Early Assessment of Functional Capacity in Patients After Brain Neoplasm Surgery

ORIGINAL PAPERS Adv Clin Exp Med 2007, 16, 5, 663 667 ISSN 1230 025X Copyright by Silesian Piasts University of Medicine in Wrocław ROBERT ŚLUSARZ Early Assessment of Functional Capacity in Patients After Brain Neoplasm Surgery Wczesna ocena wydolności funkcjonalnej chorych po operacji guza nowotworowego mózgu Neurological and Neurosurgical Nursing Department, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland Abstract Background. Brain tumors pose a great therapeutic problem because they often lead to disorders of basic func tions and disability. Objectives. The aim of this study was to assess functional capacity in patients after brain tumor surgery, determine the areas of functional capacity deficits on the day of discharge, and check whether there is a correlation between individual patients assessment scales. Material and Methods. The study was conducted at a university neurosurgery and neurotraumatology clinic and department and involved 46 patients who had had brain tumor surgery. Both observation and numerical scoring were used. The Functional Capacity Scale, Karnofsky Performance Scale, Repty Functional Index, and the Glasgow Outcome Score were used. Results and Conclusions. At discharge, most patients were independent with regard to functional capacity. Some deficits were observed with regard to satisfying physiological needs, personal hygiene activities, and experiencing considerable pain. The assessment scales significantly correlated with one another (Adv Clin Exp Med 2007, 16, 5, 663 667). Key words: functional capacity, brain tumor. Streszczenie Wprowadzenie. Guzy mózgu są dużym problemem terapeutycznym, ponieważ najczęściej powodują zaburzenia podstawowych dla życia funkcji oraz różnego stopnia kalectwo. Cel pracy. Ocena wydolności funkcjonalnej chorych po leczeniu operacyjnym guza mózgu, określenie obszarów deficytu wydolności funkcjonalnej w dniu wypisu z oddziału oraz sprawdzenie, czy istnieje korelacja między po szczególnymi skalami służącymi do oceny stanu chorego. Materiał i metody. Badania przeprowadzono w Katedrze i Klinice Neurochirurgii i Neurotraumatologii CM UMK, na grupie 46 chorych operowanych z powodu guza mózgu. W badaniach zastosowano obserwację bezpośrednią z wy korzystaniem pomiaru. W badaniach posłużono się Skalą Wydolności Funkcjonalnej FCS, skalą Karnofsky ego KPS, wskaźnikiem funkcjonalnym Repty FIR oraz skalą Glasgow wyników końcowych GOS. Wyniki i wnioski. Znaczna większość badanych w dniu wypisu z oddziału wykazywała samodzielność w zakre sie wydolności funkcjonalnej. Deficyt dotyczył jedynie takich obszarów, jak: samodzielne zaspokajanie potrzeb fi zjologicznych, samodzielne wykonywanie czynności higienicznych oraz odczuwanie znacznego stopnia dolegli wości bólowych. Zastosowane skale do oceny stanu chorego znacząco korelują ze sobą (Adv Clin Exp Med 2007, 16, 5, 663 667). Słowa kluczowe: wydolność funkcjonalna, guz mózgu. In neurology and neurosurgery, every exten sive intracranial process, both neoplastic (e.g. glio mas and meningiomas) and non neoplastic (e.g. brain abscess or arachnoid cyst), is consid ered a brain tumor [1, 2]. Brain tumors pose a great therapeutic problem because they often lead to dis orders of basic functions and to disability [3, 4]. Therefore, although they rarely metastasize, brain

664 R. ŚLUSARZ tumors are a serious threat to human life and in most cases cause disability [5, 6]. A nervous sys tem neoplasm reduces a patient s functional capacity [7]. The aim of this study was to assess functional capacity in patients after brain tumor surgery, determine the areas of functional capacity deficit on the day of discharge, and check whether there is a correlation among individual patients assessment scales. Material and Methods The study was conducted at the Neurosurgery and Neurotraumatology Clinic and Department, Collegium Medicum in Bydgoszcz, Nicolaus Co pernicus University in Torun, and