Combined Neurophysiotherapy and Accelerated Skill Acquisition Programme in Improving Upper Extremity Motor Function in Hemiplegia after Brain Tumour Resection
Correspondence Address :
Dr. Purva Hanumanprasad Mundada,
Arihant Apartment, F2, Behind Yashodeep Convent School,
Wardha, Maharashtra, India.
Astrocytomas are one of the most common primary tumours of central nervous system seen in paediatric population. Although it is treatable and has a good prognosis, some individuals suffer from motor dysfunction following brain tumour resection which could result in decreased mobility, difficulty with daily tasks, increased risk of immobility-related problems, falls, pain, anxiety/depression. Thus, having a negative impact on overall quality of life and functional independence. Comprehensive neurophysiotherapy in such cases play a critical role in preventing and alleviating motor dysfunction, and its effects, and improve functional independence. This is the report of a 10-year-old female with astrocytoma in the right frontoparietal lobe, which was diagnosed using magnetic resonance imaging and immunohistochemistry. She underwent craniotomy for the same. But after tumour resection, she developed left hemiplegia wherein involvement of upper limb was more as compared to lower limb. She was given neurophysiotherapy and Accelerated Skill Acquisition Programme (ASAP) which aided in improving upper extremity motor function and functional independence.
Diffuse fibrillary astrocytoma, Neurophysiotherapy, Quality of life, Rolling facilitation
A 10-year-old female patient presented to the Department of Neurology with the complaints of headache on and off from last 4-5 months which increased during the last month with multiple episodes of vomitting since 15 days which increased subsequently in last three days. She had history of two episodes of Generalised Tonic Clonic Seizures (GTCS), one episode of fever and incoherent talk 15 days ago. The patient was not taking any medications for the same. Magnetic Resonance Imaging (MRI) brain (plain and contrast) revealed High Grade Astrocytoma (HGA) in the right frontoparietal lobe (Table/Fig 1), (Table/Fig 2), (Table/Fig 3). Right frontal minicraniotomy and navigationguided excision of the tumour was done under general anaesthesia. The tumour was subcortical greyish white soft to firm and had no plane of cleavage with brain parenchyma. Complete tumour excision was done. Immunohistochemistry testing of the biopsy sample confirmed the diagnosis as diffuse fibrillary astrocytoma, World Health Organisation (WHO) grade II (1). Repeat MRI brain (plain and contrast with spectro) showed T2 hyperintense cystic lesion with peripheral haemorrhages involving right frontotemporal lobes (Table/Fig 4), (Table/Fig 5). Postoperatively, she developed left hemiplegia which was greater in the Upper Limb (UL) than Lower Limb (LL). She was referred to Physiotherapy Department for the same. After taking consent from her mother, physical examination was carried out.
The patient was assessed in supine lying position on the bed with pillow under cervical spine for support. On general examination, vitals were stable. She was conscious, co-operative and well oriented to time place and person. On observation, the attitude of limbs for the right UL was adduction and internal rotation of the shoulder with elbow and wrist in extension by the side. On left side, shoulder was adducted, externally rotated with elbows and wrist in extension by the side. In bilateral LL, her hips were extended, adducted, externally rotated with the knee in extension and ankle in slight plantar flexion. On examination, higher mental functions were normal (the score was 26/30 on Mini Mental Scale Examination (MMSE) (2). Cranial nerves were intact.
On sensory examination, superficial, deep, and cortical sensations were intact bilaterally over UL and LL along with the trunk. On motor examination, muscle tone was flaccid for left UL and LL and normal for right UL and LL. On Voluntary Control Grading (VCG), her left UL and LL had grade 0. Muscle power was 0/5 for UL and 1/5 for LL on left side and for right UL and LL 4/5. Grading of Deep Tendon Reflexes (DTRs) is given in (Table/Fig 6) (3) and superficial reflex (plantar) in (Table/Fig 7). As for functional ability, she was able to roll in bed on her own on the affected side.
