Functional outcome of inpatient rehabilitation in persons with brain tumors

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Functional Outcome of Inpatient Rehabilitation With Brain Tumors

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Michael W. O’Dell, MD, Karen Barr, MD, David Spanier, MS, Ronald E. Warnick, MD ABSTRACT. O’Dell MW, Barr K, Spanier D, Warnick RE. Functional outcome of inpatient rehabilitation in persons with brain tumors. Arch Phys Med Rehabil 199879: 1530-4. Objective: To document functional outcome in persons with brain tumors undergoing inpatient rehabilitation and to compare outcomes with a group of traumatically brain injured patients. Design: Retrospective, descriptive, and case-matched. Setting: A free-standing inpatient brain injury rehabilitation unit. Participants: Forty consecutive patients with a variety of tumor types (40% were either glioblastoma multiforme or meningioma) and a mean age of 53.1 (SD 15.4) years. Sixty percent were men, 25% had recurrent tumors, and 15% had metastatic disease.Also, 40 patients with traumatic brain injury (TBI) matched for age, gender, and admission functional status. Main Outcome Measures: Change in Functional Independence Measure (FIM) scores, length of rehabilitation stay (LOS), and discharge disposition. Results: The mean LOS for the tumor group was 17.8 (SD 9.9) days, mean FIM gain was 25.4 (SD 20.1) points, and 82.5% were discharged home. No demographic or tumor characteristic was statistically significant in predicting functional outcome at discharge, but greater gains were seen for persons with the diagnosis of meningioma, those with left-sided cerebral lesions, and those not receiving radiation therapy. TBI patients made statistically significant greater gains in total FIM change (34.6 vs 25.4), self-care (12.3 vs 8.5), and social cognition (5.2 vs 3.6). However, FIM efficiency and LOS were not statistically different between the TBI and tumor groups (1.9 vs 1.5 FIM points/day and 22.1 vs 17.8 days, respectively). Conclusions: Daily functional gains made by persons with brain tumor undergoing rehabilitation were similar to those made by a group of persons with TBI matched by age, gender, and admission functional status. Further research should use larger samples and address the impact of psychosocial and team factors on LOS and discharge disposition. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation From the Demrtment of Phvsical Medicine and Rehabilitation (Dr. O’Dell. Dr. Barr. Mr. Spanier) aid Department bf Neurosurgery (Dr. Wamick), University of dincinnati College of Medicine: and Mayfield Clinic (Dr. Warnick), Cincinnati, OH. Submitted for publication March 4, 1998. Accepted in revised form June 20, 1998. Presented in part at the 58th Annual Meetings of the American Academy of Physical Medicine and Rehabilitation, October 11, 1996, Chicago, IL. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Dr. O’Dell is now Medical Director, Regional Center for Brain Injury Rehabilitation. Southside Hosuital. Bav Shore. NY. and Lonrz Island Jewish Medical Center. New Hyde Park, N?. D;. B&r is now a&ated with the Department of Physicai Medicine and Rehabilitation, Eastern Virginia University Medical School, Norfolk, VA. Reprint requests to Michael W. O’Dell, MD, Medical Director, Brain Injury Rehabilitation Program, 2440 Brackett Building, Southside Hospital, 301 East Main Street, Bay Shore, NY 11706. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7912-4910$3.00/O

