Neuro Oncology - Keller

Question 1

What is rehab guided by for patients with brain tumors

Answer 1

Findings from initial exam
For cerebral tumors: headaches, seizures, mental change/behavior, hemiparesis/weakness, midline shift.

Question 2

What would be findings from a frontal lobe tumor

Answer 2

1. Weakness
2. Ataxia
3. Hemiparesis
4. Gait disturbances
5. Impaired sensation
6. Urinary incontinence
7. Impaired judgement
8. Personality changes
9. Short term memory loss
10. Behavioral changes.

Question 3

What are occipital lobe findings

Answer 3

1. Visual disturbances
2. Homonymous Hemianopia

Question 4

What are parietal lobe common findings

Answer 4

1. Sensation loss
2. Tactile localization
3. Sterognosia — recognizing form of object without visual/auditory info
4. Autopagnosia — body scheme
5. Anosognosia — lack of awareness of disability
6. Aphasia

Question 5

What are temporal lobe common findings

Answer 5

1. Difficulty with recognizing sounds
2. Memory impairments
3. Vision impairments

Question 6

What are basal ganglion common findings

Answer 6

1. Contralateral choreoathetosis — combo of chorea (irregular migrating contractions) and athetosis (twisting and writhing)
2. Contralateral dystonia
3. Movement disorders
   have to be careful with athetosis movements because they can hurt each other

Question 7

Corpus callosum findings

Answer 7

1. Apraxia
2. Agraphia

Question 8

Cerebellum findings

Answer 8

1. Ataxia
2. Dysmetria
3. Nystagmus
   treat very similar to cerebellar stroke

Question 9

Brainstem findings

Answer 9

1. Cranial nerve dysfunction
2. Ataxia
3. Papillary abnormalities
4. Nystagmus
5. Hemiparesis
6. Autonomic dysfunction
   these tumors can get really life threatening fast because of basic bodily functions

Question 10

Presenting signs and symptoms from intra-dural extramedullary tumors

Answer 10

1. Local neck or back pain
2. Radicular pain
3. Weakness or sensory symptoms below level of tumor (typically recognized first on side tumor is present on)
4. Spinal cord compression — paraplegia, loss of bowel and bladder control (saddle numbness)
5. Nerve root compression — focal muscle wasting

Question 11

Presenting signs and symptoms from intra-dural Intramedullary tumors

Answer 11

1. Constant back and neck pain
2. Pain and midline tenderness at level of tumor and at night
3. Weakness
4. Spasticity
5. Poor coordination
6. Parenthesias
7. Stiffening gait
8. Clonus
9. Scoliosis or Torticolis

Question 12

Spinal tumor interventions

Answer 12

1. Joint mobility — want to maintain ROM, prevent contractures
2. Balance
3. Motor control training
4. Strengthening — depends where tumor is and how stable the vertebrae are
5. Aerobic endurance — both on foot or in wheelchair
6. Pain management
7. Wound care
8. Functional training
9. Lymphedema management
10. Bracing needs — selected as conservative care or adjust to interventions
11. Equipment needs
12. Bowel and bladder management.

Question 13

Contraindications/precautions for spinal tumors

Answer 13

1. Ultrasound
2. Diathermy
3. Laser
4. Hot/cold or topical agents at location of skin undergoing radiation

Question 14

Barriers to rehab

Answer 14

1. Patients, families, medical providers knowledge of the benefits of rehab and accessibility to rehab
2. Overwhelmed by diagnosis, complexity, cost, resources
3. Limited workforce of rehab personnel with expertise and experience
4. Lack of coordinated care
5. Lack of standardized rehab clinical protocols and outcome measures
6. Limited coverage

Question 15

Goals of rehab

Answer 15

1. Minimize negative effects of immobilization
2. Maximize safety
3. Maximize level of function
4. Ambulation IF ABLE
5. Maximize nutritional intake
6. Educate
7. Address psychosocial stressors
8. Assist in discharge recommendations

Question 16

What are barriers in acute hospitalization

Answer 16

1. Rapid changes in medical condition
2. Lack of knowledge of the role of rehab among healthcare providers
3. Delay in identification and initials of rehab
4. Gaps in communications

Question 17

What are barriers to post-acute inpatient rehab

Answer 17

1. Medical fragility of patient and increased likelihood of emergent discharge back to acute care
2. Logistical and financial implications of rehab with chemo
3. Challenges in achieving 3 hours of therapy a day

Question 18

What are barriers to therapy at any level for these patients

Answer 18

1. Fatigue
2. Poor appetitive
3. Nausea
4. Constipation
5. Insomnia
6. Cognitive deficits
7. Depression and anxiety

Question 19

What is cerebral edema/herniation

Answer 19

Cerebral edema is often associated with brain tumors. An increase in ICP may cause brain herniation or compromise of brain’s blood supply
Signs = increase in lethargy/unable to arouse, dilated pupils, headache, change in posture, change in reflexes, coma.
Treatment that can help = hyperventilation to decrease partial pressure of CO2, Dexamethasone, emergency surgery to relieve pressure

Question 20

What is epidural cord compression

Answer 20

Most commonly due to hematogenous spread of tumor cells through bone marrow leading to vertebral collapse
Signs = pain is present in 95% and usually precedes other symptoms by 1-2 months, weakness (generally symmetric), ascending numbness, autonomic dysfunction (commonly urinary retention)
Treatment that can help = corticosteroids, laminectomy/vertibrectomy, radiotherapy, chemo

Question 21

Seizures in this population

Answer 21

Increase length of seizure or duration — can sometimes be 3-4 minutes which would def be a medical emergency
- Primary role is to continue to monitor and communicate with team: change in anticonvulsant medication or dosage.

