating.

• Risk factors – prior radiation exposure to the head; neurofibromatosis type 2

• Surgical resection

• Malignant meningiomas account for < 5% of meningiomas – grade III

Vestibular Schwannomas

• Benign, slow growing

• Account for 8% of primary tumors

• Middle aged adults (30-60 years)

• Females twice as likely to have

• Surgical resection vs. stereotactic radiosurgery

• Bilateral tumors are rare and almost associated with neurofibromatosis 2

Pituitary Adenomas

• Benign and slow growing

• Represent approx. 10%

of all primary tumors

• Can cause pressure on

optic chiasm

• Secreting vs non-

secreting

• Transphenoidal approach

for surgical resection

• May need hormone

replacement

Neurofibromatosis (NF)

• Genetic disorder that causes a predisposition to tumor formation.

• NF Type 1 Systemic Disease – Derm involvement

– Visual changes

– Bony malformations

– Vascular malformations

• NF type 2 – Vestibular

schwannomas, meningiomas, peripheral schwannomas, ependymomas

MRI – NF Type 2 – Bilateral

Vestibular schwannomas

and several extra axial

masses in posterior fossa

consistent with

meningiomas.

NF Type 1 cutaneous

and subcutaneous

neurofibromas

http://www.neurology.org/content/68/13/E14/F1.expansion.html

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CNS Lymphoma

• Immunocompromised patients are at higher risk (HIV, organ transplant recipients)

• 0.5% to 2% if all primary brain tumors.

• Most often occurs in cerebral hemisphere – can involve CSF and spinal cord.

• Diagnosed via biopsy

• Symptoms – personality and behavioral changes, increased ICP, hemiparesis, seizures

• Treatment – Resection if there is significant pressure

– Steroids to control cerebral edema

– Radiation therapy and/or chemotherapy are standard

Metastatic

CNS Tumors

Treatment - Surgical

• Total Resection or

Debulking

• Complications

– Cerebral edema

– Bleeding or contusion

– Seizures

– Infection

– CSF leak

– Increased ICP

– Residual neurological deficits

Treatment - Radiation

• Primary treatment or

adjunct to surgery

• External application

– Stereotactic

radiosurgery

– Whole brain radiation

– Palliative radiation

• Side effects Image from : http://rebuild-manifest.blogspot.com/

Treatment - Chemotherapy

• Routes

– PO

– Intravenous

– Intrathecal

– Gliadel® wafers*

• Side Effects Gliadel® wafers *

Invented and developed by

Dr. Henry Brem, Neurosurgeon

at JHH

Placed intra-operatively

Accurately and directly deliver

potent chemotherapies at the

brain tumor site.

Treatment - Corticosteroids

• Indications

– Used to decrease edema around the tumor or that is caused by

treatment

– Can be used before or after tumor resection

– Can be used to reduce edema caused by radiation treatment

• Side Effects

– Impaired glucose control

– Proximal muscle wasting

– Steroid induced personality changes (mood swings)

– Weight gain (increased appetite)

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Treatment – Cancer Immunotherapies

• Broad Categories

– Cancer Vaccines- Norovirus

– Checkpoint Inhibitors

– Oncolytic Virus Therapies

– Adoptive Cell Therapy

– Adjuvant Immunotherapies

– Monoclonal Antibodies

• Most are in Phase I/II clinical trials

– clinicaltrials.gov

– cancerresearch.org

Treatment – Seizure Prophylaxis

Drug Complications

Carbamazepine (Tegretol) diplopia, dizziness, drowsiness

Valproic Acid or Depakote drowsiness, nausea, diarrhea

Gabapentin (Neurontin) dizziness, drowsiness, fatigue, slurred

speech

Levetiracetam (Keppra) sedation, dizziness, nervousness

Phenobarbital lack of concentration, sleepiness,

depression, HA

Phenytoin (Dilantin) drowsiness, dizziness, hypotension, jerky

eye movements, imbalance

Providing Therapy in the Acute Care Setting (ACS)

Presented by

Cynthia Barbe, PT, DPT, MS, STAR/C



Current Research: Acute Care Services

• Early mobility is essential to prevent the negative effects

of immobility- including pneumonia, atelectasis, and

DVT (www.aann.org)

• Exercise may modulate the BBB integrity which may

lead to protection against metastatic progression (Wolff 2015)

• Exercise may counteract the physical and psychological

impairments associated with neurologic malignancies (Cormie 2015)

Current Research: Acute Care Services

• Early mobility in the ICU assists with increased

functional outcomes and decreased ICU and hospital

LOS (Stiller 2013)

• Early PM&R interventions in the ICU are safe and

feasible in the neuro ICU (Mendez-Teller 2012)

• Rehabilitation after surgery improves functional

outcomes regardless of tumor type (Bartolo 2011)

Acute Care Services

MD Teams

• Neurology Service

• Neurosurgery Service

• Medical Oncology Service (Manage own critical beds)

• Radiation Oncology Service

• Orthopedics (When needed)

All within JHH main campus- depending on patient presentation, patients are admitted, and consults can be obtained, plan of care put into action, and transfers between services are facilitated

Multi-Disciplinary Approach • Physical Therapy

• Occupational Therapy

• Speech Language Pathology

• Physicians

• Nurses

• Social Workers

• Palliative Care Team

• Pastoral Care

• Psychiatric Nurse Liaison

• Physiatrists

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Things to consider…

Side Effects

Chemotherapy

Myelosuppression:

• Low WBCs

• Low RBCs

• Low platelets

CIPN

• Sensory and motor changes due to damage to peripheral nervous system from neurotoxic agents

• 70% of pts develop when treated with certain chemotherapy drugs- leads to increased falls

Cognitive changes

• “Chemo-brain”

Cardiotoxicity

• Changes to the functioning of the heart muscle

• Edema in hands and/or feet, SOB, dizziness, erratic heartbeats

Side effects

• Fatigue

• N/V

• Weakness

• Lethargy

• Anemia

• Falls

• Weakness

• Balance deficits


Side Effects

Radiation • Most begin during the second or third week of treatment; however,

late effects can continue well after the final treatment

• Side effects can very depending on area radiation is given

– Fatigue

– N/V

– Weakness

– HA

– Necrosis

– Cerebral edema

www.saferadiotherapy.com


Pharmacology

Anti-convulsants

• Phenobarbital

– May reduce effects of corticosteroids

• Dilantin

– May reduce effects of corticosteroids

• Keppra

• Neurontin

• Depakote

– May decrease platelets over long term

• Tegretol


Pharmacology

Chemotherapy

• By mouth:

– Procabazine

– Vincristine- may cause CIPN

– Methotrexate

• By intravenous (IV):

– Cisplatin- may cause CIPN

– Carboplatin- may cause CIPN

– Methotrexate

• Contribute to decreased resistance to infection


Pharmacology

Types • Prednisone

• Dexamethasone (Decadron)

• Methylprednisolone (Solumedrol)

Suppression of the immune system • Used as anti-inflammatories

• Increases infection rate

• Decreases antibiotic effectiveness

Side Effects • Weight Gain

• Increases Na+, Decreases K+, and Ca++

• Proximal muscle weakness

• Mood swings- euphoria, depression

• Insomnia

• Hyperglycemia – Potentially disrupts the BBB

and result in increased cerebral edema

Corticosteroids


Pharmacology

Proton Pump Inhibitors

• Lansoprazole (Prevacid)

• Omeprazole (Prilosec)

– Increases Dilantin in the blood

• Pantoprazole (Protonix)

Side effects:

– Increase risk of c-diff

– HA

– Nausea

– Abdominal pain

H2 Blockers

• Vanitidine (Zantac)

• Famotidine (Pepcid)

