Case study: Left craniotomy and excision of left parietal lesion (Gliobastoma multiforme, GBM)

Original Editor - Kalyani Yajnanarayan Top Contributors - Kalyani Yajnanarayan

Abstract[edit | edit source]

Glioblastoma multiforme (GBM) is an aggressive, rapid growing type of tumour located in the spinal cord or the brain. It is the most common type of primary malignant brain tumour in adults. Due to the rapid growth of the tumour, the average survival time is 12-18 months. Consequently, surgery is the primary treatment option, followed by chemotherapy and radiotherapy. In most cases, a craniotomy is performed to reach the site of lesion and the tumour is resected.

Client Characteristics[edit | edit source]

Client X is a 68 year old male admitted to the neuro-surgical ward on the 18/03/16 as an elective admission for a left craniotomy and excision of left parietal lesion (Gliobastoma Multiforme (GBM)). Client X lives with his partner in a double storey house. He is a retired laundry owner, however, occasionally does cabinet refinishing. Apart from the diagnosed GBM, he is generally fit and active. His hobbies include walking the dog twice a day and fishing. He is an ex-smoker (5 pack year) and has noise induced hearing loss and has had a right trigger finger release. He hasn’t had any recent falls and can walk unaided independently.

Examination Findings[edit | edit source]

Subjective[edit | edit source]

Subjectively, client x reported experiencing a unilateral (right side) facial droop which lasted for approximately 5-10 minutes. Since then, he has also experienced mild dysphagia and dysarthria. He denies of experiencing upper and lower limb weakness and loss of sensation. Client X was on multiple medications including; Dexamethasone, clexane, laxsol, movicol and paracetamol. Although subjectively, client x reported no issues with his activities of daily living, his apprehension about his post-op function was apparent. Although retired, client x attempted to main his physical activity by completing occasional cabinet refinishing, walking the dog twice a day and fishing. Out of all of his hobbies, client x really wanted to be able to walk his dog . Hence, his main objective in the acute neurosurgical ward was to be able to walk at least 25m (down the corridor) independently post surgery to work towards his long-term goal.

Objective[edit | edit source]

Objectively, pre-op client X was able to mobilise unaided independently. Functional tasks such as walking up and down stairs, sit to stand and transfers appeared unaffected. He had full upper limb and lower limb range of motion and full (5/5) strength on the oxford scale of manual muscle testing. He also demonstrated normal sensation on light touch and touch localisation and upper/lower limb reflexes. Vision assessment including the basic visual field test, saccades and smooth pursuit all appeared normal. Coordination and proprioception also appeared normal on the finger to nose/heel to shin and joint sense tests. The Tinetti assessment tool was used to assess his balance and gait, which he scored

According to the post-op notes following his Computed tomography (CT) scan, client x had no complications during surgery. He presented with mild oedema around resection cavity, no hemorrhage and was diagnosed with receptive dysphasia. Furthermore, pneumocephalus was seen on his CT, therefore, was on a 5 litre O2 Hudsun mask.

On physio objective assessment day 1 post-op, client X exhibited a facial droop and had no other speech apart from yes or no answers. He had full range of passive and active upper and lower limb joint range of motion. On manual muscle strength assessment, client had 0/5 strength in his right upper limb and 2/5 strength in his right lower limb. He maintained 5/5 strength in his left upper and lower limb. Due to his receptive dysphasia, touch localisation test was difficult to complete, however, joint proprioception was demonstrated and conducted and appeared normal.

Clinical Hypothesis[edit | edit source]

Main Problems (Non-physio related) Physio related: Goals?
Receptive dysphasia (client input difficult) Reduced strength:

- Risk of shoulder dislocation

Physio related goal:

•To be able to walk down the corridor (approx. 25m) independently in 1-2 weeks.

Dysarthria Immobility:

-Pressure sores

-Disuse (atrophy)

-Risk of contractures

-Reduced quality of life (QoL)

-Respiratory complications

-Increase falls risk

Emotional problems:

-Risk of depression

Intervention[edit | edit source]

Session 1 Session 2 Session 3
Supine->Sitting on the edge of the bed (SOEOB) Supine-SOEOB (teaching proper technique) Parallel bars

-step ups (10-15 reps, 2 sets)

-Sit->stand (5 reps, 2 sets)

-Weight shifts

-Walking forwards + backwards

Sitting tasks

-tapping foot on ground

-touching toe to hand

Transfer bed->commode

(sling)

Gait retraining

- Walking with one crutch (approx. 10m)

Shoulder cross-body adduction- gravity eliminated using sliding board Parallel bars

-sit ->stand (5 reps, 1 set)

-Standing with eyes closed

-Turning head side to side

-walking forwards and backwards

Outcome[edit | edit source]

As illustrated above, within three physiotherapy sessions, client X made significant progress towards his goal of walking approximately 25m independently. During the first session client X showed visible frustration on not being able to move his right upper limb. Hence, physiotherapy sessions focused on his pre-op goal and improving his function through mobility eg: being able to ambulate to the bathroom rather than having the indwelling catheter. By focusing on his activities of daily living and his goal, he started to get a sense of normalcy which motivated him to continue with his rehabilitation. Although communication was a major barrier due to his receptive dysphasia and upper limb weakness, it was tailored so that actions/tasks were demonstrated and the client was able to point to yes/no cue cards with his strong arm. Furthermore, as advised by the speech and language therapist, one-step instructions were provided to the client during tasks to avoid overloading the client with information and causing fatigue. The clients wife played a large role in the physiotherapy sessions by

Discussion[edit | edit source]

Literature on rehabilitation post brain tumour resection has been scarce, focusing on the stroke population instead which cause similar neurological and functional impairments. However, the few articles that have focused on patients with brain tumours have noted the importance of post-surgical inpatient rehabilitation. According to Kushner and Amidei, rehabilitation of patients with primary brain tumours should begin immediately post neurosurgery, once the patient is stabilised, in an inpatient multidisciplinary setting. However, if patients show signs of instability such as evolving neurological signs, persistent orthostasis, recent intracranial bleeding, altered consciousness, and/or other medical complications then mobilisation should be delayed or approached with caution. Early mobilisation in this population has shown to prevent complications such as skin breakdown, venous thromboembolism (VTE) contracture development, constipation, pneumonia and/or orthostasis. Furthermore, studies have shown that participation in multidisciplinary rehabilitation significantly improved function which patient's have maintained for up to 6 months post-op. Furthermore, self-care activities are also encouraged to be included in stable brain tumour patients as participation in self-care increases endurance, strength, problem-solving awareness etc.

References[edit | edit source]

https://www.braintumourresearch.org/info-support/types-of-brain-tumour/glioblastoma-multiforme