involved 46 pa tients who had undergone brain tumor surgery. Among the 46 patients were 23 men (50%). The patients were between 19 and 64 years old. Nineteen patients (41%) were between 41 and 60 years old. The mean age of all 46 patients was 50.4 ± 16.8 years. The criteria for inclusion in the study were: patients with brain neoplasm situated supratentori ally in the hemispheres, patients who had never been operated on before, and patients who were conscious on admission (capable of making logi cal verbal contact) and without significant neuro logical deficits. Criteria for exclusion were: patients with brain neoplasm situated subtentorial ly or in brain ventricles, patients who had had more than one operation or radiotherapy/chemio therapy, and patients who were not fully conscious on admission (were not capable of making logical verbal contact). All tumors were situated supratentorially in the hemispheres, i.e. in the frontal area (10 tumors, 21.7%), parietal area (10 tumors, 21.7%), tempo ral lobe (3 tumors, 6.5%), occipital lobe (11 tu mors, 23.9%), in two lobes (11 tumors, 23.9%), and in three lobes (1 tumor, 2.2%). Most tumors were of neuroepithelial origin (gliomas, 30 tu mors, 65.2%), some were metastatic (9 tumors, 19.6%), and some were meningeal (meningiomas, 7 tumors, 15.2%). Of all the primary tumors (gliomas and meningiomas), 15 (40.6%) were grade I according to the WHO system [8], 14 (37.8%) were grade II, 4 (10.8%) were grade III, and 4 (10.8%) were grade IV. In the clinical assessment on admission, the patients received 15 points on the Glascow Coma Scale. During neurological examination before the operation, no significant focal neurological deficits were observed. All patients complained of headaches, 33 (71%) assessing their pain as severe (8 points on the Visual Analogue scale). All patients underwent an operation of com plete or partial removal of the tumor by means of craniotomy. Patients operated on for gliomas (grades III and IV) and metastatic tumors were additionally subjected to radiotherapy. Because the sample size was low, no statisti cally significant relations were found between the patients functional capacity and clinical (histolog ical kind of tumor, malignancy degree, clinical pic ture) or sociodemographic factors (age, gender). Procedure The study was conducted by direct observa tion and measurement. The Functional Capacity Scale (FCS) was used for early postoperative assessment of functional capacity [9, 10]. This scale allows one to recognize the patient s abilities in the particular clinical condition in the range of functional outcome as well as the patient s depen dence on the nursing staff, which is equal to defin ing a deficit in the particular marker. The scale has 12 markers: ambulation, alimentation, personal hygiene, physiological needs, life functions mea surement, GCS, breathing, diagnosis, pre and post surgical treatment, dressing and drainage, acuteness of pain, pharmacotherapy, and neu ropsychologic outcome. To compare functional capacity and final outcome of surgery, patients were also assessed according to the KPS (Karnofsky Performance Scale) [11], the FIR (Functional Index Repty ) [12], and the GOS (Glasgow Outcome Scale) [13]. The consent of the Bioethics Commission of Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, was obtained for the study. On arrival, each patient gave written consent to the procedure. Statistical Analysis The results were calculated using MICROSOFT EXCEL 2000 and STATISTICA v. 5.1. Correlation was calculated using Spearman s rank correlation coefficient (r s ). Statistical hypotheses were verified according to a significance level of p < 0.001. Results On the day of discharge, patients classified in group I of the FCS (40 persons, i.e. 87.0%) were dominant (Table 1). This means that this was a self sufficient population (did not require assis tance from the nursing personnel). The average number of points on the FCS was 43.7 ± 3.5. None of the surveyed people were classified in group IV

