Neuro Oncology Therapy Update March 2019 Cecily Moore – Physiotherapist Helen Spear – Speech and Language Therapist Helen Marshall – Occupational Therapist

Current OT/PT Service Physiotherapy and SLT representative at neurooncology MDT meetings Identification of patients for prehab from MDT based on referral information Neurooncology nurse specialist contacts therapist to assess in neurosurgery clinic if required Post operative therapy available on the wards

Prehab statistics 5 patients referred for prehab in 6/12 (4 brain, 1 spine). 4 patients seen in clinic, 1 patient received telephone triage SLT sees patients pre-operatively for awake craniotomy with language mapping as requested by the neuro surgical team Outcomes All patients received baseline assessment, although 2 patients unable to complete full assessment due to fatigue following neurosurgery clinic. 2 patients given orthotics 1 patient given a walking aid. 1 patient referred to visual impairment team and given advice/education. 3 patients referred to local community therapy teams for further assessment at home/provision of equipment for ADLs.

Prehab Assessment Baseline cognitive assessment Baseline physical assessment Baseline speech and language assessment Education re neurological deficits and strategies to manage these deficits (e.g. how to manage sensory impairment) Education for family members of how to manage cognitive and behavioural impairments Signposting to support agencies Referrals to community services including rapid response, rehabilitation teams, equipment prescription Referrals to orthotics Discussions with GPs and members of hospital neuro-oncology MDT re medical management of patients (e.g. seizure control) Education regarding preparation for surgery Anxiety management

Pro’s/ Con’s Prehab Pro’s Con’s Allows for more timely support services to be put in place Enables therapists to establish if there have been any changes post op Can help increase the speed of discharge following surgery Can help reduce anxiety of patient and their families Con’s Pre-op clinic can be lengthy and thus fatiguing for the patient, hence engagement in therapy assessment at this time may not be considered a priority for the patient and they may not wish for assessment at this time Relies on therapy staff being available

Post operative assessment Ward based Holistic assessment of: Function Physical performance Cognition / communication / mood Physio, OT, SLT, neuropsychology (on request) Anticipate needs on hospital discharge Highlight areas of vulnerability Highlight areas of potential for improvement (could be remedial or compensatory) Identify patient and family awareness of condition, prognosis etc. Inform MDT of assessment outcomes to enable treatment decision making

Challenges Lack of robust pathway to ensure all patients that require prehab are referred and assessed prior to their operation date Insufficient referrals to accurately interpret benefit Logistical complications with timely appointment bookings, transport, room availability, therapist availability Quick turnaround between being identified at MDT and the operation date Emotional impact of diagnosis and preparation for surgery-increased length of time of appointments and interventions required Lack of inpatient 7 day service impacts LOS; Patients may opt not to have surgery. Insufficient numbers – we were anticipating more referrals. Logistical examples - Variability in patient/family awareness of diagnosis and surgical options which impacted on Discussions and questions asked. Difficult to fit appointment in prior to surgery for high grade. Difficult to coordinate with nursing colleagues timings of their pre op assessment and pre op planning scans. People not wishing to travel twice.

MDT Reflections/Suggestions How many patients do you feel would benefit from prehab coming through the clinics? Consultants/ANPs to contact therapist directly from clinic if assessment required? (Depending on numbers this may require more funding) More discussion in MDT meeting to help identify appropriate patients? Joint assessment post op – continuing to work on our efficiences and resource allocation.