Craniotomy of Gliobastoma Multiforme: A Case Study
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]
On subjective assessment, 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.
Objective[edit | edit source]
Objectively, pre-op client X had 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. Coordination and proprioception also appeared normal on finger to nose/heel to shin and joint sense tests.
According to the post-op notes following his CT, client x had no complications during surgery, he had no haemorrhage, mild oedema around resection cavity, Pneumocephalus and as a result was on 5L O2 Hudsun mask and diagnosed with receptive dysphasia. On physio objective assessment, post-op client X exhibited a facial droop and had no other speech apart from yes or no answers.
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. Although communication was a major barrier due to his receptive dysphasia and upper limb weakness, it was tailored so that 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.
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
