1. Neuro-oncology neu · ro-on · col · o · gy n. The branch of medical science dealing with tumours of the nervous system. Anmari Reynders Anne Venter Annami Havenga

2. VEELS GELUK liewe ANMARI met jou VERJAARSDAG!

3. Definition Neuro-oncology (brain cancers) can develop from: 1.Primary brain cells (membranes, blood vessels) 2.Metastatic brain cells (cancers cells spread to the brain via the bloodstream from other organs) Brain tumours are growths in the brain, but not all of them are cancerous. Cancer refers to malignant tumours. “Malignant tumours grow and spread aggressively, overpowering healthy cells by taking their space, blood, and nutrients. Like all cells of the body, tumour cells need blood and nutrients to survive. This is especially a problem in the brain, as the added growth within the closed confines of the skull can lead to an increase in intracranial pressure or the distortion of surrounding vital structures, causing their malfunction.”

4. Pathophysiology Cancer is a disease where a specific part of the body undergoes uncontrolled, abnormal tissue growth that leads to tumours. Alteration of the genes cells that control the growth and differentiations will change normal cells into cancer cells.

5. Pathophysiology The affected genes are divided into two broad categories. Oncogenes – genes that promote cell growth and reproduction. Tumour suppressor genes -genes that inhibit cell division and survival. Malignant transformation can occur through the: formation of novel oncogenes inappropriate over-expression of normal oncogenes under-expression or disabling of tumour suppressor genes.

6. There is a number of mechanisms by which tumours can develop that produces neurological manifestations. Specific neural pathways in the brain may be damaged even by small tumours that are located close to these pathways. Normal function can be disrupted because tumours can invade, infiltrate and supplant normal parenchamal tissue. Growth of intracranial tumours normally leads to the presence of oedema and this may compress normal tissue and impair normal function. New blood vessels (ex. angiogenesis) develop due to the tumour growth and this disrupts the normal blood-barrier and then lead to a further increase in oedema. Hydrocephalus may also develop when the flow of cerebrospinal fluid proximal to the third and fourth ventricle are obstructed. All the above mentioned factors contribute to increase of the intracranial pressure (ICP) which interns also impairs cerebral perfusion.

7. Medical treatment It’s unlikely that there will ever be a single "cure for cancer“ Management for cancer includes the following: chemotherapy radiation therapy surgery immunotherapy monoclonal antibody therapy It depends upon the location, type of cancer and the stage of the cancer which treatment is used. The goal of surgery is always to remove all cancer, if possible.

8. Medical treatment Alternative treatments They are used by alternative medicine practitioners. This includes: herbal preparations massage acupuncture electrical stimulation devices It has never been proven to be affective at killing cancer cells. These modalities are more used by physicians to manage the symptoms. Palliative care It aims to reduce physical, spiritual, emotional and psycho-social distress experienced by patients with cancer. The goal is to make the patient feel better.

9. Causes & Risk factors The exact cause of primary brain tumours is unknown. These risk factors that can play a role: Radiation to the brain (head) Genetic (inherited risk factor) HIV infection Smoking (Cigarette) Environmental toxins (embalming chemicals, rubber industry chemicals)

10. Signs and symptoms Symptoms are caused by a tumour pressing on specific parts of the brain that causes neurological dysfunction. This happens when swelling occur caused by a tumour or its surrounding inflammation. Most common symptoms: Headache Weakness Clumsiness Difficulty walking Seizures

11. Other nonspecific symptoms and signs: Altered mental status: changes in concentration, attention, memory or alertness Nausea, vomiting – especially early in the morning Abnormalities in vision for example double vision, loss of peripheral vision Difficulty with speech Changes in emotional and intellectual capacity. Signs and symptoms P.S. In some cases a patient can act as if he or she had a stroke. Symptoms can also be more pronounced if it is in a specific brain lobe. For example: behavioural changes in frontal lobe cancers and difficulty with speech or movements in parietal lobe cancers.

