Original Article

Palliative Medicine 25(8) 788796 The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216311398699 pmj.sagepub.com

Exploring access to rehabilitation services from allied health professionals for patients with primary high-grade brain tumours
Aileen McCartney Wisdom Hospice, Rochester, UK Claire Butler Pilgrims Hospices, East Kent, UK Sue Acreman Velindre Cancer Centre, Cardiff, UK

Abstract Primary brain tumours account for less than 2% of cancer diagnoses in the UK but more people under 40 die from a brain tumour than from any other cancer. Despite developments in some treatment options, survival remains poor and patients suffer with considerable functional and cognitive deficits. Rehabilitation for patients with primary brain tumours produces statistically and clinically significant improvements in function. When compared, similar functional gains are made following rehabilitation for brain tumour patients and for those following stroke and traumatic brain injury. There have been very few studies looking at access to rehabilitation for this group of patients as a primary objective. However, existing studies and clinical experience suggest that patients with brain tumours do not access rehabilitation services frequently or easily, either locally or nationally. Therefore, this qualitative study addressed the reasons for this through semi-structured interviews of healthcare professionals, investigating their experiences of rehabilitation for this patient group and describing commonly identified barriers under key themes. The interviews gauged the views of eight healthcare professionals representing three professions in different settings, including hospital and community based. The resultant barriers fell under the following themes: professional knowledge and behaviours; services and systems; and the disease and its effects. Suggested solutions were wide ranging and included education, multidisciplinary meetings and specialist clinicians to co-ordinate care. The barriers to accessing rehabilitation for this group of patients are complex, but some of the solutions could be reached through education and co-ordination of services. Further research into the benefits of, and access to, rehabilitation for this group of patients is essential to ensure that patients with brain tumours are given opportunity to gain from the benefits of rehabilitation in the same way as other diagnoses, both cancer and non-cancer. Keywords Allied health professionals, brain tumours, health services access, rehabilitation

Introduction
Although brain tumours account for a small number of all cancers1 they cause signicant functional loss for patients.2,3 High-grade brain tumours, in particular, often cause considerable impairment, which can progress quickly and these patients often have a very poor prognosis.4,5 This means that services must be
Corresponding author: Aileen McCartney, Wisdom Hospice, Rochester, Kent ME1 2NU, UK Email: aileenmccartney@nhs.net

able to react quickly and then continue to provide input as the disease progresses and patients needs change. The symptoms of a brain tumour vary according to the location and type of tumour, but patients may present with problems such as hemiparesis, ataxia, communication and swallowing diculties,

McCartney et al. fatigue and impaired cognition.68 Although treatment regimens, such as surgery or radiotherapy, aim to relieve symptoms and improve function, the above problems may be caused or increased by such treatments.9 In addition, the use of corticosteroids, while able to greatly improve function by reducing swelling in the brain, can also have an adverse eect and cause further functional diculty with the onset of steroid-induced proximal myopathy.10 Cancer rehabilitation attempts to maximize patients ability to function, to promote their independence and to help them to adapt to their condition,11 oering a major route to improving their quality of life, no matter how long or short the timescale.12 Rehabilitation in cancer care currently has a high prole, with several government directives prioritizing this agenda. With particular relevance are the Improving Outcomes Guidance (IOG) for Supportive and Palliative Care for adults12 and the IOG for Brain and Central Nervous System Tumours.13 Both documents recommend rehabilitation for all who require it, based on a mixed-level range of evidence from a wide variety of rehabilitation studies.1417 The evidence for cancer rehabilitation is growing and is particularly strong regarding cancer related fatigue18 and breathlessness.16 Rehabilitation for brain tumour patients has been shown to be eective in producing signicant functional improvements6,19 and the same improvements have also been shown when comparing rehabilitation programmes for stroke and head injured patients with those for brain tumour patients.20,21 However, studies looking at access and barriers to access to rehabilitation services are lacking and therefore this qualitative study aimed to identify the barriers to accessing rehabilitation from allied health professionals (AHPs) for patients with primary high-grade brain tumours.