Side effects

– Increases Dilantin in the blood

– Muscle pain

– Insomnia

– N/V

Sucralfate

– Decreases absorption of Dilantin

Gastric Acid Inhibitors

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Things to Consider…

Hemodynamics

Blood Pressure

• Watch with changes in position; orthostasis

• MDs targeting systolic at <160mmHg

Mean Arterial Pressure (MAP)

• May have a defined goal set by the MDs

Heart Rate (HR)

• Can be affected by dehydration

O2sat (vent settings if in critical care)

• Weaning dependent upon pt. status and MD/facility

Intracranial Pressure (ICP)

• 7-15 mmHg normal; MUST be clamped prior to position changes

Vitals


Lab Values

• Decreased WBCs- neutropenia (<1K)

– Fever, chills, sore throat, SOB, inc risk for infections

• Decreased RBCs - anemia (<8 g/dL)

– Fatigue, dizziness, headache, SOB, increase in heart/respiration

rate, decreased exercise/activity tolerance

– Hgb & Hct- may be low due to dehydration or BLEED

• Decreased Platelets- thrombocytopenia (<20K)

– Easy bruising, gum and nose bleeds, petechiae, affected by

fevers


Lab Values

Glucose

– Hyperglycemia

• Result of steroid

therapy

• Supplemental feeding

Potassium • Increased-

Arrhythmias

Sodium

– SIADH- Syndrome of

Inappropriate Anti-

Diuretic Hormone

• Hyponatremia due to

excess of water

• Inappropriate

continued secretion

or action of hormone

• Confusion, delirium,

ataxia, seizures,

coma


Environment & Equipment

Ventilator

External

Ventricular

Device

Monitor


Lines/Tubes/Drains


Clinical Picture

Pain

Edema

Guarding

Tone

Spasticity

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ACS Objective Measures

• AMPAC- “6-Clicks”

• Cancer Related Fatigue Scale (CRF)

• Functional Assessment of CA Therapy Fatigue (FACT-F)

• Brief Fatigue Inventory (BFI)

• Piper Fatigue Scale (PFS)

• Timed up and Go (TUG)

• Gait Speed

• Berg Balance Scale (BERG)

• Dynamic Gait Index (DGI)

• Tinetti-POMA (Tinetti)

• Semmes Weinstein

Monofilaments

• JFK Coma Scale

Physical Therapy

Inpatient AM PAC Short Form:

Mobility

How much difficulty does the patient currently have:

4- Unable; 3- A lot; 2- A little; 1- None

1. Turning over in bed (adjusting bed clothes, sheets, and blankets); 2- A Lot

2. Sitting down on and standing up from a chair with arms; 1- Unable

3. Moving from lying on back to sitting on the side of the bed; 2- A Lot

How much help from another person does the patient currently need:

4- Total; 3- A lot; 2- A little; 1- None

4. Moving to and from a bed to a chair (including a wheelchair); 2- A Lot

5. Need to walk in hospital room; 1- Total

6. Climbing 3-5 steps with a railing; 1- Total

Raw Score: 9 /24

Percentage of Disability: 81.38%

CMS Severity Modifier: CM

Cancer Related

Fatigue Screening • Do you have significant fatigue? YES

• Do you have diminished energy? YES

• Do you have an increased need to rest, disproportionate to any

recent change in activity level? YES

Visual Analog Scales

• Fatigue Severity ( 0= No fatigue 10= Unbearable )

• A. Rate how severe your fatigue is right now: 4

• B. Rate how severe your fatigue is on your worst day: 10

• C. Rate how severe your fatigue is on average: 7


Occupational Therapy

• AMPAC- “6-Clicks”

• Cancer related Fatigue Scale

(CRF)

• Montreal Cognitive

Assessment (MoCA)

• Mini Mental State Exam

(MMSE)

• Medication Management

• JFK Coma Scale

Speech Language

Pathology

• Normative Outcome

Measurement System-

NOMS

• Repeatable Battery for the

Assessment of

Neuropsychological Status-

RBANS

• Video Fluoroscopic Swallow

Studies

Inpatient AM PAC Short Form:

Activity

How much help from another person does the patient currently need:

4- Total; 3- A lot; 2- A little; 1- None

1. Putting on and taking off regular lower body clothing; 2- A Lot

2. Bathing (including washing, rinsing, drying); 3- A Little

3. Toileting, which includes using toilet, bedpan, or urinal; 2- A Lot

4. Putting on and taking off regular upper body clothing; 3- A Little

5. Taking care of personal grooming such as brushing teeth; 3- A Little

6. Eating meals; 3- A Little

Raw Score: 16 /24

Percentage of Disability: 53.32%

CMS Severity Modifier: CK

The Montreal Cognitive Assessment

(MoCA)

• A rapid screening tool for mild cognitive dysfunction.

Visuospatial/Executive: Patient scored 3/5 on visuospatial/executive

subtest.

• Naming: Patient scored 3/3 on naming subtest.

• Memory: Patient correctly recalled 2/5 words on first trial.

• Memory: Patient correctly recalled 3/5 words on second trial.

Attention

• List of digits: Patient correctly stated 1/2 digit sequences (forwards &

backwards).

• List of Letters: Patient had less than 2 errors with letter tapping

sequence.

• Serial 7 Subtraction: Patient with 1 correct serial 7 subtractions,

starting from 100.

2/23/2016

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The Montreal Cognitive Assessment

(MoCA)

Language:

• Sentence Repeat: Patient scored 2/2 on repeating sentences

subtest.

• Fluency: Patient recited less than 11 words starting with the letter

"F" in 1 minute.

• Abstraction: Patient scored 1/2 with word similarity.

• Delayed Recall: Patient recalled 2/5 words with no cues. Pt able to

recall 1 word without cues and 1 word with multiple choice cues

• Orientation: Patient scored 5/6 on orientation.

MoCA Total Score = 19 /30

Comments: Normal is greater than or equal to 26/30.

NOMS- 7 point system that describes

changes in patients’ functional

communication and/or swallowing

Alaryngeal

Communication

Attention

Augmentative-Alternative

Communication

Fluency

Memory

Motor Speech

Pragmatics

Problem Solving

Reading

Spoken Language

Comprehension

Spoken Language

Expression

Swallowing

Voice

Voice following

Tracheostomy

Writing




• Spoken Language Expression Level 5- Patient

initiates structured conversations with familiar and

unfamiliar partners. Requires minimal cueing to frame

more complex sentences. Patient will occasionally

self-cues when encountering difficulty.

• Spoken Language Comprehension Level 3- The

patient usually responds accurately to simple yes/ no

questions and is able to follow simple directions out

of context, with moderate cueing. Accurate

comprehension of more complex directions/

messages is infrequent.




• Attention Level 4- Maintains attention during simple

living tasks of multiple steps and long duration within

a minimally distracting environment with consistent

minimal cueing

• Memory Level 3- Patient usually requires maximum

cues to recall or use external aides for simple routine

and personal information in structured environments.

