exercise post removal of glioma (SOL)

I would value your opinion on my approach to a patient I assessed for the first time on Wednesday.
I was asked to see a patient who had 2 wks previously undergone surgery to remove the SOL. The diagnosis from my understanding is that it was a malignant glioma that requires 6 months of intensive daily radiotherapy and chemotherapy with a rather poor prognosis and high rate of recurrence.
In terms of what he (or should I say his wife ) wanted me to do to help him was to teach him a few exercises to get him back in to shape.(Previously he was a triathlete). I did a full neuro exam and found: diminished fine hand movements (strength reduced), very slightly reduced strenth in the right arm all mm groups. His balance on the right leg was poor and there was reduced strength (slighly) in the right leg. Sensation was altered in R foot and R hand. His joint proprioception LL was also poor.
Otherwise gait was good.
From a pyschological perspective it was clear that the family was not coming to terms easily with the diagnosis. He was quiet and she was super positive.
I felt I could offer him a treatment programme to address his issues to a certain degree but the next intense phase of treatment made me feel that I should hold back a bit and wait to see how he felt on starting his treatment. Was I right in my decision or should I have got in there been dynamic and started right away? I spent 50 minutes with him and the next day dropped in some patient exercise sheets of the basic exercises that i had shown him. I simply left it that I could see him whenever suited him and looked forward to this opportunity.

Any comments?

[sdkashif]

What ever is the neurological deficit, keep in mind that there may be the deficits that may remain permanently after surgery due to the effects of surgery that might have caused damage to the brain cells. That could be the permanet damage. And there might be the neurological dysfunction that may be the oedema of the surrounding neural tissue of being excised. So there still are the chances, that the remaining neurones may be in good function when that oedema resolves. Also don't forget the development of alternative path ways. Do a good neurological assessments to assess the disabilities, abilities and needs of the patient & make a suitable plan of Physiotherapy according to that.

Do the assessment of followings:

Sensory Assessment

Co ordination assessment

Motor assessment

Gait analysis

Functional assessment

Environmental assessment

Psychosocial assessment

Orthotic assessement

Make your strategies to improve motor control and motor relearning accordingly.

Also have a look over these information resources.

<a href="http://www.emedicine.com/pmr/topic226.htm" target="_new">Physiotherapy for Oncology</a>

<a href="http://www.csp.org.uk/uploads/documents/csp_statement_physioandcancer.pdf" target="_new">The Role of
Physiotherapy for People with Cancer - CSP Position Statement</a>

<a href="http://www.csp.org.uk/uploads/documents/evidencebrief_palliative_EB04.pdf" target="_new">The effectiveness of physiotherapy in the palliative care of older people</a>

<a href="http://www.acpopc.org.uk/acpopc/home.asp" target="_new">Oncology and Palliative Care- The Association of Chartered Physiotherapists in Oncology and Palliative Care</a>

<a href="http://www.oncologypt.org/pubs/index.cfm" target="_new">American Physical therapy Oncology Section</a>

<a href="http://www.ncnm.ie/files/publications/National%20Advisory%20commitee%20on%20palliative%2 0care.pdf" target="_new">National Advisory Committee on Palliative Care</a>

Thank you for your detailed reply. I did a detailed neuro exam when I saw the patient and identified problems to work on and used the same cl reasoning as to the selection of exercises to facilitate the creation of new neuro pathways and improved function. I am just waiting for the pt to get back to me to start rx. He has just started very aggressive chemo and radiotherapy. He is also doing a general strengthening programe with another physio. I hope he will want to do a more neurologically based rx with me but his schedule is packed with hospital visits.

I would say use your judgement in terms of treatment intensity. There is little to be gained from backing off, but at the same time you can expect a deterioration for around 2-4 days post chemo especially if associated with nausea, headaches and fatigue. Same for RTx but usually less nausea (if not whole brain irradiation). If he had sx 2/52 ago most of the post op oedema should have settled and you should have a fairly realistic picture of impairments. Was there any gliadel wafers inserted? any dex used, seizures etc. (The amount of dexamethasone is a good indicator of brain swelling)

It is often very difficult for pts to deal with aggressive brain tumours especially if they have been very fit, physio offers them a way of tackling the tumour effects on their own- giving some semblence of control back.

I understand your predicament but it is likely that the family are aware exactly of what the diagnosis entails - you have to trust your patient and his wife and let them handle it in their own way- maybe suggest referral to mcmillan team/ local hospice for support? If you are concerned try and get him alone- maybe suggest she makes you all a cup of tea while you make some goals, or have him come to an OP appointment with you. I've always found both parties are afraid to upset the other - as one patient told me 'there's plenty of time for that later'

Try an make short term goals and suggest looking into what may happen IF (no guarantees) there is a functional deterioration. What is the minimum he need to be able to do to stay successfully at home? The earlier the support goes in/ is made aware of the situation the better. You are looking at quality not quantity of life here and always keep that in mind.

Thank you very much for your reply. It really helps to know that there are fellow physios to help even though I work alone. I was asked to see this gentleman by a family friend because we live in a non english speaking country. Physio is rather different here and it is true that the physio he is having here with another physio takes a non neuro approach. I however have very limited SOL experience. I have done alot of reading and I understand the emphasis you have encouraged me to have on treatment. I hope I have the opportunity to treat him as genuinely physio will provide a very positive approach. I wish we had McMillan nurses here they provide an enormous amount of support that this family needs. The difficulty for me will be getting the information from the surgeon about diagnosis treatment and prognosis. I am the physio who has been referred the patient by the consultant. Instead I came in as a private physio to give an opinion and provide a pilates program which in the end is not absolutely what he needs.
Thanks for your reply.