12. Physiotherapy problems Problems: Fatigue Pain Maintaining and regaining fitness (exercise tolerance) Muscles weakness due to staying in bed for long periods Decreasing in joint mobility Cord compression

13. Physiotherapy treatment Treatment for pain: Specific exercises : relaxation exercises Postural re-education Massage Soft tissue mobilisation TENS Heat and cold packs pain Treatment for regaining mobility after treatment by physiotherapists: Exercise programs specifically for patient For those who cannot walk: Asses for appropriate walking aids and advice on transfers to wheelchair or chair. mobility fatigue cord compression

14. Physiotherapy treatment Treatment for fatigue and muscle weakness and regaining fitness: Radiotherapy and chemotherapy cause a lot of tiredness. Coping with cancer is psychologically draining In the past standard advice has been to rest but current evidence shows that it is better to do moderate aerobic exercises – walking, cycling or treadmill. It will combat fatigue and rebuild muscle strength and fitness. Treatment for patients with cord compression: Carefully planned exercise regime for improving exercise tolerance and building up towards walking. If not – transfers from bed to wheelchair using sliding board.

15. Hydrotherapy: Very useful for some patients. Contraindicated in patients who are immunosuppressed It is very important to discuss the care of patient with other members of the multidisciplinary team regarding mobilisation, discharging planning and continuing care after discharge. Specific treatment of patients with brain tumours: Physiotherapy will focus on: Respiratory care, especially when ventilated Exercises and stretches for maintain normal ROM Neurological rehabilitation exercises: - sitting balance, walking re-education

16. JOURNAL OF PALLIATIVE MEDICINE Volume 6, Number 1, 2003 © Mary Ann Liebert, Inc. The Utilization of Physical Therapy in a Palliative Care Unit MARCOS MONTAGNINI, M.D.,1,2 MOHAMMED LODHI, M.D.,1,2 and WENDI BORN, Ph.D.2 ABSTRACT Background: In the supportive oncology and palliative care settings, rehabilitation interventions are often overlooked and underutilized, despite high levels of functional disability in these patients. As a result, little is known about the utilization or effectiveness of rehabilitation interventions in palliative care populations. Objective: To assess the utilization of physical therapy (PT) in a hospital-based palliative care unit, to characterize functional disabilities in patients who received PT, and to identify factors related to functional improvement following a course of PT. Methods: Retrospective chart review of 100 patients (mean age 70 years, 97% male) discharged from the Milwaukee Veterans Hospital Palliative Care unit over 15 months. Activities of daily living (ADL) performance scores were recorded on admission, at 2 weeks, and at completion of the PT program and correlated with demographic and disease-related variables. Results: Thirty-seven patients received a formal PT assessment, and 18 patients underwent PT. The most common functional disabilities in patients who received PT were deconditioning, pain, imbalance, and focal weakness. Ten patients demonstrated improvement in ADL function at 2 weeks. Six patients completed the course of PT. Albumin was significantly correlated with functional improvement. When controlling for albumin, patients with diagnosis of dementia were more likely to show improvement in functional status than patients without a dementia diagnosis. Conclusion: PT assessment and utilization were uncommon in this group. When utilized, PT benefited 56% of patients. Factors related to functional improvement following a PT course were a higher albumin level and a diagnosis of dementia. Prospective trials of PT in palliative care patients are needed to better define response rate and predictors of response.

17. References 1.www.emedicinehealth.com/brain_cancer/article_em.htmwww.emedicinehealth.com/brain_cancer/article_em.htm 2.www.estroric.org/GENERALINFORMATION/Pages/Physiotherapyandcancercareaspx.htmwww.estroric.org/GENERALINFORMATION/Pages/Physiotherapyandcancercareaspx.htm 3.http://www.rehab.research.va.gov/jour/99/36/3/taub.htmhttp://www.rehab.research.va.gov/jour/99/36/3/taub.htm 4.http://emedicine.medscape.com/article/779664-overview#a0104http://emedicine.medscape.com/article/779664-overview#a0104 5.JOURNAL OF PALLIATIVE MEDICINE, Volume 6, Number 1, 2003, The Utilization of Physical Therapy in a Palliative Care Unit Thank you!