• Swallowing Level 4- Swallowing is safe, but requires

moderate cues to use compensatory strategies, and/

or the patient has moderate diet restrictions, and/ or

still requires tube feeding and/ or oral supplements


Physicians & Palliative Care

– Palliative Performance Scale (PPS)

– Karnofsky Performance Scale (KPS)

– Eastern Cooperative Oncology Group (ECOG)

Interventions

Physical Therapy

– Strength

– Gait

– Balance

– Coordination

– Mobility

– Transfers


– ADLs

– Cognition

– Safety

Speech Language Pathology

– Language

– Articulation

– Swallowing

– Cognition

Social Work

– Discharge planning

– Community resources

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Case Presentation

Mr G.H.K. presented to the ED with 3 day h/o:

• worsening mental status

• R sided weakness

• personality changes

• labs with decreased Hct

Neuro Team consulted and admitted to NCCU;

diagnostics demonstrated worsening peritumor

vasogenic edema and midline shift/uncal

herniation

Case Presentation

PMHx:

• L sided weakness

• R frontal & parietal

enhancing lesions (concern

for high grade glioma

versus metastatic disease)

• Adrenal Mass

• HTN

• Chronic Renal Failure

• Prior MI

• DM

PSHx:

• Open, awake R craniotomy

– Pathology: anaplastic

astrocytoma

• Post-op MRI: vasogenic

edema

• Persistent L hemiparesis

2/2 tumor infiltration at

motor cortex and vasogenic

edema

• Chemo & XRT

Case Presentation

ACS medications: – Pantaprazole (Protonix) &

Omeprazole (Prilosec)-

gastric secretions

– Dexamethasone

– Keppra

– Hypertonic solution- Na+

– Dilantin

NUS consulted not a surgical

candidate transfer to ONC

service

BLOF:

– Scoot to w/c with wife

– Stand with PT or OT’s

assistance

Home:

– Functional 1st floor with ramp

– Owns w/c

Goals:

– Neuro Team: Take steps and

walk- Neuro

– Oncology Team: Transfer to

w/c with wife

Case Presentation: Imaging

9/18/15 CT 11/18/15 MRI & CT

Case Presentation: Objective

Findings

• Bed mobility: R- Mod A; L- Min A; S/L to sitting- Max A

• Transfers

• PROM: WFL L UE/LE; AROM WFL R UE/LE

• Sensation: decreased to touch L UE/LE

• MMT: L UE 0/5; L LE hip flex/knee ext/ankle PF 1+/5

• Balance: Max A sitting

• Edema: L UE- Moderate

• Decreased attention; Max VCs to focus

• Inattention: L side; Mod VCs

ICF Model

2/23/2016

12

Anaplastic Astrocytoma

with vasogenic edema &

uncal shift

Dec AROM L UE &

LE, MMT L>R,

edema, impaired

cognition- L side

inattention &

distractibility Dec balance, bed

mobility, transfers,

& locomotion

Motivated to

perform,

decreased

functional abilities

& neuro-muscular

function

Motivated to participate,

supportive family, quick

progression of disease

1 level home with

ramp to enter, family

support

ICF Model for Case Presentation

Body

Functions &

Structure

Health Condition

Participation

Activity

Environmental

Factors Personal

Factors

Equipment for lower level patients to

progress

Tilt-Bed MOVEO XP-DJO Combilizer

Letto Bike

Settings will depend on

tone, spasticity, and

strength PROM, AAROM, AROM

Progress in the bed to OOB

ICU bed itself!

Transfer boards,

resistance bands,

physioballs

Sara Plus by ArjoHuntleigh

Room prep- transfer from

EOB to W/C

Sitting with UE support and

trunk control- not leaning back

into the sling


VCs for hip and trunk

extension- tactile cues on

L pelvis and glutes

Euphoria (“tear towel”) of

corticosteroids

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13


Weight shifting L and R for

trunk/core strengthening

and awareness

Can take off the footplate

to progress to ambulation

Maxi Mover by ArjoHuntleigh

Lift System Dependent to Ambulatory

Lift sling with 4 point cross bar

Walking Jacket with 2

point crossbar

EVA Pneumatic Support Walker

(PSW)

Sit to stand

Supported standing

EVA Pneumatic Support Walker

(PSW)

Unsupported throwing and

catching PSW

Palliative & Hospice Care

Presented by




What is palliative care?

• According to World Health Organization

– “…an approach that improves the quality of life of

patients and their families facing the problem

associated with life-threatening illness, through the

prevention and relief of suffering by means of early

identification and impeccable assessment and

treatment of pain and other problems, physical,

psychosocial and spiritual”

• “The goal of palliative care is the achievement of

the best possible quality of life for patients and their

families.” (Santiago-Palma 2001)

http://www.who.int/cancer/palliative/definition/en/

http://www.who.int/cancer/palliative/definition/en/

2/23/2016

14

What is hospice care?

• “…designed to give supportive care to people in the final

phase of a terminal illness and focus on comfort and

quality of life, rather than cure. The goal is to enable

patients to be comfortable and free of pain, so that they live

each day as fully as possible. Aggressive methods of pain

control may be used.”

• “The philosophy of hospice is to provide support for the

patient's emotional, social, and spiritual needs as well as

medical symptoms as part of treating the whole person.”

http://www.medicinenet.com/scrip

t/main/art.asp?articlekey=24267

Why investigate the research?

• Early palliative care shows improved quality of life,

decreased medical cost, increased survival time (duration of

services correlate with survival time)

• Manages physical symptoms, prognostic awareness, and

psychological distress

• Inaccurate survival estimates can lead to delays in care

discussions that affect goals and timing of care

• Majority of the research regarding exercise and involvement

of therapies is in patients undergoing curative treatment

• General belief that there is not a role for therapy or exercise

in this population because they will never “get better.”

Palliative Care in Patients with

Brain Tumors

• 2006 NICE Guidelines recognize patients with BT may need a

palliative approach from the time of diagnosis (Ford 2012)

• “Different from others in the cancer patient population due to

the:

– Complexity of supportive care needs

– Trajectory of disease

– Very short life expectancy

– Presence of specific symptoms related to neurological deterioration

• Therefore need a specific palliative approach” (Pompili 2014)

• If a patient has a BT, there is a decreased likelihood of receiving

care from a palliative care specialist, while having the highest need

for better symptom control. (Catt 2008)

Current Research: Palliative

• Roberts 2014: Patients with GBMs in inpatient rehabilitation.

– Showed in 412 patients: 96.8% improved mobility; 88.4% self

care, 75.8% in communication/social based on their FIM score

– Median survival: 14.3 mons (Rehab) vs 17.9 mons (No rehab)

– Although shorter survival- functional improvements for quality of

life

• Pompili 2014: Home Palliative care in GBM

– Good palliative care at home avoids improper and expensive

hospitalizations and trains/helps families/patients facing difficult

situations

– Seizures are most common reason for rehospitalizations

decreased QOL and increased overall costs

– Family members and caregivers QoL is often neglected

recommends a global approach to care for the whole family.

Current Research: Palliative

• Faithfull 2005: Palliative care in Primary BTs

– Only 10% of pts were admitted to hospice centers; rest in the

community

– Spouse was primary caregiver in 2/3s of pts

– ½ of caregivers had difficulty with finances, and overall coping

– 50% of pts referred to SW; only 21% saw a SLP while 65% had

problems

• Ford 2012: Systematic Review of support care in primary

malignant BT

– Pts were surveyed on what would improve supportive care

• Having well-resourced specialist nurse availability

• Providing better community support for families

• Better access to PT

• More integrated services/ team clinics

• Better access to psychologists/ counselors

Palliative Care

• Indications for services

– Patients pursuing curative measures

– Patients experiencing physical or emotional pain that is not under

control

– Patients are experiencing symptoms that are not under control

– Patients require assistance understanding their condition

– Patients who need help in coordinating care; can be initiated at

any point in the disease process- even at time of diagnosis

2/23/2016

15

Hospice Care

• Indications/qualifying for services

– Not pursuing curative measures

• Care not Cure- focus on QoL & comfort

– DNR in place (not required)

– Hospice diagnosis of “debility unspecified” (ICD-10 ) leading to

“adult FTT”- Cancer Related Fatigue

– MD certification of < 6 month life expectancy

– Imminent death

– There exists a benefit for skilled services

– Patients can opt out

JHH Palliative and Hospice

Palliative

• JHH Palliative Care

Service is a consulting

service throughout the

hospital.