Functional Capacity After Brain Neoplasm Surgery 665 Table 1. Functional capacity on the day of discharge assessed using the FCS Tabela 1. Wydolność funkcjonalna chorego w dniu wypisu z oddziału oceniana za pomocą SWF SWF (FCS) N % I independence, a self sufficient patient (samowystarczalny/niezależność) 40 87.0 II moderate independence, patient needs help (wymaga pomocy/niewielka zależność) 5 10.9 III moderate dependence, patient needs significant help (wymaga dużej pomocy/znaczna zależność) 1 2.1 IV* dependence, the patient needs intensive care (wymaga intensywnej opieki/zależność całkowita) 0 0 Razem (Total) 46 100 Average number of points in the scale ± standard deviation 43.7 ± 3.5 (Średnia liczba punktów w skali ± odchylenie standardowe) * Value excluded from the calculation due to a lack of cases. * Wartość pominięta w obliczeniach ze względu na brak przypadków. of the FCS (totally dependent patients, requiring intensive care from other people). The patients functional capacity deficits involved first of all such fields as satisfying own physiological needs [4] (5 patients, 10.9%, group IV), maintaining own body hygiene by oneself [3] (5 patients, 10.9%, group III), and feeling intensi fication of pain to a significant extent [10] (6 patients, 13.0% group III). The least extent of deficiency was found in breathing [6] (46 people, 100.0%, group I) and measurement of vital func tions [5] (46 people, 100.0% group I) (Table 2). The scales for the assessment of a patient s functional capacity and final assessment of treat ment results were verified (Table 3). The high, sta tistically significant (p < 0.001) values of Spearman s rank coefficient (r S = 0.78) for the cor relation between FCS and FIR result from the sim ilarity in the structure of these scales. FCS compo nents are similar to FIR components and both scales classify patients into four groups. In the case of the GOS and KPS, the correlation coeffi cients were lower, but also statistically significant. Discussion A survey conducted on a group of 40 patients with diagnosed brain tumor [14] showed that on discharge, most of the patients (80%) were classi fied into group I of functional capacity (minimal care required from other people), and 2% were classified to group IV (intensive care). It was also found that the patients required minimal care in such fields as moving about, maintaining body hygiene, and relieving themselves. In a study by Table 2. Functional capacity deficit on the day of discharge Tabela 2. Deficyt wydolności funkcjonalnej chorego w dniu wypisu z oddziału Indications for nursing (Wyznaczniki opieki) Care group (Grupa opieki) I II III IV N % N % N % N % 1. Ambulation (Poruszanie się) 28 60.9 14 30.4 4 8.7 0 0 2. Alimentation (Odżywianie) 41 89.1 4 8.7 1 2.2 0 0 3. Personal hygiene (Czynności higieniczne) 30 65.2 11 23.9 5 10.9 0 0 4. Physiological needs (Potrzeby fizjologiczne) 28 60.9 12 26.1 1 2.2 5 10.9 5. Life functions measurement, GCS 46 100 0 0 0 0 0 0 (Pomiar czynności życiowych GCS) 6. Breathing (Oddychanie) 46 100 0 0 0 0 0 0 7. Diagnosis (Diagnostyka) 41 89.1 4 8.7 1 2.2 0 0 8. Pre and post surgical treatment (Przygotowanie do zabiegu i opieka po) 37 80.4 9 19.6 0 0 0 0 9. Dressing and drainage (Opatrunki, drenaż) 38 82.6 8 17.4 0 0 0 0 10. Acuteness of pain (Stopień nasilenia bólu) 19 41.3 21 45.7 6 13.0 0 0 11. Pharmacotherapy (Farmakoterapia) 25 54.3 18 39.1 3 6.5 0 0 12. Neuropsychological outcome (Stan psychiczny) 10 21.7 34 73.9 2 4.3 0 0