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M

ANY IMPAIRMENTS and subsequent disabilities are associated with cancer, prompting some authors to state that nearly all patients with cancer can potentially benefit from rehabilitation assessment and intervention.‘” At least one author’ has suggested that rehabilitation evaluation should be routinely incorporated into the health care of all cancer patients. Relatively little outcome data are available, however. Among persons with disability from cancer, those with brain tumors (BTs) are a special challenge, given the potential for a combination of physical, cognitive, and communication deficits in addition to the psychological stress associated with the diagnosis of malignancys4 The incidence of BTs is increasing with more than 17,500 primary BTs diagnosed each year in the United States.5Gliomas make up approximately 50% of all primary brain tumors.6 The most common and aggressive type is glioblastoma multiforme (GBM).7 Metastatic tumors account for approximately one half of all BTs and most often originate from primary tumors of the lung, breast, and gastrointestinal tract.8 Functional deficits associated with BTs result from primary tumor effects (destruction of tissue, compression of normal brain, increased intracranial pressure), side effects of treatments (postsurgical tissue loss, steroid myopathy?) sedating medications for pain or seizures, and the immediate or delayed effects of radiation and chemotherapy. lo Common neurological impairments associated with BT are hemiparesis, cranial nerve deficits, and cognitive deficits including visual perceptual problems, attention deficits, and language dysfunction.11J2 In addition to focal neurological deficits, patients can experience deconditioning from protracted illness, nutritional compromise, and psychological stress (for both patient and family).13 Vocational reintegration is a reasonable consideration in certain circumstances.14Early detection with advanced neuroimaging and aggressive combination treatments may allow rehabilitation professionals the opportunity for earlier evaluation and treatment of functional deficits in BTs over longer periods.15 Given the increasing numbers of BTs, multiple functional deficits in this population, and promising treatment advances, health care professionals and third-party payers might ask whether these individuals are appropriate for rehabilitation services, including inpatient rehabilitation. Therefore, the purposes of this study were (1) to document functional outcome in a group of patients with BTs undergoing inpatient rehabilitation within a brain injury rehabilitation program, (2) to identify factors associated with functional outcome at discharge, and (3) to compare functional outcome with a group of patients with traumatic brain injury (TBI) matched for age, gender, and admission functional status. METHODS We retrospectively reviewed all patients with a diagnosis of BT admitted to The Drake Center Brain Injury Rehabilitation Unit from March 1994 to December 1996. The majority of patients were referred from a large, tertiary teaching hospital. Charts were reviewed for age, gender, concurrent treatments (radiation and/or chemotherapy), acute care transfer, and discharge disposition. Tumor characteristics were documented,

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including tissue diagnosis, location by neuroimaging and/or operative report, and whether the tumor was newly diagnosed or recurrent, primary or metastatic. In some cases, the referring neurooncology and neurosurgery services were contacted for further clinical information. Admission and discharge functional status were measured using the Functional Independence Measure (FIM), which measures disability in the areas of self-care, mobility, locomotion, sphincter control, communication, and social cognition. Each of 18 items is scored from 1 (dependent) to 7 (independent.) FIM scoreswere assigned by an interdisciplinary brain injury rehabilitation team that undergoes yearly training and reevaluation for interrater reliability. The validity and reliability of the FIM have been well documented.16-ls We also identified patients with an admitting diagnosis of TBI who completed inpatient rehabilitation on the same unit during the same approximate time period. TBI patients were matched to BT patients by admission FIM score (2.5 FIM points), age (t5 years), and gender, in that order. Under these criteria, all patients were matched for admission FIM score and age, with 36 of 40 (90%) matched for gender (4 women with BT were matched with men with TBI). Statistical Analysis Descriptive statistics such as means, medians, and standard deviations were used to characterize continuous variables and frequency distributions for categorical variables. Significant differences in discharge outcomes among BT subgroups and between the BT and TBI groups were tested using x2 analysis for categorical variables, Mann-Whitney U (for comparison of two groups), or the Krusgal-Wallis test (for comparison of three groups) for noncontinuous variables, and two-sample t tests for continuous variables. All analyses were completed using Statistix for Windows.lg RESULTS Demographics Forty-two persons with an admitting diagnosis of BT were identified. Two (4.8%) were excluded: one for neurological deficits caused by an unrelated stroke and a man with a 12-year history of recurrent meningioma admitted for deconditioning after multiple seizures without a documented new cerebral lesion. The final sample consisted of 40 patients, the demographic and clinical characteristics of whom are presented in table 1. In general, the sample represents a wide range of BT types, but most were primary tumors of glial derivatives, consistent with the overall demography of brain tumors.‘j The tumors were recurrent in 10 of 40 (25%) of cases.All 5 patients (12.5%) with metastatic BTs presented with primary disease of the lung. Although many patients received radiation therapy and chemotherapy after discharge from inpatient rehabilitation, only 17.5% and 12.5%, respectively, received these modalities during inpatient rehabilitation. Functional Outcome and Comparison to TBI Outcome data for the BT group are presented in the first column of table 2. The group had a mean length of stay (LOS) of 17.8 days (SD 9.9). The mean FIM scoresat admission to and discharge from inpatient rehabilitation were 71.5 (SD 23.6, median 71.5) and 96.9 (SD 23.5, median 101.5), respectively, for a mean FIM change of 25.4 points (SD 20.1, median 20.5). The variability of admission and discharge FIM scores were considerable, including an admission score of 126 in a patient with a 2-day LOS. Another patient dropped 14 FIM points to a