• May receive this service

while in house and/or

continue after we

discharge.

• Can make referral to

hospice organization

Hospice

• Referral from JHH to

Gilchrist Hospice center

(largest hospice

organization in MD)

• Provides support at home

or in acute inpatient center

(Gilchrist Center)

• Services provide support

in:

– Physical

– Social

– Spiritual

Rehabilitation Therapy

Goals of Care

• Decrease pain

• Increase sleep quality

• Stretching

• Positioning

• Deep breathing

• Pulmonary function

• Safety- pt, family,

environment

• Equipment

recommendations

• Psycho- social aspects

• Maximize strength &

endurance

• Decrease risk of falls &

increase safety

• Maximize mobilization &

functional activities

• Edema management

• Energy conservation

• Communication

strategies

• Provide Exercise

Program

Practice Patterns

• Rehabilitation: Light

– Patients can & want to improve

• Low to moderate intensity

• Lower frequency of follow up

– Therapy 1-2x/week with subsequent follow up by

family, caregivers, RNs

• Noted gradual improvement

– RISK: improvement does not mean disease is gone

– Rehabilitation & medical potential do NOT always

match

Practice Patterns

• Rehabilitation in reverse

– Moving from high to low level of functioning

– New issues & equipment recommendations

– Re-establish goals at each level

– Caregiver training with anticipated changes

– Variable frequency based on progression

40 y/o with Grade II Astrocytoma s/p falls B DF weak cane, AFO progressed to Grade III Astrocytoma RW, weak quads progressive ascending weakness sliding board, w/c, drop arm BSC mechanical lift

Practice Patterns

• Skilled maintenance – Skilled intervention without functional gain

• PT, OT, & SLP- to assist as what can be accomplished is beyond family member/caregiver to perform

• Assist with facilitation, coordination, positioning/posturing

– Quality of life

– Comfort

– Letting go

• Recognizing when patient &/or family has decided to discontinue skilled need

• As healthcare providers, want patients to improve- sometimes difficult to shift care & discharge recommendations

2/23/2016

16

C.O.M.F.O.R.T

Communication: Using clear & familiar language

Orientation: Setting realistic expectations

Mindfulness: Centering attention on the patient

Family: Including families in conversations

Ongoing: Continually communicating with the

patient/family/caregiver

Reiterative: Restating the messages repeatedly

Team: Sharing information within the interdisciplinary

team

“You matter because you are you. You matter to the last

moment of your life, and we will do all we can not only to help

you die peacefully, but also to live until you die.”

Dame Cicely Saunders

1918-2005

Subacute Rehabilitation

Presented by




What about SAR?

• Paucity of research of outcomes of BT pts who go to SAR

• In a QI for improving referrals to SAR from a Cancer

Center in 2013, 1 of 25 pts referred to SAR returned for

further treatment

• Initiative to discus pts’ POC with multi-disciplinary team-

attending, therapies, SW, RN, and Palliative Care-

regarding referrals to inpatient rehab meshing with goals of

care

• Early intervention of the Palliative Care team assisted with

dec referrals to SAR, discussing initiation of hospice care,

and thus preventing pt dissatisfaction and re-admission

back from SAR only to be placed in hospice care

Inpatient Rehabilitation

Presented by




Current Research: Inpatient

Rehabilitation

• Half of all rehabilitation hospitals do not treat more than

10 patients with BT annually (Kirshblum 2001; Boake 1993)

• Persons with BT, across tumor types, have significantly

improved function after course of inpatient rehabilitation (Kirshbum 2001)

• No RCTs to date looking at best evidence for

rehabilitation

– Ten studies addressed efficacy of multi-disciplinary

rehabilitation (Khan 2013)

• Report significant reduction in disability after period of multi-

disciplinary inpatient rehab

2/23/2016

17

Current Research:

Cochrane Review: Khan 2013

• No significant difference in functional outcomes

between different BT types. (Fu 2010)

• Compared BT verse TBI or stroke (6 studies)

– All reported BT greater gains compared to

stroke or TBI

• Four studies reported shorter length of stay (LOS)

in BT compared to TBI/stroke (Greenberg 2006; Huang 1998;

2000; 2001)

• No different in LOS in BT verse TBI in study by O’Dell 1998

• Discharge location to home/ community was

comparable or greater in BT compared to

stroke/TBI (Greenberg 2006; Huang 1998; Huang 2000; O’Dell 1998)

Bartolo 2010

Fu 2010

Geler-Kulcu 2009

Greenberg 2006

Huang 1998

Huang 2000

Huang 2001

Marciniak 2001

O’Dell 1998

Tang 2008

JHH Comprehensive Intensive Inpatient

Rehabilitation Program (CIIRP)

• Located in same hospital complex

as acute care (ACS) floors for

neurology and oncology

• Ability to transfer between ACS

and CIIRP (Marciniak 2001)

– Radiation (normally PM)

– Chemotherapy

– Acute medical changes

– Neuro-Ophthalmology

– Dialysis

– Modified Barium swallow

study

– Wound Care

If patient from far away and

undergoing treatment at CIIRP

or OP, ability for family to stay

at:

– Hackerman House: suites or

apartments; specifically for

patients with cancer who are

receiving treatment 3 or more

days consecutively.

– McEldery House: Fully

furnished town homes, or

single bedrooms with or

without private bathrooms at

discounted rates.

JHH CIIRP

– Physical Therapy

– Occupational Therapy

– Speech Language

Pathologists

– Recreational Therapist

– Pet Therapy

– Pastoral Care

– Social Worker

– Nurses

– Physiatrists

– Rehab Psychologists

– Other MD services as

consultative nature

CIIRP multi-disciplinary team members

Multi-disciplinary team use in inpatient rehabilitation supported by research from Cochrane Review by

Khan 2013, and Gabanelli 2005; however limited due to no RCTs.

JHH CIIRP: Outcome Measures

Research/ Inpatient Rehabilitation Specific

Test TBI

EDGE

Strok-

EDGE

Highly

Recommended

JHH

uses

Based on

research

Functional Independence

Measure (FIM) X X X X X

Karnofsky Performance

Status Scale (KPS) X

Disability Rating Scale

(DRS) X X

Length of Stay (LOS) X X

Discharge location X

Sitting/ standing balance X X

Functional Assessment of

Cancer Therapy- Brain

(FACT-BR)

X

AMPAC 6-Click X

JHH CIIRP: Outcome Measures Neuro Specific

*Highly Recommended

Per research recommendations for outcome measures similar to stroke and traumatic brain injury populations

Test TBI

EDGE StrokEDGE

JHH

uses

Based on

research

5x sit to stand X X

6MWT X X*

9 hole peg test X X

10meter WT X X*

Action reach arm test X

Activities Balance Confidence Scale X

Agitated Behavioral Scale X

Barthel Index X

Berg Balance scale X X* X X

Coma Recovery Scale X* X

JHH CIIRP: Outcome Measures Neuro Specific

*Highly Recommended

Per research recommendations for outcome measures similar to stroke and traumatic brain injury populations

Test TBI

EDGE

Strok-

EDGE

JHH

uses

Based on

research

Dynamic Gait Index X* X

Functional Assessment Measure X

Modified Ashworth Scale X X X

Modified Rankin scale X

Moss Attention Rating scale X*

Patient Health Questionnaire X

Quality of Life after Brain Injury X

Sf-36 X

Timed Up and Go X* X X

Trunk impairment scale X

2/23/2016

18

JHH CIIRP: Interventions

EasyStand Evolv

Evolv Glider

http://medmartonline.com/;

http://www.invacare.ca/;

http://doarpt.com/nu-step/;

www.litegait.com

NuStep Recumbent

Bike

Classic Parallel Bars

LiteGait

ArmeoSpring

Pneumatic Support Walker (PSW)

Impact of a Pneumatic Support Walker on

Functional Mobility, and Patient Safety in the

Neurological Patient Population in the Acute Care

Setting

• Study Type: Prospective case series per JHH IRB approval

• Patient population: Patients with sensory, proprioceptive, and/or

coordination deficits

• Outcome Measures: Impact of the PSW was measured using gait

distance, gait speed, 6 Click AMPAC score, 2 minute walk test (MWT)

distance, level of assistance, and length of stay.