Question 22

Venous thromboembolism in this population

Answer 22

Common in individuals with brain tumor
Signs of DVT = heat, swelling, pain. Need an IVC filter placement

Question 23

Red flag headache symptoms

Answer 23

1. Change in headache intensity or duration
2. Association with fever
3. Occurring with new neurological signs

Question 24

Paraneoplastic Cerebellar Degeneration

Answer 24

Thought to have an autoimmune etiology, most common paraneoplastic syndrom affecting the brain
- Subacute syndrome that progresses over weeks ro months
- Severe truncal and limb ataxia and dysarthria

Question 25

Hydrocephalus

Answer 25

Increase in brain tumor mass impacts ventricles or normal passage of CSF Signs/Symptoms = confusion, disorientation, lethargy, headaches, irritability/personality changes, blurred or double vision, seizures, urinary incontinence, walking difficulties/balance deficits *they’ll probs need a shunt*

Question 26

Fatigue factors that contribute to cancer related fatigue

Answer 26

1. Direct cancer burden 2. Cancer treatment burden - surgery, chemo, radiation, hormone therapy 3. Psychosocial burden - depression, anxiety, sleep disruption, pain, expectancy, self-efficacy, cognition, strain on relationship 4. Comorbid conditions - anemia, muscle wasting, thyroid disease, cardiac disease, pulmonary disease, renal disease, malnutrition, infection

Question 27

Management for fatigue

Answer 27

1. Addressing pain 2. Addressing psychiatric or metabolic causes 3. Adjusting medication 4. Sleep hygiene 5. Nutrition 6. Energy conservation techniques and physical exercise 7. Psychosocial supports

Question 28

Types of cancer related pain

Answer 28

1. Nociceptive — pain triggered by activation of peripheral receptive terminals in response to noxious irritants 2. Neuropathic — pain that includes sensory abnormalities such as thermal allodynia, parenthesis, hyperalgesia, dysesthesia 3. Myofascial — pain that arises from myofascial trigger points 4. Thalamic — pain that is a central pain syndrome characterized by burning, may be activated in changes in temps 5. Funicular — central pain syndrome characterized by excruciating pain that does not follow any dined dermatomes pattern and occurs caudal to lesion due to lesion to ascending spinothalamic tracts

Question 29

Meds for cancer related pain

Answer 29

Morphine, methadone, oxycodone, fentanyl, buprenorphine - Gabapentin - Peripheral nerve block - Neuroaxial pump — infuse meds to epidural or intrathecal space - Radiation - Psychological approaches - Acupunture

Question 30

Cognitive deficits in this population

Answer 30

1. Cog deficits are common with gliomas and can impair patients’ abilities to comprehend info and specifically their capacity to provide informed consent for treatment and making plans

Question 31

What is cancer survivorship

Answer 31

- Focus is on health and well-being of an individual from the time of diagnosis to death - Inclusive of the physical, mental, emotional, social, and financial effects of cancer - Starts at the time of diagnosis and continue through treatment and beyond.

Question 32

What are 3 stages of survivorship

Answer 32

1. Acute — focused on cancer treatment and is initiated at diagnosis through the end of active treatment 2. Extended — occurs after the end of treatment and focuses on the effects of treatment and follow-up care 3. Permanent (long-term) — focuses on the years after cancer treatment has ended

Question 33

What are the important elements of survivorship

Answer 33

Nutrition — achieve and maintain close to normal BMI (referral to oncology specialist dietician) Exercise — safe , tolerable, and effective for most cancer survivors to exercise with positive effects on fatigue, emotional well being, balance, and QOL Rehab medicine is very important too

Question 34

NCCN guidelines for recommended exercise for cancer survivors

Answer 34

Participate at least 150-300 minute of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week, along with 2-3 sessions of strength/resistance training per week

Question 35

Incidirla strategy for acquiring prognostic information

Answer 35

Use all sources of information on disease and disease process — support groups, internet, opinions, emotion support groups *may have to educate them on what is accurate info or not*

Question 36

What is palliative care

Answer 36

Approach that improve the quality of life of patients and their families facing life threatening illness Addresses suffering by providing support to patients and families addressing practical needs and providing bereavement counseling Person centered

Question 37

Essential components of palliative care

Answer 37

1. Building rapport, communication, and supportive relationships with patient and family caregivers 2. Managing symptoms and existential distress like: pain, dyspnea, fatigue, sleep impairments, mood/anxiety/depression 3. Exploration of understanding and education about illness and prognosis 4. Clarification of treatment goals through ongoing communication 5. Assessment and support of coping and adjustment needs for patient and caregivers. 6. Assistance with medical decision making 7. Rehab directed toward optimizing functionality, self-efficacy, self-esteem, and independent capability 8. Coordination of care with other healthcare providers