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Table

1: Characteristics

Parameter

of Patients

-

%

With Mean

Range

SD

53.1 11.1

26-87 Z-60

15.4 9.5

17.8

4-46

9.9

Age (vrs) Acute LOS (days) Rehabilitation LOS (days) Gender Male

60.0

Female Recurrent Concomitant

tumor RT

Concomitant Metastatic

CT disease

40.0 25.0 17.5 12.5 15.0

Histology GBM

20.0 20.0

Meningioma Astrocytoma

12.5 12.5

Metastatic* Oligodendroglioma Pituitary Other

5.0 5.0

adenoma

25.0

Tumor location Frontal lobe Parietal

BT (II = 40)

27.5 12.5

lobe

Temporal lobe Ventricular Frontoparietal

10.0 10.0 7.5 5.0

Occipital Parietooccipital

5.0 5.0

Pituitary Other

17.5

Abbreviations: BT, brain tumor; SD, standard of stay; RT, radiation therapy; CT, chemotherapy; multiforme. * All metastatic tumors were from lungs.

deviation; GBM,

LOS, length glioblastoma

discharge score of 28 before transfer back to acute care, where she died. Both cases reflect extremes but are included here as representative of the continuum of possible outcomes in this population. Eventual home discharge occurred in 33 (82.5%) patients, transfer back to acute care in 3 (7.5%), and nursing home placement in 4 (10%). Two of three patients who were transferred to acute care returned to rehabilitation and were discharged home, bringing the ultimate home discharge rate to 87.5%.

No demographic or tumor characteristic effectively distinguished outcome in the BT group. Table 3 compares mean change in FIM scores based on various tumor or patient parameters. Because of the small sample, tumor types and locations were combined post hoc to achieve acceptable numbers for analysis in each cell. In general, the outcomes were fairly balanced in most categories, and in no case were statistically significant differences for change in FIM scores found. However, the absolute differences in mean change scores were notable for higher gains among patients with a diagnosis of meningioma, lesions in the left hemisphere, and those not receiving concomitant radiation therapy. As expected, the matched variables of age (means, 52 years for TBI vs 53.0 years for BT; two-sample t test), gender (30% female for TBI vs 40% female for BT; x2 analysis) and admission FIM scores (means, 71.2 points for TBI 71.4 points for BT, Mann-Whitney U test) were not statistically different between the TBI and BT groups. Mean gains among the six subcategories of the FIM and comparisons to matched TBI cases are presented in figure 1. Mean gains were uniformly greater in the TBI group compared with the BT group. Arch

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1532 Table

2: Outcome

Parameter

for BT and TBI Groups BT Group

Admission FIM Mean Median SD Discharge FIM Mean Median SD Change in FIM* Mean Median SD Disposition (%)+ Home Nursing home Acute care Length of stay (days)* Mean Median SD FIM efficiency” Mean Median

IN BRAIN

(n = 40)

TBI Group

(n = 40)

71.5 71.5 23.6

71.1 71.5 22.0

96.9 101.5 23.5

105.8 111.0 14.9

25.4 20.5 20.1

34.6 31.5 15.1

82.5 10.0 7.5

92.5 7.5 0.0

17.8 15.5 9.9

22.1 19.5 13.6

1.5 1.1

1.9 1.1

Abbreviations: BT, brain tumor; TBI, traumatic Functional Independence Measure; SD, standard * p < .02, Mann-Whitney Utest. + Not significant, x2 analysis. * Not significant, two-sample ttest. * Not significant, Mann-Whitney Utest.

brain injury; deviation.