• Per subjective reports, patients felt more support, increased

independence, and confidence due to increased mobility post-surgery.

Impact of a Pneumatic Support Walker on

Functional Mobility, and Patient Safety

Age

Gender

Diagnosis

Length of

Stay (days)

Discharge

Location

No PSW PSW No PSW PSW No PSW PSW No PSW PSW No PSW PSW No PSW PSW

Gait

Distance (ft)325 1530 10 220 68 45 200 1750 74 145 113 615

Gait Speed

(sec)1.250 1.600 0.380 0.297 0.380 0.667 0.909 2.085 0.380 0.940 0.550 0.932

Level of

AssistCGA S Min A Min A

ModA x 1;

CGAx1

Min A x

2Min A CGA Min A CGA

Assistive

DeviceNone PSW Walker PSW Walker PSW Walker PSW Walker PSW Walker PSW

2 MWT (ft) 220 230 46 133 2329 (only

60 sec)85 253 64 112 73 126

2MWT # of

rests1 0 0 0 0 1 0 0 0 0 0.2 0.0

# of falls 0 0 0 0 0 0 0 0 0 0 0 0

6 Click

AMPAC21 23 19 18 15 19 18 19 16 17 15 16

3 7 7

Rehab >90Home PT Rehab >90

CIDP Brain tumor (BT) Brain tumor (BT)

Subject 1 Subject 2 Subject 3

27 45 40

F M F

2 HomePT, 3

Rehab >90

Home PT

(denied rehab

>90)

Subject 5

40

F

CVA

7

Rehab >90

Subject 4

29

F

Brain tumor (BT)

8

Average

36

1 M, 4 F

CIDP, 3BT,

CVA

6

JHH CIIRP: Balance Interventions

NeuroCom

Balance

Master

www.optp.com

www.aptrehab.com

www.amazon.com

Bosu

Ball Standing

Foam Mat

Case Example: Meningioma

Dynamic Body weight support system video: Balance

2/23/2016

19


Dynamic Body weight support system video: Walking


Dynamic body weight support system video: Step Ups

Home Health

Presented by




Current Research: Home Health

• Study showed significant functional gains based on:

– Barthel Index

– Karnofsky Performance Status Scale (KPS)

• Improved quality of life was also noted after multi-

disciplinary rehabilitation approach in home setting

– European Organization for Research and Treatment of

Cancer (EORTC)

• General and brain tumor specific questionnaire

(EORCT QLQ-C30-BN20)

(Pace 2007)

JH Home Care Group (JHHCG) • Johns Hopkins Home Care Group (JHHCG) is a full-service home

care provider.

• Provides bridge from Acute care or inpatient rehabilitation to

Outpatient or Palliative/ Hospice

• Multi-disciplinary team available 24/7

– Registered nurses

– PT

– OT

– SLP

– Certified home health aides

– Social workers

– Nutritionist

• Staff members are chosen for their expertise in specialized areas

of clinical care and patient education.

JHHCG: Outcome Measures

Physical Therapy†

• Timed Up and Go (TUG)

• BORG Rate of Perceived

Exertion

• Tinetti-POMA

• Short Physical Performance

Battery

• 5x sit to stand (FTST)

• Home Care AMPAC

Occupational therapy †

• BORG Rate of Perceived Exertion

• Modified Barthel~

• Activities Balance Confidence

Scale (ABC)

• Functional Reach

• Home Care AMPAC

†Based on what JHHCG uses; ~ Based on current research

• Outcome measures are performed at initial examination, after 30 days,

and discharge.

• Use of OASIS data collection

• Functional scores reported publically on Centers for Medicare/

Medicaid services

• 9 outcomes and 11 process measures

2/23/2016

20

Outpatient Rehabilitation

Presented by




Current Research: Outpatient

Families/caregivers

struggle to cope with new

demands: (Khan F 2013)

– Increased care needs

– Inability to drive/return

to work

– Financial constraints

– Marital stress

– General functional

limitations in patient

Utilized multi-disciplinary

rehabilitation and reported

favorable participation

outcomes that maintained at 8

months after discharge. (Sherer

1997)

Based on:

• Community

independence (Level of

assistance)

• Employment via

vocational

(productivity) outcomes

Current Research: Outpatient

Brain tumor verse other acquired

brain injury (Kirshblum 2001)

People with brain tumors have:

– Progressive functional decline

– Psychologic adjustment to

changing disability and

overall prognosis

– Role depression, fatigue, and

medical instability in rehab

progress

– Increased need for

reassessment and

adjustment of interventions

Whitten 1997:

– Survivors of BT, who 90%

were ambulatory,

reported some type of

morbidity affecting their

health

– 80% of those reported

multiple impairments

(sensory, emotional, and

cognition)

JHH Outpatient Programs

Pure Cancer

Rehabilitation

JHH Cancer

Rehabilitation

Program (CRP) • Based on STAR

oncology program

Restorative/

Compensatory

Rehabilitation

JHH Brain Rehabilitation Program (BRP)

Generally ends up as a combination of the two programs

Most patients seen in BRP

**Allows team members to develop an individualized approach for

each patient (Sherwood 2006)

JHH Cancer Rehab Program (CRP)

Program Details

• Based on the principles of the STAR Program™ (Survivorship Training

and Rehab Program)

• Our goal is to improve daily function and quality of life for the cancer

survivor.

• Interventions based on symptoms from chemotherapy or radiation

– Chemotherapy Related Fatigue

– Deconditioning/ Decreased balance

– Postural changes

– Generalized Weakness

– Lymphedema (generally not BT specific)

– Pain/ joint stiffness

– Peripheral Neuropathy

JHH Cancer Rehab Program (CRP)

Multi-Disciplinary Team

• Physiatry

• Physical Therapy

– Lymphedema Management

– Men and Women's Health

• Occupational Therapy

– Lymphedema Management

• Rehabilitation Psychology

• Speech-language Pathology

2/23/2016

21

JHH CRP: Outcome Measures

Cancer Specific

Cancer’s Overall Impact JHH uses Based on

research

Perceived Impact Problem Profile Scale (PIPP) X

Cancer Rehab evaluation System- Short form

(CARES-SF) X

Cancer Survivor Unmet Needs Measure

(CSUN) X

Fatigue JHH uses Based on

research

Fatigue Analog Scale (FAS) X* X

FACIT (Used it FAS screen identifies a problem) X* X

Cancer Survivor Unmet Needs Measure

(CSUN) X

* Required at initial evaluation

JHH CRP: Outcome Measures

Cancer Specific

Pain JHH uses Based on

research

Visual Analogue Pain Scale X* X

Diagnosis Specified JHH uses Based on

research

6MWT (if endurance an issue) X

Neck Disability Index (NDI) (head and neck

cancers) X*

Balance measures (see BRP section) X* X

Functional Reporting JHH uses Based on

research

AMPAC- Mobility X*

AMPAC- ADLs X*

* Required at initial evaluation


• Patient with BT have limitations in activity and participation

domains of the WHO ICF model.

