Brain Tumor and multi-disciplinary management Flashcards
Brain Tumor
- often poor prognosis
- benign brain tumors are often difficult to remove because they can be close to a part of the brain with important functions ex. acoustic neuromas that lye beside the brainstem
and there can be no clear boundary between tumour tissue and normal brain tissue
resectioin is the removal of part of an organ- doing this can result in a permanent brain injury
Primary
Primary:
- Gliomas- collective term that originate in the brain or spinal cord CNS
ex. Astrocytomas are the most common primary brain tumor in adults and children- grows bigger but does not spread
Secondary Tumors
Metastatic
- spread in the CNS from systemic cancer sites outside the brain
- start outside the CNS
Common Brain tumors
- Gliomas
- can be both benign and malignant
- astrocytomas are most common glial tumor
Grade 1= benign
ex.
1. Meningioma- arise from the meninges
2. Pituitary adenomas: affect the optic tract, edocrine disturbance
3. Acoustic Neuroma- large size cause brainstem displacement and raised intracranial pressure
Grade 4: highly malignant
ex. metastatic carcinoma- 60% of all brain tumors
Astrocytomas and metastic carcinomas comprise of 60% of all brain timors
Symptoms
- Raised intracranial pressure
- epilepsy
- neurological deficits
Meningiomas
- another common brain timor
- always benign
- from any part of the meninges
- Possible for total removal as long as it is not attached to dural venous sinuses
Pituitary adenomas
- Space- occupying effects- the space that is occupied lead to effects
- compressing the optic nerves/chiasm/tracts
- commonly presented with monocular blindness due to optic nerve compression or hemianopia from optic tract compression- loss of half of the visual field
See picture!
Symptoms of pituitary adenomas
- Double vision
- simultaneous perception of 2 images of a single object
result of impaired function of the extraocular muscles, both eyes are still functioning, but cannot converge to target
the desired object - muscles controlling the object don’t work as well
Endocrine disturbances
- if tumor cells are secretory there is a positive disturbance
- if preventing normal secretions- negative disturbance
Pituitary adenomas and cranial nerves
lateral expansion can compress the cranial nerves 3, 4 and 6 and also cause numbness of the forehead
If there is a tumor on the chiasm= tunnel vision
3rd cranial nerve
- Looking up in the abducted position
- Looking down in the abducted position
- Adducting medial
- Looking up in the adducted position
4th cranial nerve
- looking down in the adducted position
6th cranial nerve
- abducting laterally
Summary
benign
- grade 1-2 glioma
- meningioma
- pituitary adenoma
- Acoustic neuroma
Malignant
- Primary- grade 3-4 glioma
- secondary- metastatic carcinoma
One hemisphere too large
supratentorial midline structures
- ex. corpus callosum and 3rd ventricle are pushed towards the opposite side of the skills
- the inferior medial part of the cerebral hemisphere is pushed which compresses the mid brain
- brainstem pushed down
impacts
this can cause a decrease in consciousness, decrease in pupil’s reaction to light (3rd cranial nerve palsy)
decrease in vital functioning including breathing
- coning caused by downward movement of brainstem
Mass lesion situated in the midline
- cause obstruction of CSF
- pushing both the cerebral hemispheres
- pushing down midbrain
- similar effects as above
Unilateral posterior fossa mass lesion
- compress the 4th ventricle, block downward flow of CSF
cerebellum function implicated- movement, coordination and balance
Coning may occur depending on the size of the mass
What are the key characteristics of cerebellar dysfunction
- Intention Tremor
- occurs during voluntary movement
- absent at rest
-intensifies at the termination of movement
-MS
Tests- problems with precision and can do the finger to finger test and the finger to nose test - Adiadochokinesis- related to coordination
- unable to perform rapid alternating movements ex. pronation and supination, and elbow flexion and extension