FIM,

However, differences were statistically significant only in self-care and social cognition, with trends toward significance in mobility and locomotion. When the shorter LOS in the BT group were considered, however, the gains per day (so-called FIM efficiency20-22)were not significantly different between groups (TBI, 1.9 (SD 1.1); IT, 1.5 (SD 1.1); p = NS, MannWhitney U test; table 2). DISCUSSION Over the past decade, the treatment of BTs has advanced considerably with the addition and refinement of chemotherapy, radiation, and surgical approaches, as well as newer advances in gene therapy and alternative delivery systems.4~23,24 Although survival remains relatively poor in high-grade gliomas15 and metastatic disease,25some improvements have been achieved, especially among specific subtypes and presentations.26 Treatment advances and subsequent enhanced survival time have focused concern on the quality of life in BT, including physical and cognitive disability.27,28 In addition to the physical and cognitive sequelae of the neoplasm itself, longer survival magnifies the importance of disability caused by subacute and long-term complications associated with treatment modalities, especially radiation therapy.4,10,2g-31 The role of rehabilitation medicine in the care of persons with cancer in general has been discussed extensively.1-3,32-34 Until the past few years, however, relatively little has been published examining rehabilitation management or outcomes, including specifically BTs. Marciniak and colleaguesi examined functional outcome in a group of 159 persons with cancer undergoing inpatient rehabilitation from 1989 through 1991,72 of whom had “primary intracranial neoplasms.” Of the BTs, 75% were discharged home with a mean LOS of 34 days. Thirty-five percent required transfer to acute care, and 18% Arch

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received radiotherapy during rehabilitation. Rasch-converted FIM gains were approximately 13 points for the entire sample, although not delineated specifically for the BT group. Huang and coworkers22 recently reported preliminary data comparing inpatient rehabilitation outcome between 49 BT and acute stroke patients matched for age, gender, and location of lesion. The BT group had similar functional outcomes (measured by the FIM) and a shorter rehabilitation LOS (24 vs 36 days) compared with the stroke group. Sherer and associatest4 retrospectively described outcomes in 13 patients with BT (mostly anaplastic gliomas) who participated in a postacute, outpatient rehabilitation program designed primarily for patients with TBI. Mean age was 34 years, and time from BT diagnosis to admission was 75 months, reflecting a group with relatively nonaggressive disease. After a mean treatment time of 2.6 months (mean number of treatments, 20), most of the group made gains in independence and productivity that appeared to be maintained at a mean S-month follow-up. The authors concluded that the outpatient approaches developed for patients with TBI are also efficacious with patients with BTs. Our data on age, concomitant RT, gender distribution, home discharge rate, and tumor histology compare favorably with those of Marciniak.l’ LOS and rate of transfer to acute care in our sample, however, were considerably lower than those reported by Marciniak. Our 18-day LOS may reflect a more “managed” market 5 years after collection of the Marciniak data and is in line with more recent reports.22In that our facility is several miles from an acute care hospital, we may have a higher threshold for medical stability at admission, resulting in fewer acute transfers. Unfortunately, it is not possible to compare functional outcomes because our FIM scores are not Rasch-transformed. Unfortunately, we were not able to identify demographic or tumor characteristics that effectively distinguished functional Table 3: Factors

Associated

Parameter(n)

Gender Male (24) Female (16) Concomitant CT Yes (5) No (35) Concomitant RT Yes (7) No (33) Recurrent tumor Yes (IO) No (30) Tumor location Frontal lobe (15) Nonfrontal (25) Hemisphere(s) Right (16) Left (16) Bilateral (8) Tumor histology Meningioma (8) GBM (8) Other (24)

With

Outcome

Mean FIM Change

in Patients

With

(SD)

p Value

26.8 (23.5) 26.5 (18.0)

>.10*

21.0 (11.5) 26.0 (21.1)

>.lO”

17.0 (15.3) 27.2 (20.1)

>.lO”

26.8 (21.9) 24.9 (19.9)

>.10*

24.9 (17.4) 25.6 (21.9)

>.lO”

20.6 (17.3) 30.3 (20.9) 25.3 (23.8)

>.10+

32.8 (20.8) 18.6 (16.5) 25.2 (20.1)

>.10+

Abbreviations: BT, brain tumor; FIM, Functional sure; SD, standard deviation; CT, chemotherapy; GBM, glioblastoma multiforme. * Mann-Whitney Utest. + Krusgal-Wallis test.