Leads to:

– Cumulative effect over time

– Distress to cancer survivors and their loved ones

– Reduced quality of life (QoL). (Ness 2010)

Patient with BTs rarely avoid experiencing impairments in

cognitive function related to their diagnosis

• Critical to work to address all of these limitations based on

the WHO ICF model.


• Created with a multi-disciplinary approach

• Program caters to all neuro diagnoses:

– Multiple Sclerosis

– Parkinson’s disease

– Stroke

– Traumatic brain injury

– Brain tumor

– Rare neuro diagnoses

• Interventions based on location of brain tumor and residual neuro

deficits related to:

– Surgical intervention

– Radiation intervention

– Chemotherapy intervention

JHH Brain Rehabilitation

Program (BRP)

Patient

Physical Therapy

SLPs

Neuropsych

Social Worker Orthotist/

Prosthetist

Physiatrists


Role of family

and caregiver

Importance of Multidisciplinary team

• Patients with BTs present with

deficits including

– Memory

– Strength

– Coordination

– Attention

– Executive Function

– Verbal Fluency

– Visuospatial Perception

• Deficits impact overall QOL of patient and caregivers.

• Need for development of realistic and timely goals due to quicker progression of disability

• Multi-disciplinary team assists each

other and the patient in developing

their own skills to manage their own

care including

– Coping ability

– Knowledge Base

– Improving quality of life

– Self-advocating behavior

– Goal-based interventions

– Improving functional deficits

– Improving cognitive deficits

(Cormie 2015; Gabanelli 2005; Huang 2011; Khan 2013; Kirshblum 2001)

Huge role of OT, SLP, rehab psychologists, and family/caregivers.

Collaboration is critical.

2/23/2016

22

JHH CRP/BRP: Outcome Measures

*Highly Recommended

Balance TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

5x Sit to stand X X

Activity Balance Confidence Scale

(ABC) X X X

Berg Balance Scale X X* X X

Dynamic Gait Index (DGI) X

Tinetti Balance Assessment Tool X X


*Highly Recommended

Gait TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

2 Minute walk Test X

6 Minute walk test X X* X X

10meter walk test X X* X X

Community Balance and Mobility

Scale X X

High Level Mobility Assessment

Tool (HiMAT) X* X

Timed Up and Go (TUG) X* X X

TUG Cognitive X


Cognitive/ Dual Tasking TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Kettle Test for Cognition X

Montreal Cognitive Assessment

(MoCA) X

Medication management test X

Mini-mental exam X X

Stroop color word test X X

Letter digit substitution test X

Memory scanning Test X

Trail Making Test A/B X

Forward and Backward Digit Span

Test X X


*Highly Recommended

Pain TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Visual Analogue pain Scale X X X

Vestibular TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Dizziness Handicap Index X X X

Neuropathy TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Brief Peripheral Neuropathy Score X

Modified Total Neuropathy Score X


Mood TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Depression Anxiety Stress Scale

(DASS) X X

SF-36 X X X

Disability Rating Scale X

Quality of Life TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Community Integration Questionnaire (CIQ) X

EORTC: General and Brain tumor specific

-QLQ-C30- BN20 X

Functional Assessment of Cancer Therapy-

Brain (FACT-Br) X

Quality of Life after Brain Injury X X


Upper Extremity TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

9 Hole Peg Test X X

Action Reach Arm Test (ARAT) X X

Functional Reach X

Boxes and Blocks Test X

Fatigue TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

BORG X X

FACIT X X

Multi-dimensional Fatigue Inventory

(MFI) X

Global Fatigue Inventory X

2/23/2016

23


SLP Specific TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

ASHA National Outcome

Measurement System (NOMS) X X

AMPAC TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Mobility X

ADLs X

Tone TBI

EDGE

Strok

EDGE

JHH

uses

Based on

research

Modified Ashworth Scale X X X

Interventions:

Gait Training

– LiteGait

– NuStep

– Classic parallel

bars

Weighted Walker

H-P Cosmos Treadmill with

virtual reality component

Alter-G Treadmill

www.justwalker.com;

www.alterg.com;

www.h-p-cosmos.com/

Interventions:

Orthotics/ Prosthetics *Note all electrical

stimulation should

be cleared by

medical team

prior to initiation

www.bioness.com; www.givmohrsling.com/

L300 Foot Drop

System

Custom Ankle

Foot Orthosis

(AFO)

GivMohr

Sling

L300

Plus

System

H200 Hand

Rehab System

Estim

Trigger

Case Example: Anaplastic Oligodendroglioma

TI Coronal MRI

post-op 3/14

T2 FLARE MRI

Pre-op 7/13

T2 Sagittal

MRI 2/15

TI Coronal

MRI

10/14

Interventions: Anaplastic

Oligodendroglioma

R Sided Weakness, presenting

like stroke patient

Case Example: Hemangioblastoma

Cerebral Angiogram MRI Cerebral Angiogram

Pt provided consent for use of scans

Involvement of posterior fossa

(cerebellum) leads to balance,

vestibular, and gait deficits.

2/23/2016

24

Case Example: Vestibular Schwannoma

Involvement of Cranial Nerve VIII leads to balance,

vestibular, and gait deficits.

Interventions:

Balance/ Vestibular/ Vision

VOR X1: Horizontal

VOR X1: Vertical

VOR X2: Horizontal

Can be performed in

sitting or standing Alrwaily 2011

Interventions:

Balance/ Vestibular/ Vision

Tracking

Gaze Stability

Foam

Eyes Open

Eyes Closed

Single leg stance

Community Integration

Presented by




Return to…….

• Work

• Childcare

• School

• Family Activity

• Competitive

Sports

• Recreational

exercise

• Limited research to address the long-term effects

affecting the ability to perform everyday life activities (Kahn 2013)

• Determine clearance from primary team: Neurosurgery

and/or Oncology

• Discuss with BRP multi-disciplinary team

• Consider:

– Time since surgery

– Prognosis

– Feasibility

– Safety

– Needs from BRP team to complete patient’s goal

Return to Driving

• State Dependent

• MD clearance needed

• Good to have protocol for OP setting because this is a huge

priority/goal for many patients

JHH BRP: Provides handout for patient/family with “Who, What, Where, Why, How” of

Driver Rehabilitation

OT recommends/ refers patient to see Driver Rehabilitation Specialist at a different facility via state Motor vehicle administration, AOTA or Association of Driver Rehabilitation Specialist websites/ phone numbers

www.aota.org/practice/productive-aging/driving.aspx; 1-800-377-8555

http://aded.site-ym.com/search/custom.asp?id=1984; 1-866-672-9466

2/23/2016

25

Case Example: 55 yo male presents with slurred speech, severe

nausea, dizziness, diagnosed with Glioblastoma (R temporal

region) who underwent resection at OSH in another state

complicated by R basal ganglia CVA. Transferred to JHH for

oncology management

ACS: Admitted to Neuro Critical Care Unit initially for CVA management

Medical Oncology service: started chemotherapy/ radiation

CIIRP: Spent 4 wks in rehabilitation with SLP, OT, PT, neuropsych.

Complicated by L leg DVT. Undergoing radiation concurrently in PM.

OP: Attended ONRP program for preparation for discharge home once

radiation was complete. Stayed at Hackerman House during stay.

Discharged from therapy to location closer to home

Palliative: Involved throughout stay from ACS OP

RESOURCES FOR PATIENTS

AND FAMILIES

• American Brain Tumor Association

– 800-886-2282 www.abta.org

• American Cancer Society

– 800-227-2345 www.cancer.org

• The Healing Exchange Brain Trust

– 877-252-8480 www.braintrust.org

– T.H.E. Brain Trust runs online support groups and forums for discussion on all

brain tumors for patients, providers, researchers, educators and caregivers

• Musella Foundation for Brain Tumor Research and Information

– 888-295-4740 www.virtualtrials.com

– Musella Foundation offers education, support (emotional and financial),

advocacy and guidance to brain tumor patients. Videos, articles, online

support groups, and information about fundraisers for brain tumor research.