789 specialists (CNSs) and therapy radiographers. The latter two professional groups were targeted due to the nature of their role making it likely they would have managed a patient with a primary brain tumour. GPs were targeted in order to give an alternative view from professionals in a non-cancer specic setting. The participants had to meet the study inclusion criteria (Table 1). The three groups of professionals were sampled in dierent ways to ensure appropriate recruitment: GPs were identied via the consultant oncologist at the regional cancer centre providing the GP contact details for the last 10 patients with primary highgrade brain tumours who had attended the outpatient clinic. This was to ensure recruitment of GPs with appropriate experience of this diagnosis. The oncologist was not included in the sample despite her experience, as she had been involved in the research planning discussions at which point the researchers views may have been expressed and therefore may have introduced bias to the oncologists views if interviewed. CNSs were sampled from a group of three hospices and were approached via their team manager who distributed study packs. Finally, after initial local investigation, Macmillan specialist therapy radiographers were targeted as they had the necessary experience with this diagnosis. In turn, the radiographers identied an oncology nursing sister with considerable experience who was then approached to take part.

Data collection
A researcher (AM) recorded the profession of each participant and the location of interview. Semi-structured interviews were the main method of data collection, using a pre-piloted interview guide. The interviews were conducted by a researcher (AM) at the participants place of work, were tape recorded, anonymized and transcribed. All interviews were supported by eld notes. Interviews were conducted from June to September 2009.

Method Setting
The study interviews took place at the participants places of work which were two hospices, two general practitioner (GP) practices and an acute oncology centre.

Data analysis
Data analysis started immediately following each interview, employing an inductive thematic analysis that aims to identify patterns, themes and categories in the data.22 This was achieved through a process of coding the data and grouping the responses of the participants into categories that bring together similar themes.23 Initial data analysis of all of the transcripts was carried out by one researcher (AM) who used paper

Sampling
Purposive sampling was used to identify healthcare professionals with relevant experience of patients with the rare diagnosis of a primary high-grade brain tumour to take part in interviews. Three groups were identied: GPs, hospice clinical nurse

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Table 1. Study inclusion criteria Inclusion criteria 

Palliative Medicine 25(8)

Qualified professionals who are identified as being actively involved in the care of a person with a grade III or IV brain tumour in the last 2 years  Professionals working in NHS and Primary Care Trusts and independent hospices where ethical approval obtained  Consent to take part

Table 2. Participant professions Participant study number (PSN) 1 2 3 4 5 6 7 8

Table 3. Main themes drawn from the data 1. Professional knowledge and behaviours: a) Knowledge of concept of rehabilitation b) Lack of experience with brain tumours c) Knowledge of potential AHP role for brain tumour patients d) Behaviours/responses to referrals e) Knowledge of services available 2. Services and systems a) Resources of rehabilitation services b) Pathways, patient flows and access routes c) Categorization of brain tumour patients 3. The disease and its effects a) Rarity and prognosis b) Effect on patient behaviours and abilities 4. Solutions to barriers

Profession Clinical Nurse Specialist Clinical Nurse Specialist Clinical Nurse Specialist MacMillan Specialist Therapy Radiographer MacMillan Specialist Therapy Radiographer Oncology Nursing Sister GP GP

records to perform the analysis, reading and re-reading the data to become fully immersed in the information.24After this, some general themes became clear after which the data was re-analysed and coded for these themes and new themes were added to the list as necessary. The transcripts were also independently analysed by two co-researchers (CB and SA) and the themes compared. Once no further relevant themes were noted, that is saturation reached, recruitment ceased. The frequently repeated concepts and ideas were used to nalize the main themes, which were labelled with a key phrase and further analysis and consensus between the researchers conrmed sub-themes.

Results Participant demographics

Eight healthcare professionals provided written informed consent and all were interviewed (Table 2). The participants consisted of two GPs, three hospice CNSs, two MacMillan therapy radiographers and one oncology nursing sister.

Themes
Four main themes emerged from the data with several sub-themes (Table 3).