Therapeutic intervention: Neurophysiotherapeutic interventions and Accelerated Skill Acquisition Programme (ASAP) with rationale, strategy and regimen are given in (Table/Fig 8) (4),(5) and (Table/Fig 9) (6), respectively. Follow-up and outcome details are stated in (Table/Fig 13),(Table/Fig 14),(Table/Fig 15),(Table/Fig 16) (7),(8).
Action Research Arm Test (ARAT): ARAT is an arm-specific activity limitation test that evaluates a patient’s capability to handle objects of various sizes, weights, and shapes. It is ordinally graded on a scale of 3 (normal movement) to 0 (no movement) (9). Intervention induced changes on different ARAT components (Grasp, grip, pinch and gross movement) is shown in (Table/Fig 14)a,b,c,d. For all the components, findings were nil on day 1. However, intervention induced improvements were notable on day 28 and day 56.
Wolf Motor Function Test (WMFT): The WMFT is a test that evaluates stroke survivors’ UE motor skills (10). Intervention induced changes on different WMFT tasks is shown in (Table/Fig 15). From the figure, it can be noted that before intervention the tasks that were affected were- Extending elbow with weight (side), lifting pencil and paper clip and flipping cards, however, as with other tasks, notable intervention induced changes were seen in these tasks as well on day 28 and 56.
European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Brain Neoplasm (EORTC QLQ-BN20)
It is a validated 20-item QOL questionnaire for PBT patients. Later two extra questions were included to test cognitive function (11). Intervention induced changes on EORTC QLQ-BN20+2 is shown in (Table/Fig 16). It could be noted that following neurophysiotherapeutic and ASAP intervention, changes were seen not only in motor dysfunction and leg weakness components, but on some other components as well showing these interventions play an important role in improving overall QOL and necessitating utilisation of holistic approach in terms of patient and caregiver’s counselling and constant encouragement.
Astrocytic Brain Tumours (BT) are the most frequent type of juvenile neoplasm, accounting for almost 20% of all intracranial tumours in children under the age of 18 (12). Central Nervous System (CNS) tumours account for 1.9% of all cancers diagnosed in India (13). Astrocytomas (38.7%) were the prevalent Primary Brain Tumors (PBT), with the majority being high-grade gliomas (59.5%), according to an analysis of hospital-based datasets tracking CNS malignancies (14). In both children and adults, gliomas are the frequently seen PBT arising from glial cell neoplasia (15). The World Health Organisation (WHO) divides this diverse group of tumours into four main categories i.e, astrocytomas, oligodendrogliomas, mixed oligoastrocytomas, and ependymal tumours (16). The most frequent of these tumours is astrocytoma (17). Astrocytomas are tumours that develop from astrocytes, which are glial cells having a star-shaped form that protect and support neurons, as well as assist in the transmission of information between them and are important for decoding signals in the brain (18). There are the four types of astrocytic tumors defined histopathologically according to WHO criteria (1):
• Pilocytic astrocytoma (grade I),
• Diffuse astrocytoma (grade II)
• Anaplastic astrocytoma (grade III)
• Glioblastoma (grade IV).
Histologically grade II astrocytomas are defined by homogeneous masses with uneven boundaries and worsened differentiation, caused by a suspected p53 gene mutation (causing hereditary propensity to cancer) and loss of chromosome 17 heterozygosity (12). These tumours have more likelihood to develop in younger adults as well as they frequently advance to higher-grade tumours, although sequential evolution is seldom recorded in children (15). They have a high recurrence rate because of hypercellularity and widespread invasion into the surrounding cerebral parenchyma (1),(17).
Bases on the tumours, location, aggressiveness, and age of onset, the signs and symptoms may differ (19). Before being diagnosed, almost half of the children will have experienced symptoms for 6 months or more (20). Symptoms are vague and could be the result of increased intracranial pressure caused by ventricular obstruction, viz headache particularly in the morning, nausea, vomiting and lethargy. Reduced upward gaze, sixth cranial nerve palsies and papilledema are among the physical examination findings. Seizures, behavioural abnormalities, unilateral paresis, monoparesis, hemisensory loss, dysphasia, aphasia, irritability, an alteration in feeding pattern, and deterioration of recent memory are among other clinical manifestations (19),(20). This is consistent with the clinical findings reported in the present case.
