Scottish Cancer Network: Clinical Management Pathways
Recognition of the benefit of cancer rehabilitation is increasing as improved survival associated with treatment advances leads to increased prevalence of brain tumour ‘survivors’ with neurological or functional impairments. The provision of cancer rehabilitation services remains variable across Scotland due in part to local funding and historical variation in existing services. We propose here a guide to referral and assessment of brain tumour patients with the goal of optimising the benefit of formal neurorehabilitation within the clinical management pathways for brain tumours in Scotland.
Neurorehabilitation
Warning
This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of these guidelines, taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
Not every patient will benefit from inpatient neurorehabilitation and especially in circumstances of very limited prognosis supported care at home may be the better option for patient and family.
Key to optimal case selection for rehabilitation is multidisciplinary consideration of benefit and setting realistic expectations for patients and carers.
Criteria for referral for MDT assessment for rehab:
- New neurological deficit due to tumour or treatment
- Life expectancy of at least 9 months
- Realistic potential for rehabilitation (expected outcome to be met), including consideration of impact of cognitive impairment on outcome.
The MDT structure should enable discussion of complex patients to weigh up possible benefit of inpatient neurorehabilitation versus alternative options for support. Ideally all patients should have access to possible MDT review occurring through local cancer centre on minimum of monthly basis.
Neurological function and deficits should be recorded at diagnosis and again after any initial therapy -surgery or radiotherapy. This should be coupled with an estimate of prognosis and likely course of disease to inform what the needs will be over time.
The goal of rehab should be agreed with the patient at outset, identifying the single most important goal impacting quality of life. Setting realistic expectations and managing expectations is crucial.
For shorter term prognosis the goal may be to aim for shorter length of stay, if an inpatient, to facilitate early safe discharge. This will be more important than the traditional measures of changes in United Kingdom Functional Independence Measure + Functional Assessment Measure (UK FIM + FAM) scores. For longer term prognosis then these validated tools may be appropriate but again the key is to set goals at the outset informed by prognosis and agreed with the patient.
It is important also to acknowledge that in some cases where there may be no measurable physical benefit from rehab, the psychological benefit obtained by structured support can itself constitute a worthwhile goal for patients to attain.
Current inpatient neurorehab facilities in Scotland exist in Edinburgh (Astley Ainslie Hospital), Glasgow (Queen Elizabeth), Lanarkshire (plus Murdostoun Castle specifically for brain injury), Dundee, Aberdeen, Inverness and Dumfries.
Work remains to be done to clarify numbers, approximate waiting lists for assessments or for inpatient admission and also to describe what facilities are available as outpatients to support neurorehabilitation.