Professional knowledge and behaviours Rigour

Ethical approval was obtained from the Local Research Ethics Committee, the Comprehensive Local Research Network and the Research Department of the acute oncology centre. Participants received written and verbal information and provided written informed consent and all interview data was anonymized and held securely on National Health Service (NHS) premises. The three researchers analysed the data independently and then shared their ndings on categories and themes. a) Knowledge of the concept of rehabilitation. All participants stated what they thought rehabilitation was in varying depth and detail. The most common response was the idea of living life as well as possible/quality of life. Mobility was also mentioned frequently, as were daily activities and equipment and adaptations. In terms of the professions involved, all participants mentioned physiotherapy, with all but one stating occupational therapy. Half of participants mentioned speech and language therapy. The most interesting nding was the interchangeable use of physiotherapy and occupational therapy

McCartney et al. in discussions by many participants, indicating a lack of understanding of the distinction between these two professions:
Thats probably where my knowledge isnt very good, certainly with primary brain tumours, Im not sure what they could help with specically. . . certainly I said like the OT Im not quite sure, Im vague as to where OT stops and physio starts (PSN 1)

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Because I know a lot of professionals dont understand the concept of rehabilitation within palliative care they just see them as you know, how can you rehab someone thats dying, when actually its getting them some sort of quality of life back, within reason (PSN 3) People think why bother with rehab because they are not actually going to achieve anything because their goals are too far in the future and they havent got much of a future (PSN 5)

b) Lack of experience with brain tumours. Participants indicated their lack of experience in managing patients with a brain tumour with the eect of a lack of understanding of the diagnosis and its management:
I dont have enough experience to give you a straight answer to that. . . Its dicult when you dont have much experience (PSN 8)

An interesting view raised by the CNS participants was to wait until a patient deteriorated before referring for rehabilitation, perhaps indicating a further lack of understanding about preventative and preparatory rehabilitation work:
Obviously at some point she is going to deteriorate so I will be having the conversations about OT and helping her mobility wise like that. So if we tell them fairly soon, as soon as we see any signs of deterioration Id usually make a referral (PSN 1)

Linked with this was the perception that rehabilitation professionals may also not have the necessary knowledge and experience to manage this group of patients:
At the moment I would just refer to the general physio department or the general OT but I dont know if they would be specialised enough, probably not (PSN 7)

Unfortunately this approach carries the risk of missing the opportunity for rehabilitation:
She was doing very well and has now recently deteriorated and were doing the end of life care thing with her now so . . . (PSN 2)

c) Knowledge of potential AHP role for brain tumour patients. There appeared to be a genuine lack of knowledge about what AHPs could oer patients with primary brain tumours:
If someones got a brain tumour they dont specically get rehab per se, so rehab and brain tumours arent synonymous as it were, not linked in my mind (PSN 1)

d) Behaviours/responses to referrals. This section drew on some interesting views from the participants around the idea that referring patients to rehabilitation services was someone elses job, and in particular is expected to be the role of other AHPs. The majority of the participants made reference to relying on other people to refer to rehabilitation services, which once acknowledged appeared to make the participants reect on the appropriateness of this method:
One tends to hope if youve referred on to someone like an OT, if they really felt someone needed a physio they would say but then maybe thats just a cop out and Im just hoping (PSN 1)

There was also a common view that rehabilitation was not appropriate for some patients because the patient was perceived to be too unwell:
Well I think he is in decline I dont think rehab is the prime interest at the moment. Its just managing his symptoms, I think hes got a poor prognosis, the rehab aspect is limited (PSN 8)

Interestingly two of the participants had a better understanding of AHP roles and the lack of understanding:

The GP participants in particular made clear their reliance on specialists to make appropriate referrals or at least to indicate clearly to them when such referrals should be made. They appeared to feel it was not always their place to refer these patients as they did not have the experience in dealing with brain tumour patients in order to make these judgements.