666 R. ŚLUSARZ Table 3. Patients functional capacity on the day of discharge Tabela 3. Wydolność funkcjonalna chorego w dniu wypisu Group (Grupa) Measurement scale (Skala pomiarowa) FCS/SWF GOS WFR/FIR KPS N % N % N % N % I 5 40 87.0 24 52.2 36 78.3 27 58.7 II 4 5 10.9 17 37.0 3 6.5 8 17.4 III 3 1 2.1 5 10.9 4 8.7 9 19.6 IV * 2 ** 0 0 0 0 3 6.5 2 4.3 1 ** 0 0 Total (Razem) 46 100 46 100 46 100 46 100 Average number of points in the scale ± standard deviation (Średnia liczba punktów w skali ± odchylenie standardowe) 43.7 ± 3.5 4.4 ± 0.7 90.4 ± 20.9 76.7 ± 15.5 Spearman s rank correlation test r s = 0.49, r s = 0.78, r s = 0.56, (Współczynnik korelacji rang Spearmana) p < 0.001 p < 0.001 p < 0.001 * FCS value excluded from the calculation due to a lack of cases. ** GOS value excluded from the calculation due to a lack of cases. * Wartość dla SWF pominięta w obliczeniach ze względu na brak przypadków. ** Wartość dla GOS pominięta w obliczeniach ze względu na brak przypadków. Markiewicz et al. [15], patients with diagnosed brain stem tumor showed neurological state disor ders in the form of paresis, balance and vision dis orders (deficiency in movement), swallowing dis orders (nutrition deficiency), and speech disorders. According to the authors, operative treatment of this condition (brain stem tumor) is connected with risks and complications that impair the quali ty of life of patients. Surveys by other authors [7] verifying the application of quantitative methods for the assess ment of a patient s state confirm a high correlation of clinical scales (KPS, WHO) and care in neuro oncology (Self care Capacity Scale). The author conclude that a significant majori ty of the surveyed patients showed self sufficiency in the field of functional capacity on the day of dis charge. Functionality deficiency involved only such fields as satisfying one s own physiological needs, maintaining own body hygiene, and feeling intensive pain. The scales applied for the assess ment of the patients state (FCS, GOS, FIR, KPS) correlated significantly, which recommends the application of these scales in clinical assessment and in planning nursing care at the neurosurgery department. References [1] Greenberg MS: Handbook of Neurosurgery, Thieme 2006. [2] Lindsay KW, Bone I: Neurologia i neurochirurgia. Red.: Kozubski W, Elsevier U&P, Wrocław 2006, wyd. 1 pol. [3] Glioblastoma Multiforme. Available at: http://www.emedicine.com (last updated: January 10, 2007). [4] Ząbek M: Zarys neurochirurgii. PZWL, Warszawa 1999. [5] Hickey JV: Brain tumors. In: Neurological and neurosurgical nursing. Eds.: Hickey JV, Lippincott Williams & Wilkins, 2003, 483 508. [6] Cattell E, Mei Sheng Lu: Neurologic system. In: Patient Care Standards. Collaborative planning & nursing inter ventions. Eds.: Tucker SM, Canobbio MM, Paquette EV, Wells MF, Mosby 2000, 540 543. [7] Rola J, Turowski K: Ocena stanu klinicznego i wydolności w zakresie samoopieki chorych z nowotworami mózgu. Annales UMCS 2002, suppl. 11, 317 325. [8] Louis DN, Ohgaki H: The 2007 WHO Classification of Tumours of the Central Nervous System. Acta Neuro pathol 2007, 114, 2, 97 109. [9] Ślusarz R, Beuth W, Kasprzak HA: Psychometryczne właściwości skali wydolności funkcjonalnej. Valetu dinaria Post Med Klin Wojsk 2003, 3 4, 100 104. [10] Ślusarz R, Beuth W, Książkiewicz B: Functional Capacity Scale as a Suggested Nursing Tool for Assessing Patient Condition with Aneurysmal Subarachnoid Hemorrhage Part II. Adv Clin Exp Med 2006, 15, 4, 741 746. [11] Mor V, Laliberte L, Morris JN, Wiemann M: The Karnofsky performance status scale. Cancer 1984, 9, 2002 2007.

Functional Capacity After Brain Neoplasm Surgery 667 [12] Opara J: Analiza przydatności wybranych skal udarów do oceny wyników rehabilitacji chorych z niedowładem połowiczym. Rozprawa habilitacyjna. Katowice 1996. [13] Jennett B, Bond M: Assessment of outcome after severe brain damage: a practical scale. Lancet 1975, 1, 480 484. [14] Wilk K: Wydolność chorych leczonych z powodu guzów mózgu w zakresie samoopieki. Praca magisterska. Bydgoszcz 2004. [15] Markiewicz P, Obszańska K: Opieka nad chorymi z guzami pnia mózgu. Annales UMCS 2002, supl.11, 219 224. Address for correspondence: Robert Ślusarz Neurological and Neurosurgical Nursing Department CM NCU Techników 3 85 801 Bydgoszcz Poland Tel.: +48 052 585 21 93 Mobile: 668 121 095 E mail: zpielnin@cm.umk.pl, robert_sl@o2.pl Conflict of interest: None declared Received: 28.05.2007 Revised: 12.06.2007 Accepted: 18.10.2007