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Rehabilitation of Patients with Neurologic Tumors and Cancer-Related Central Nervous System Disabilities

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Rehabilitation of Patients with Neurologic Tumors and Cancer-Related Central Nervous System Disabilities 3601_e22_p470-492 2/19/02 9:04 AM Page 470 22 Rehabilitation of Patients with Neurologic Tumors and Cancer-Related Central Nervous System Disabilities THERESA A. GILLIS, RAJESH YADAV, AND YING GUO Neurologic tumors may involve the brain or spinal cord compression can occur in 5% to 10% of can- cord and are either primary or metastatic. Patients cer cases (Barron et al., 1959). Immediate functional may become increasingly less independent as a re- consequences can include pain, sensory deficits, mo- sult of direct injury of neural structures responsible tor deficits, neurogenic bowel and bladder, and sex- for motor, sensory, cognitive, and speech functions. ual dysfunction. The indirect effects of chemotherapy and radiation Rehabilitation management of impairments and therapy (RT) add to the functional deficits patients disabilities is approached in the same manner as in experience. The number of patients involved is quite noncancerous neurologic diseases. However, the large. More than 15,000 new cases of primary brain pathology of the tumor and the anticipated course of tumor and 4000 new spinal tumors are diagnosed disease progression must be considered carefully every year (American Cancer Society, 1990). Ap- when developing rehabilitation goals as well as the proximately 2% of all cancer deaths are caused by time frame required to achieve these goals for an in- brain tumors, which account for roughly 11,000 dividual patient. The purpose of rehabilitation for deaths per year (American Cancer Society, 1990). cancer patients is similar to that for patients with Metastatic lesions from various sites account for 20% other diseases; emphasis is placed on restoring or to 40% of brain tumors (American Cancer Society, maximizing independence with activities of daily liv- 1990), occur in approximately 15% of cancer pa- ing (ADL), mobility, cognition, and communication. tients (Black, 1991), and produce neurologic symp- Rehabilitation interventions can be applied in all toms in approximately 85,000 patients each year. stages of the disease, although rehabilitation goals Most spinal tumors are extradural and are predomi- change as the stage of illness advances. Preventive re- nantly metastatic carcinomas, lymphomas, or sarco- habilitation maintains maximum functional indepen- mas (Posner and Chernik, 1978). dence in patients who undergo treatment and who Patients may undergo surgical resection, chemo- have potential loss of function. When tumor progres- therapy, and/or radiation to combat their tumors. It sion causes a decline in functional skills, or the dis- is important to note that significant functional deficits ease causes fluctuating abilities, rehabilitation as- can exist even before treatments. The following signs sumes a supportive role, with goals adjusted to were noted in 162 patients with cerebral metastases: accommodate persistent anatomic and physiologic impaired cognition (77%), hemiparesis (66%), uni- limitations. During terminal stages of illness, pallia- lateral sensory loss (27%), ataxia (24%), and apha- tive rehabilitation can improve and maintain comfort sia (19%) (Caraceni and Martini, 1999a). Spinal and quality of life until the end of life. An optimal re- 470 3601_e22_p470-492 2/19/02 9:04 AM Page 471 Rehabilitation 471 habilitation team consists of a physiatrist, primary Table 22–2. Common Complications of Brain Tumors and physician, nurse, Their Treatments physical therapist, occupational therapist, speech- Weakness language therapist, recreational therapist, social Sensory loss worker, case manager, dietitian, and chaplain (Gar- den and Gillis, 1996). Benefits of rehabilitation are Visuospatial deficits noted in Table 22–1. Hemi-neglect or bilateral visual deficits Ataxia Cognitive deficits: thought processes, memory changes, REHABILITATION OF BRAIN apraxia, etc. TUMOR PATIENTS Speech difficulties Dysphagia It is important to understand that even a small low- Bowel and bladder dysfunction grade malignant tumor may cause significant resid- ual functional deficits if it resides in a critical loca- Psychological issues tion. Lesions located near the brain stem can be Behavioral abnormalities particularly damaging to motor functions, sensory Endocrine issues functions, coordination, and cranial nerves. Primary Skin issues malignant tumors in adults are mostly gliomas, which Fatigue account for more than 90% of lesions (Bondy and Wrensch, 1993). Of these, glioblastoma multiforme has the worst prognosis and low-grade astrocytoma, kidney, and pancreas, as well as malignant mela- the best (Black, 1991). The location of these tumors nomas. These tumors tend to be highly