Test: within several seconds count how many alternations a patient can make- compare affected with unaffected limb
- Dysdiadochokinesia
- decrease ability to perform rapid alternating movements smoothly - Ataxia
- delayed initiation of movement responses
- results in jerky, poorly controlled movement, poor postural stability- poor agonist and antagonist coordination
Test: observe patient reaching- look for ataxic gait
- Nystagmus
- involuntary oscillating movement of eyes
- also appears in brainstem and vestibular lesions
- Tests: observe patient when he/she is looking at a fixed object- dysarthria- speech problem - Romberg sign
- inability to maintain standing balance with feet together and eyes closed- push slightly to see whether patients are able to compensate and regain posture- a positive romberg sign is excessive swaying or even falling over - Proprioceptive dysfunction: damage anywhere along the pathway from the proprioceptive sensors to the cerebellum can give rise to cerebellar ataxia
Specific Symptoms of Brain tumors
- headaches
- nausea and vomiting
- changes in speech, vision, or hearing
- problems with balance or walking
- changes in mood or ability to concentrate
- problems with memory
- Muscle jerking or twitching
- Numbness or tingling in the arms or legs
Clinical features and implications on functions
- Intracranial pressure
- head ache, vomiting, depression of conscious level, coning, false localizing signs ( 6th cranial nerve palsy, frontal signs and behavioural changes)
Clinical features- Frontal
tend to present late since tumors can become large before producing a definite neurological deficit
- dementia
- alteration of mood and behaviour
- incomplete insight
- olfactory or optic nerve malfunction
Clinical features- Central
tend to present early
- contralateral limb weakness and sensory loss
- dysphasia if dominant hemisphere
Clinical features- parietal
if non-dominant hemisphere
- spatial disorientation and dressing dyspraxia
If dominant
- dyslexia
- dysgraphia
- dyscalculia
- neglect of contralateral limbs
for occipital- hemianopia
Clinical Features- temporal
If dominant hemisphere= dysphasia
- memory impairment, alteration in mood, alteration in behaviour, visual field deficits
Clinical features- lateral posterior fossa
eg. acoustic neuromas- benign tumors of the schwann cells along the course of the acoustic nerve
- progressive unilateral nerve deafness
- contains the brainstem and the cranial fossa
Cranial nerve 5= jaw muscles
7= facial muscles
9= larynx
10= pharynx
12= tongue
Medical Treatment
- complete or partial removal
- biopsy
- Shunting- midlin tumors cause ventricular dilation, insertion of a shunt tubing under the skin
- radiotherapy
- chemo
- dexamethasone- relief of symptoms so that patients can go home and enjoy a short period
Treatment complication- surgical
- pain management
- treatment of infection
- bowel and bladder complications
- nutrition
- thromboembolic and antiepileptic precautions
Treatment complication- radiation
- optic nerve is most vulnerable to radiation toxicity
- posterior fossa radiation- delated syndrome of ataxia, diplopia, dysarthria and nystagmus- can recover after several weeks
- chronic diminished cognitive function
- children who receive full brain radiation are at risk of processing speed and cognitive function deficits
Treatment complication- chemo
peripheral neuropathy cardiac effects fatigue headache weakness
IMPLICATIONS FOR OT
- affects patients ability to participate in OT session- due to fatigue, low blood count, gastro complaints ** important to be flexible**
2. Psychological challenges- depression and hopelessness after going through repetitive medical treatments
3. Mood fluctuations- support to patient and family
4. watch for burnout and depression- symptoms include headache, joint pain, lack of mood/creativity, withdrawal behaviours
OT Strategies
- incorporate pacing and break times
- relaxation techniques
- emotional support
- balance in all occupational performance areas
- meaningful activities
- caregiver education
strategies
For those with complete or partial removal
- create a permanent lesion
- resemble brain injury- but how does this make treatment different?