Independence RT, radiation

BT

Meatherapy;

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Selfcare’*

Sphincter

IN BRAIN

Mobility*

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Locomobd

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Communication Cognition**

Fig 1. Comparison

of TBI (U) and BT (H) groups

gains during inpatient rehabilitation of BT patients. The small sample size certainly limits the power of these analyses. Substantially, if not significantly, better gains noted in patients with a diagnosis of meningioma or left hemispheric lesions and in patients not receiving radiation therapy, however, are interesting and warrant further comment. Davies and associates2ghave also noted a detrimental effect on physical function and Scheibel and colleagues35on cognitive function among persons receiving cranial radiation therapy. Scheibel also found no difference in cognitive function between those patients with GBM and those with other, less aggressive tumor types after surgery. However, data in both the above studies were collected in an outpatient setting considerably further from the time of surgery than our sample. The poorer performance of radiationtreated patients in our study might also reflect more aggressive disease, requiring multiple modalities for treatment, rather than a detrimental effect of the modality itself. Better functional gains in persons with left hemispheric lesions might reflect relatively poor outcomes seen with neglect in right-sided lesions. This finding must be confirmed in future, larger studies because this trend has not been observed with other braininjured patients undergoing inpatient rehabilitation.36,37 Consistent with the preliminary data by Huang22 as discussed above, our data indicate that patients with BTs show functional gains comparable to those of patients with other causesof brain injury, in this case TBI. Although the absolute functional gains were smaller in the BT group, the shorter LOS resulted in FIM efficiencies not statistically different from those of the TBI group (1.5 for BT vs 1.9 for TBI.) The shorter LOS in the BT group (also noted by Huang) may be related to several factors. Patients with traumatic injuries tend to fall in the lower socioeconomic strata and experience substantial behavioral problems,3g which may place BT patients in a relatively better position for family support at home and resource availability, resulting in earlier home discharge. Although not specifically tracked, the rehabilitation team also may have made a special effort to discharge BT patients home earlier to “enjoy their

(*p <

.lO;

**p

< .05; Mann-Whitney

Utest).

remaining time with family.” It has been suggested that BT patients experience fewer cognitive deficits than stroke patients who have similar lesions.39 Although our comparison group was traumatically injured and not matched for site of lesion, they were well matched for functional status (in so much as the FIM accurately represents cognitive and motoric status), making milder deficits among the BT group an unlikely explanation for the shorter LOS. This study has several limitations. The relatively small sample size, combined with a large variety of tumors and locations, limits the analyses of specific factors for prognosis of functional outcome. We studied only patients who were admitted to inpatient rehabilitation, which most likely restricts our sample to persons with moderate to severe disability caused by BT. Our data are retrospective and were collected at a single site as part of a brain injury rehabilitation program; results may not generalize to other institutions or to BT patients cared for on general rehabilitation units. Although we chose to match BT and TBI by admission FIM score, other matching strategies such as anatomical location of lesion or function-related groups are also reasonable and may have led to different conclusions. In summary, daily functional gains made in inpatient rehabilitation by persons with BTs appear to be comparable to those made by persons with TBI. Although the absolute functional gains are somewhat less in the BT group, the shorter LOS results in similar FIM efficiencies. Neither tumor nor demographic characteristics effectively distinguished discharge outcome, although these analyses are limited by the small sample size. Further research using larger samples should attempt to identify factors associated with functional outcome, including lateralization of tumor and impact of psychosocial factors on discharge planning, and assessthe need for models of inpatient rehabilitation tailored specifically to persons with BT. References 1. Ganz PA. Current issues in cancer rehabilitation. 742-51. Arch

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