invasive and may or may not permit resection. Pituitary tumors destructive. Edema is often present and may extend may result in headaches, bilateral visual loss (due to for some distance beyond the tumor. Leptomeningeal their central location), and hormonal abnormalities metastases with multiple cranial nerve and spinal root (Black, 1991). With acoustic neuromas, hearing loss involvement may also occur. and/or vertigo may occur due to their proximity to the cranial nerve. Other symptoms associated with General Considerations these tumors include facial palsy and numbness, dys- phagia, and hydrocephalus. Visual loss and sexual It is essential to consider the fluctuant nature of dis- dysfunction can be present with craniopharyngiomas ease progression for many of these patients and that in adults, and growth failure may occur in children the overall prognosis may not be very good when these with these tumors. Changes in behavior, appetite, tumors are present. Rehabilitation interventions should memory, and endocrine function may be seen fol- be guided by the evidence regarding the nature and be- lowing radiation treatment (Black, 1991). havior (aggressive or indolent) of each patient’s tumor, The lung and breast are the most frequent primary the ongoing clinical course, and the patient’s neuro- sources of metastatic CNS tumors. Other common pri- logic status. If the prognosis is very limited, or severe mary sources are carcinomas from the colon/rectum, cognitive injury impedes patient learning and retention of new information, caregiver education and adapta- Table 22–1. Benefits of Rehabilitation tion of the patient’s environment become dominant components of the rehabilitation plan. In cases of ex- Training to maximize functional independence pected survival of less than 2 months, primary goals Facilitation of psychosocial coping and adaptation by patient usually shift to injury prevention, safety for patient and and family caregivers, and ease in performing tasks of hygiene and Improved quality of life through community reintegration: transfers into and out of bed. Common complications includes resumption of prior home, family, recreational, influencing the rehabilitation program for these pa- and vocational activities tients are listed in Table 22–2. Recognition, management, and prevention of co-morbid With temporal lobe tumors, dysnomia, disturbance illnesses that limit or impede function of comprehension, and defective hearing and mem- 3601_e22_p470-492 2/19/02 9:04 AM Page 472 472 SYMPTOMS SECONDARY TO CANCER AND ITS TREATMENT ory may occur (Nelson et al., 1993). Loss of vision, those with significant weakness and balance impair- spatial disorientation, memory loss, dressing apraxia, ment. Occupational and physical therapists should be and proprioceptive agnosia may occur with parietal consulted early for evaluation and teaching of ADL, lobe tumors. Behavioral abnormalities can occur with ambulation, and strengthening and stretching exer- frontal lobe tumors, and these may include person- cises. Speech therapists can assist with the assessment ality or libido changes, with impulsive behavior, la- of cognition, linguistic, and communication deficits. bile emotions, and excessive jocularity. Hypona- They can also determine the presence of swallowing tremia, as seen in the syndrome of inappropriate difficulties and recommend therapeutic exercises, diuretic hormone (SIADH), may lead to mental sta- compensatory maneuvers, and modified-consistency tus changes (Nelson et al., 1993). Fatigue may be- diets. come an issue with radiation treatment. Steroid psy- Seizures and hydrocephalus are complications of chosis occasionally complicates the rehabilitation brain tumors that often negatively impact the course course. of rehabilitation through declining functional perfor- With prolonged immobility in bed, supportive care mance. Todd’s paralysis and subclinical seizures may is important. Measures should be taken to prevent mimic other etiologies for declining neurologic sta- pressure ulcers and deep venous thrombosis. Range tus and prevent participation in a rehabilitation pro- of motion of all joints should be maintained with daily gram. Hydrocephalus may also have a presentation exercises or passive stretch if paralysis or altered suggestive of other diagnoses, may be acute or mental status is present. Sensory stimulation should chronic in nature, and usually leads to a decline in be provided, along with socialization. functional status. It is classically described as a triad Corticosteroids, which are commonly used to com- of subcortical dementia, incontinence, and gait dis- bat peritumoral edema, tend to improve diffuse neu- order. Hydrocephalus should be suspected when rologic dysfunction rather than focal deficits. Myopa- changes in mentation occur, when a patient fails to thy with proximal muscle weakness often ensues and make expected functional
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