• National Brain Tumor Society

– 800-770-8287 www.braintumor.org

https://www.youtube.com/watch?v=uICPnfvSg2U

Questions?

Rose Madison

2/15/16

REFERENCES

https://www.youtube.com/watch?v=uICPnfvSg2U

2/23/2016

26

Intro/ Background References

• Ostrom QT, Gittleman H, Liao P, et al. CBTRUS Statistical Report:

Primary Brain and Central Nervous System Tumors Diagnosed in

the United States in 2007-2011. Neuro Oncol. 2014; 16(s5):iv 1-

iv63.

• CBTRUS factsheet [Internet]. 2015.

http://www.cbtrus/factsheet/factsheet.html. Accessed 10/26/2015.

• American Brain Tumor Association. A Primer of Brain Tumors: a

patient’s reference manual. 8th Edition, 2004.

• https://www.braininjurymn.org/library/AGuideToBrainAnatomy.pdf

• http://www.hopkinsmedicine.org/neurology_neurosurgery/exper

ts/profiles/team_member_profile/EF48C2ECB225F29CCA8C801

AAEB2BE26/Henry_Brem

ACS References

• Guide to the Care of the Patient with Craniotomy Post- Brain Tumor Resection; AANN Reference Series for Clinical Practice; American Association of Neuroscience Nurses; Illinois

• Oludamilola, et al. Validation of the Palliative Performance Scale in the Acute Tertiary Care Hospital Setting, Jour Pallia Med 2007; 10(1): 111-117.

• Glantz, et al. Practice Parameter: Anticonvulsant Prophylaxis in Patients with Newly Diagnosed Brain Tumors. Neuro 2000; 54: 1886-1893.

• McGough et al. Associations between Physical Performance and Executive Function in Older Adults with Mild Cognitive Impairment: Gait Speed and the Timed Up and Go Test. Phys Ther 2011; 91: 1198-1207.

• Needham, D et al. Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project. Arch Phys Med Rehabil. 2010; 91: 536-42.

• Mendez-Tellez, P et al. Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist. The Neurohospitalist. 2012; 2(3): 96-105.

• Stiller, K. Physiotherapy in Intensive Care. An Updated Systematic Review. Chest. 2013; 144(3): 825-847.

• Gillick, B et al. Mobility Criteria for Upright Sitting With Patients in the Neuro/Trauma Intensive Care Unit: An Analysis of Length of Stay and Functional Outcomes. The Neurohospitalist. 2011; 1(4): 172-177.

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• http://www.omicsonline.org/open-access/relationship-of-balance-and-mobility-status-to-quality-of-life-in-patients-with-primary-brain-tumors-a-pilot-study-2329-9096.1000196.php?aid=26578- Krug and Litofsky

• http://www.webmd.com/epilepsy/medications-treat-seizures?page=3

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• www.oncologypt.org; CIPN Fact Sheet, Wampler, M. 2006

• https://powermobilityalberta.wordpress.com/ICF-model/

ACS References

• Wolff, et al. Exercise Maintains Blood-Brain Barrier Integrity during Early Stages of Brain Metastasis Formation. Bioche Biophys Resear Commun 2015; 463: 811-817.

• Krug, et al. Relationship of balance and Mobility Status to Quality of Life in Patients with Primary Brain Tumors: A Pilot Study. Int J Phys Med Rehabil 2014; 2(3): 1-7.

• Aprile, et al. Occurrence and Predictors of the Fatigue in High-Grade Glioma Patients. Neuro Sci 2015; 36: 1363-1369.

• Kim, et al. Fatigue assessment and Rehabilitation Outcomes in Patients with Brian Tumors. Support Care Cancer 2012; 20: 805-812.

• Gewandter, et al. Falls and Functional Impairments in Cancer Survivors with Chemo-Induced Peripheral Neuropathy (CIPN): A University of Rochester CCOP Study. Support Car Cancer 2013; 21(7): 2059-2066.

• http://www.cancerresearchuk.org/about-cancer/type/brain-tumour/treatment/chemotherapy/chemotherapy-drugs-for-brain-tumours

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• http://www.hospicepatients.org/karnofsky.html

• http://www.mactheknife.org/Preop_assessment/Exercise_files/PastedGroup.png

ACS References

ACS Image Hyperlinks

• http://www.motomed.com/en/models/motomed-letto2.html

• http://www.arjohuntleigh.com/products/patient-transfer-solutions/standing-raising-

aids/sara-plus/features-benefits/

• https://www.google.ae/search?q=arjo+walker&biw=1366&bih=622&tbm=isch&tbo=

u&source=univ&sa=X&ved=0ahUKEwjAv4qKvNPJAhUGOhoKHYi5CSAQsAQIKg

&dpr=1

• http://www.pattersonmedical.com/app.aspx?cmd=getProduct&key=IF_921117019

• http://www.medicalproductsdirect.com/evasuwapnad.html

• https://www.google.ae/search?q=beezy+board&biw=1366&bih=622&tbm=isch&tbo

=u&source=univ&sa=X&ved=0ahUKEwjD7b6hy9PJAhWFOxoKHSciA1UQsAQILQ

#imgrc=_

• https://www.google.ae/search?q=theraband+images&biw=1366&bih=622&tbm=isc

h&tbo=u&source=univ&sa=X&ved=0ahUKEwjGicW8kN7JAhUFtg8KHTcBAdIQsA

QIGQ

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h&tbo=u&source=univ&sa=X&ved=0ahUKEwjGicW8kN7JAhUFtg8KHTcBAdIQsA

QIGQ#tbm=isch&q=physioball+images

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blood-sodium/faq-20058465

Palliative/ Hospice References

• http://www.who.int/cancer/palliative/definition/en/

• http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/He

alth/RoleofPTinHospiceandPalliativeCare_HOD_P06-11-14-11.pdf

• http://www.medscape.org/viewarticle/494007_3

• http://learningcenter.apta.org/Student/CourseProgress.aspx?CourseID=9

013dc34-141c-4db4-94e6-c0d1f34c6ee0&Attempt=0- “Hospice and

Palliative Care: The Collaborative Role of Physical Therapy”

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and supportive-care needs in high-grade glioma." The lancet

oncology 9.9 (2008): 884-891.

• Ford, Elizabeth, et al. "Systematic review of supportive care needs in

patients with primary malignant brain tumors." Neuro-oncology (2012):

nor229.

http://www.cbtrus/factsheet/factsheet.html

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Palliative/ Hospice References

• Faithfull, Sara, Karen Cook, and Caroline Lucas. "Palliative care of

patients with a primary malignant brain tumour: case review of service

use and support provided." Palliative medicine 19.7 (2005): 545-550.

• Roberts, Pamela S., et al. "The impact of inpatient rehabilitation on

function and survival of newly diagnosed patients with

glioblastoma." PM&R 6.6 (2014): 514-521.

• Santiago‐Palma, Juan, and Richard Payne. "Palliative care and

rehabilitation." Cancer 92.S4 (2001): 1049-1052.

• http://www.medicinenet.com/script/main/art.asp?articlekey=24267

• Dy, S et al. “A quality improvement initiative for appropriateness of

referrals from a cancer center to subacute rehabilitation.” Jour Pain

Symptom Management 2013.

Inpatient Rehabilitation References • Bartolo M, Zucchella C, Pace A, et al. Early rehabilitation after surgery improves functional outcome in

inpatients with brain tumours. J Neurooncol. 2012;107(3):537-544.