- some regions are permanently lost- consider compensation at early stage of treatment- train alternative strategies ex. loss of hearing or vision
Assessment
For those undergoing chemo:
- look at vital signs, medical stability and tolerance
- measure functional abilities
- reasons functional assessment:
- consider AT eg. modified wc
- can also consider training but need to consider the reality
- discharge planning
Other assessments
- Functional assessment of cancer therapy (FACT)
- QOL measures
- Brief fatigue index- quick assessment of fatigue and its impact of daily function
- M.D. Anderson Symptom Inventory
- severity of cancer- related symptoms
OT Intervention- pre-operative
-facilitate continued engagement in activities
- compensate for side effects of treatment
Techniques:
- Energy conservation
-fatigue management
-identify performance patterns- how might it be altered by future medical treatments, think ahead for ways to tackle the problems
- Assessment
- Expectations
Post operative intervention
- ADL and IADLS
- focus on basic and main issues first
- social participation
- treatment plans for remediation (cognitive, physical)
- aware of psychological factors- body structures, outlook, insight
- est. long-term goals
Specific OT interventions
- Light activities to maintain cardiovascular function and avoid deterioration due to inactivity
- If condition or grading of the tumor not too bad, can train motor and cognition
- optimize functional abilities
- encourage pursue meaningful lifestyle
- discharge planning- community care and resources, support group, recreation, train family to be caregivers at home
- transfer to hospice care facilities
Palliative care
family members needs and preparation
- patients wishes
- help pts to engage in realist level of activity (some may still want to be productive)
- support system
Important to note
- some patients can recover some energy as blood count recovers
- there are phases of decline and stabilization- focus on short term aspects of function and goal setting
- some patients do want to engage in occupation and activities through the end of life stages
- beware of patients feeling about adjustment to loss and feelings about death
- take not of meds and treatment side-effects
ROLE OF OT
- functional engagement
- cognitive impairment
- visual deficits
- sensory and perceptual deficits
- fatigue
- pain and discomfort
- numbness or weakness
- caregiver education and support
Procedure
interview with family members and caregivers to understand their needs
- functional evaluation
- come up with goals (medical, remedial, compensatory) with the team
- establish care plan
- Initiate assessment and treatment
- regularly update progress and status
OT role in team
- provide proper equipment to compensate for patient’s functional limitation
- adaptive home environment
- energy conservation principle
- Splinting, bed rest too long, develop contractures
- report to team members any important info
- consider mobility devices and proper wc
- Teach caregiver proper technique to assist patients with ADLS and IADLS
- Educate caregiver to train patients on visual-perceptual needs and cognitive processing
- Extremity management, edema, peripheral nerve problems
Epilepsy
common symptom of brain tumors in adults and children
- disturbed electrical rhythms in the CNS
- repeated occurrence of sudden excessive and synchronous discharges in large groups of neurons
- resulting in almost instantaneous disruption of consciousness, disturbances of sensation, convulsive movements, impairment of mental function or some combination of these behaviour signs
Causes of epilepsy
family history, previous intracranial pathology, birth traumas to the brain, trauma to brain or skull, meningitis, encephalitis, cerebral hemorrhage, neurosurgery, drugs,
can also be an early sign of a brain tumor, but the brain tumor itself rarely leads to epilepsy
Negative and Positive signs
epileptic discharge originates in only certain areas of the brain, most notably the cerebral cortex and amygdala
symptoms
-positive sign- exaggeration of normal function ex. jerking of a limb or seeing of flashing lights
negative sign- loss of particular function ex. capacity to form new memories of an activities during the seizure
Generalized epilepsy
electrical discharges arise with deep midline structures of the brain and spread rapidly and simultaneously to all parts of the cerebral cortex
Focal Epilepsy
affects only 1 part of the brain
- Focal motor seizures- strong convulsive movements of one part of the contralateral face, body or limbs
- focal sensory seizures- strong unpleasant, slight painful, tingling, or electrical sensations in one part of the contralateral face, body or limbs
- frontal lobe epilepsy
- temporal lobe epilepsy
Implications for OT practice
- Photosensitivity- seizures triggered by flash light ex. TV, computer, games
- Occupation: jobs in armed forces, fire serves, nursing, child care, work at heights
- feel second class, psychological reaction, self-injury in the seizure is upsetting, stress, difficulty coping with life, establish precise pattern of a patients attack for correct management