Basic MRI modalities, native T1-Weighted Images (T1WIs), T2-WIs and T2-Fluid-Attenuation Inversion Recovery (T2-FLAIR) sequences, provide preliminary information about tumours (21). On conventional MRI, HGA usually shows strong contrast enhancement, peritumoral edema, mass effects, heterogeneity, central necrosis, and intratumoral haemorrhage (22). This is in consistence with the present case which revealed ill-defined intra-axial mass lesion in right frontoparietal lobe with significant mass effect and perilesional white matter oedema. The lesion was iso to hyperintense in both T1WIs and T2WIs and showed hyperintense Signal Intensity (SI) on FLAIR images. Postcontrast study revealed nodular and patchy areas of enhancement within the lesion. Diffusion Weighted Images (DWIs) showed multiple foci of low Apparent diffusion coefficient (ADC) in right caudate nucleus, right Basal Ganglia (BG) and corpus callosum with corresponding diffusion restriction. DWI findings are not consistent with those reported by Alshoabi SA et al., (21). In present case, on Magnetic Resonance Spectroscopy (MRS), reduced N-Acetylaspartate (NAA) levels were noted which is in consistence with Alshoabi SA et al., (21). Although, MRI findings were suggestive of HGA, immunohistochemistry testing of the biopsy sample confirmed the diagnosis as diffuse fibrillary astrocytoma (WHO grade II). Some of the postoperative MRI findings were in consistence with those reported by Soliman S and Ghaly M, (23) (Table/Fig 17).
The primary treatment for high-grade gliomas is surgical excision, it allows pathologists to obtain a tumour sample, lowers intracranial pressure, and shrinks the tumour. Complete resection has been linked to a better prognosis, but it is difficult to obtain. The fact that BT borders are difficult to determine and surgery could affect brain function pose challenges (19). Furthermore, due to the close vicinity to the brain stem and enlarged and soft cranial nerves (oedema) during tumour resection, neurological deficit usually occurs in 30% of postoperative patients, but half of this is transitory (24). In most cases, complete surgical removal of these tumours is not possible (17). Post-tumour resection, hemiplegia is one of the common neurological issues seen in these patients which affects functional independence and thus an individual’s quality of life (23). In present case as well, post-tumour resection, hemiplegia was noted.
Brain tumours has been demonstrated to be a risk factor for acute ischaemic infarction, and vice versa. Ischaemic stroke patients are more likely to develop BT, usually glioma, as a result of alterations in the cell’s functional and metabolic status caused by ischaemia and hypoxia. Astrocytic activation, reactive gliosis, angiogenesis, and other changes in the tumour microenvironment are all generated by cerebral ischaemia as a result of glioma growth and are thought to play a role in the interaction among the two processes. Moreover, the frequency with which gliomas are resected increases the risk of ischaemic damage (23). 50 % of the patients experienced ischaemic infarction in an acute stage post tumour resection in a research trial of 66 patients with ischaemic stroke and an antecedent BT (25).
Preoperatively, the index patient suffered from weakness over right side and postoperatively, from left sided hemiplegia. Given the resemblance in symptoms between stroke and BTs, this is not astonishing that rehabilitative efficiency is comparable in terms of several outcome measures. Yu J et al., found significant functional improvements in BT patients who received comprehensive rehabilitation for motor, balance, cognition, and Activities of Daily Living (ADL) function. This was comparable to the improvement seen in stroke patients (26). Motor dysfunction in PBT results from direct impact of tumour site and swelling, and/or treatments such as surgery, chemotherapy, radiation, steroids, and/or other medications. It is characterised by unilateral or bilateral weakness, ataxia, spasticity, and the inability to execute complex movements (3). Following brain surgery, paralysis-related weakness is most noticeable. Over the course of weeks or months, strength may recover. In general, the sooner one regains strength, the faster the recovery (27). Consequently, patients need long-term integrated and coordinated management, comprising of rehabilitation, in order to improve their functional, mental and emotional well-being, and quality of life.