• Boake, C, Meyers CA. Brain tumor rehabilitation: Survey of clinical practice. Arch Phys Med Rehabil.

1993;74:1247.

• Dorsay, Jan Park, Shucui Jiang, and David Harvey. "Rehabilitation in primary and metastatic brain tumours." J Neurol 255 (2008): 820-827.

• Fu, Jack B., et al. "Comparison of functional outcomes in low-and high-grade astrocytoma rehabilitation inpatients." American Journal of Physical Medicine & Rehabilitation 89.3 (2010): 205-212.

• Gabanelli, P. "A rehabilitative approach to the patient with brain cancer."Neurological Sciences 26.1

(2005): s51-s52.

• Gehring, Karin, et al. "Cognitive rehabilitation in patients with gliomas: a randomized, controlled

trial." Journal of clinical oncology 27.22 (2009): 3712-3722.

• Geler-Kulcu, D., et al. "Functional recovery of patients with brain tumor or acute stroke after

rehabilitation: a comparative study." Journal of Clinical Neuroscience 16.1 (2009): 74-78.

• Giordana, M. T., and E. Clara. "Functional rehabilitation and brain tumour patients. A review of

outcome." Neurological Sciences 27.4 (2006): 240-244.

• Greenberg, Elina, Iuly Treger, and Haim Ring. "Rehabilitation outcomes in patients with brain tumors and

acute stroke: comparative study of inpatient rehabilitation." American journal of physical medicine &

rehabilitation 85.7 (2006): 568-573.

• Huang, Mark E., David X. Cifu, and Lori Keyser-Marcus. "Functional outcome after brain tumor and acute stroke: a comparative analysis."Archives of physical medicine and rehabilitation 79.11 (1998): 1386-

1390.

• Huang ME, Cifu DX, Keyser-Marcus L. Functional outcomes in patients with brain tumor after inpatient

rehabilitation: comparison with traumatic brain injury. Am J Phys Med Rehabil Assoc Acad Physiatr.

2000;79(4):327-335.

Inpatient Rehabilitation References • Huang, Mark E., Jennifer E. Wartella, and Jeffery S. Kreutzer. "Functional outcomes and quality of life in

patients with brain tumors: a preliminary report." Archives of physical medicine and rehabilitation 82.11 (2001): 1540-1546.

• Huang, Mark E., and James A. Sliwa. "Inpatient rehabilitation of patients with cancer: efficacy and treatment considerations." PM&R 3.8 (2011): 746-757.

• Khan F, Amatya B. Use of the International Classification of Functioning, Disability and Health (ICF) to

describe patient-reported disability in primary brain tumour in an Australian community cohort. J Rehabil

Med. 2013;45(5):434-445.

• Khan F, Amatya B, Ng L, Drummond K, Olver J. Multidisciplinary rehabilitation after primary brain tumour

treatment. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester,

UK: John Wiley & Sons, Ltd; 2013.

• Khan F, Amatya B. Factors associated with long-term functional outcomes, psychological sequelae and quality of life in persons after primary brain tumour. J Neurooncol. 2013;111(3):355-366.

• Kirshblum, Steven, et al. "Rehabilitation of persons with central nervous system tumors." Cancer 92.S4 (2001): 1029-1038.

• Krug, Jeffrey Bart. Functional outcome and self-perceived overall health status following surgery to

remove primary brain tumor. Diss. University of Missouri--Columbia, 2008.

• Marciniak, Christina M., et al. "Functional outcomes of persons with brain tumors after inpatient

rehabilitation." Archives of physical medicine and rehabilitation 82.4 (2001): 457-463.

• O'Dell, Michael W., et al. "Functional outcome of inpatient rehabilitation in persons with brain

tumors." Archives of physical medicine and rehabilitation79.12 (1998): 1530-1534.

• Tang, Vivien, et al. "Rehabilitation in primary and metastatic brain tumours."Journal of neurology 255.6

(2008): 820-827.

Inpatient and OP: StrokEDGE and

TBI Edge

• Sullivan, Jane E., et al. "Outcome measures for individuals

with stroke: process and recommendations from the

American Physical Therapy Association Neurology

Section Task Force." Physical therapy 93.10 (2013): 1383-

1396.

• McCulloch, Karen, et al. " Outcome measures for

individuals with Traumatic Brain Injury: process and

recommendations from the American Physical Therapy

Association Neurology Section Task Force." CSM 2013.

http://www.neuropt.org/professional-resources/neurology-

section-outcome-measures-recommendations/traumatic-

brain-injury

Home Health References

• Pace, A., et al. "Home rehabilitation for brain tumor

patients." J Exp Clin Cancer Res 26.3 (2007): 297-300.

• Home health OASIS medicare

– Shaughnessy, Peter W., Kathryn S. Crisler, and Robert E.

Schlenker. "Outcome-based quality improvement in home health

care: the OASIS indicators." Quality Management in

Healthcare 7.1 (1998): 58.

– Koroukian, Siran M., Patrick Murray, and Elizabeth Madigan.

"Comorbidity, disability, and geriatric syndromes in elderly

cancer patients receiving home health care." Journal of Clinical

Oncology 24.15 (2006): 2304-2310.

Outpatient Rehabilitation References

• Alrwaily, Muhammad, and Susan L. Whitney. "Vestibular rehabilitation of older adults with

dizziness." Otolaryngologic clinics of North America 44.2 (2011): 473-496.

• Bell, Kathleen R., et al. "Rehabilitation of the patient with brain tumor."Archives of Physical Medicine and

Rehabilitation 79.3 (1998): S37-S46.

• Cormie, Prue, et al. "The potential role of exercise in neuro-oncology."Frontiers in oncology 5 (2015).

• Gabanelli, P. "A rehabilitative approach to the patient with brain cancer."Neurological Sciences 26.1

(2005): s51-s52.

• Gehring, Karin, et al. "Cognitive rehabilitation in patients with gliomas: a randomized, controlled trial." Journal of clinical oncology 27.22 (2009): 3712-3722.

• Huang, Mark E., and James A. Sliwa. "Inpatient rehabilitation of patients with cancer: efficacy and treatment considerations." PM&R 3.8 (2011): 746-757.

• Khan F, Amatya B, Ng L, Drummond K, Olver J. Multidisciplinary rehabilitation after primary brain tumour

treatment. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester,

UK: John Wiley & Sons, Ltd; 2013.

• Khan F, Amatya B. Factors associated with long-term functional outcomes, psychological sequelae and

quality of life in persons after primary brain tumour. J Neurooncol. 2013;111(3):355-366.

• Kirshblum, Steven, et al. "Rehabilitation of persons with central nervous system tumors." Cancer 92.S4

(2001): 1029-1038.

• Levin, Gregory T., et al. "Exercise Improves Physical Function and Mental Health of Brain Cancer

Survivors Two Exploratory Case Studies." Integrative cancer therapies (2015): 1534735415600068.

• Ness, Kirsten K., et al. "Physical performance limitations among adult survivors of childhood brain tumors." Cancer 116.12 (2010): 3034-3044.

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Outpatient Rehabilitation References

• Sherer, Mark, Christina A. Meyers, and Paula Bergloff. "Efficacy of

postacute brain injury rehabilitation for patients with primary malignant

brain tumors." Cancer 80.2 (1997): 250-257.

• Sherwood, Paula R., et al. "Predictors of distress in caregivers of

persons with a primary malignant brain tumor." Research in nursing &

health 29.2 (2006): 105-120.

• Whitten, AC, Rhydderch, H, Furlong, W, Feeny, D, Barr, RD. Self-

reported comprehensive status of adult brain tumor patients using the

health utilities index. Cancer. 1997;80:258–265.

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