As per reports, people with BT can achieve functional improvements comparable to those with stroke and traumatic brain injury when undergoing inpatient rehabilitation. Physiotherapy and occupational therapy are recommended by the Australian Cancer Network (ACN) for patients with residual motor deficits (strength, coordination, and balance) and residual issues in self-care and functional independence respectively (28). As soon as the patient is stabilised following surgery, neurophysiotherapeutic rehabilitation should begin in PBT patients during an acute care stay.
Preventing medical problems and encouraging early mobilisation and resuming of self-care activities are the primary consideration during acute care (3). Along with, all of these above-mentioned facts, thorough patient assessment and reference from literature related to physiotherapy management of hemiplegia were taken into consideration while designing rehabilitation protocol for the present case. As literature have stated, main focus of rehabilitation was on improving functional mobility, strength, coordination, balance, gait and ability to execute ADLs and also more importantly on prevention of hazards of bed rest. Needless to say, all of these motor functions are inter-related with each other, so all of them should be given attention to while designing treatment protocol as well as while administering the same. Rationale, strategy and regimen of all the neurophysiotherapy interventions is mentioned in therapeutic intervention (Table/Fig 8). As mentioned previously as left UL was more involved than left LL, along with conventional neurophysiotherapy interventions we have also given one of the proven UE motor training intervention- ASAP to the patient (Table/Fig 9).
The ASAP is a patient-centred motor training intervention. The acquisition of skilled movements is achieved through taskoriented training, impairment is reduced, and self-confidence is built through correct task selection, problem solving, and decision-making (29). It is a task-oriented intervention reported to improve functional abilities by addressing activity limitations and participation restriction. The fundamental problems that ASAP addresses are conceived as the learning or relearning of motor skills to optimally affect neural plasticity as well as skills to self-direct post training activities. Skill acquisition is facilitated by mitigation of impairments (e.g., muscle weakness and low self-efficacy) to enhance capacity. In this intervention, attention is given to motor learning, motor control and basic exercise physiology (e.g., overload in terms of training load/intensity and speed) principles. Social-cognitive psychological theories of motivation are applied in this intervention for immediate and particularly longer-term participant motivation (30).
The ASAP have demonstrated faster performance, improved quality of movement, and better functional improvement especially in individuals with hemiplegia (31). Authors adopted this treatment method as their was motor impairment (muscle weakness) in the UE which resulted in functional limitations (inability to perform ADLs) and also because it was proven to be effective in individuals with hemiplegia for mitigating motor impairments thus producing functional improvements. The main aim of physiotherapeutic intervention was to improve or restore independence in ADLs and thus improving quality of life. For that purpose, we mainly focused on improving mobility, strength, balance and co-ordination. Also, as UE was more involved, both gross and fine UE motor skills were affected, for which along with neurophysiotherapeutic interventions (ROM exercises, Rood’s facilitatory techniques initially and later inhibitory techniques, Manual Muscle Stimulation (MMS), Functional Electrical Stimulation (FES) and gripping or prehension exercises) the patient was given ASAP. This resulted in fulfilment of the main aim of physiotherapeutic intervention which was observable in terms of improvement in ARAT, WMFT and EORTC QLQ-BN20+2 scores.
Prognostic factors include number of patient and tumour characteristics, such as age at diagnosis, gender, performance status, histology subtype, presence of seizures at diagnosis and extent of resection. Female patients had a longer survival compared with males (1). Postoperative management is directed toward close clinical and radiographic follow-up (MRI), especially if the tumour histology has concerning features (20). Differential diagnosis for astrocytoma includes-Glioblastoma multiforme, brain metastasis, brain abscess, oligodendroglioma, encephalitis, multiple sclerosis, cardioembolic stroke (32).
Motor dysfunction following brain tumour resection is likely to occur and can result in decreased mobility, difficulty with daily tasks, increased risk of immobility-related problems, falls, pain, anxiety/ depression, functional dependency and QoL. This case study demonstrated the effectiveness of conventional neurophysiotherapy and ASAP in improving UE motor function and functional independence thus improving overall quality of life in a case of hemiplegia postbrain tumour resection.
Date of Submission: May 14, 2022
Date of Peer Review: Jun 11, 2022
Date of Acceptance: Jul 21, 2022
Date of Publishing: Oct 01, 2022
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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