792 A common nding was the habit of most of the participants to refer patients with brain tumours to hospice services, with the assumption that they would then receive all the interventions they required, including rehabilitation, from one team. It was suggested that this was a method of obtaining a variety of services easily. However, the hospice CNSs indicated they could not always access rehabilitation services so it appears the assumption around service provision placed upon palliative care services may be misplaced. One of the most striking ndings from this theme was the apparent professional guilt from participants about past behaviours with regards to referring patients with brain tumours for rehabilitation, which may have come to the forefront simply because the participants were given this opportunity to reect:
I mean [consultant] calls you in some times and you think what can I do for this patient, what can I do? When you think about it, it feels like you may have failed everyone (PSN 5)

Palliative Medicine 25(8) have to navigate to access services were mentioned here, particularly the belief that if patients did not follow the pathway via hospice services they could often end up without any service provision at all:
They go o into the community where quite frankly Im sure they could be forgotten about because once they have gone out of the hospital unless you can refer on its that much more dicult (PSN 4)

There were also issues around restrictive referral criteria of rehabilitation services, which tend to exclude brain tumour patients due to their cancer diagnosis and the perception of their poor prognosis. c) Categorization of brain tumour patients. This issue, linked to the theme regarding the disease itself, focused on the way in which rehabilitation services dealt with referrals for brain tumour patients. Many participants felt that rehabilitation services do not allocate patients with brain tumours the same priority as other diseases, with some mentioning specically motor neurone disease, head and neck cancer and head injuries. The participants who mentioned these other diseases pointed out the fact that despite their small incidence, similar to that of brain tumours, patients with these other conditions often enjoy dedicated rehabilitation services in stark contrast to brain tumour patients:
They fall between dierent stalls really theyre not really brain injured as such and sometimes their needs are a bit dierent as well and nobody knows quite where they should sit (PSN 6)

Services and systems

a) Resources of rehabilitation services. This rather unsurprising theme arose from most of the interviews undertaken, with both general resource issues and specialist rehabilitation services being discussed. It was suggested that service provision was hit and miss within the region and that services took too long to respond to the needs of this group of patients:
I just dont think its out there, if we do those referrals it can take weeks you know and patients dont sometimes have weeks, you know they need it and they need it now (PSN 2)

The disease and its effects

a) Rarity and prognosis. The low incidence and poor prognosis of brain tumour patients was raised in some way by all participants. Participants suggested their rare nature limits professional expertise in their management and also meant any knowledge gained through managing one patient could be lost as they may not see another brain tumour patient for some time. For those teams managing a mixed caseload, such as the majority of community rehabilitation services, brain tumour patients form a very small part of those numbers and therefore may not take priority. The poor prognosis was also a key issue raised by all the participants, meaning patients are either not considered appropriate for rehabilitation or are not

There were particular mentions about the diculties in accessing physiotherapy that were not mentioned for any other profession. Despite this, the participants appeared to have an understanding of why these access diculties existed, mainly related to the fact that rehabilitation services cover a wide variety of patients and diagnoses and referrals for patients with brain tumours may be quite infrequent. There were also comments about the short-term input from rehabilitation services when they were accessed and the lack of exibility in provision. b) Pathways, patient flows and access routes. The complex routes that brain tumour patients may

McCartney et al. a priority for limited rehabilitation resources:

Not only are they rare, they are not going to live that long which is a bit of an against as well, you know when theyve got a prognosis 6 or 9 months or so then you know theres not always the impetus or sadly the resources for people to pour in for that length of time (PSN 1) For many of them the prognosis is not good, yes there can be some improvements but the likelihoods are obviously not so high, I would anticipate that probably they are seen as less of a priority (PSN 4)

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and it has to be made clear that there is a limit to what you can rehab (PSN 3)

Solutions to barriers. Although specically asked for

suggestions for solutions during each interview, many participants spontaneously suggested these during the interview process. The two most common solutions identied related to services and systems in the form of multidisciplinary meetings for brain tumour patients and a rehabilitation service directory. This raised the issue around the lack of a multidisciplinary meeting for this group of patients within this geographical area, due to these patients receiving their surgical management at a tertiary centre out-with the area. Most participants also wished to know not just what rehabilitation services are available but specically what they could oer brain tumour patients. There were also suggestions of the need for a specialist nurse or other professional for this patient group and various suggestions for education regarding brain tumours, rehabilitation in palliative care and palliative care generally. All of the suggestions made were very practical in nature and provide a useful starting point for local service improvement.

One participant in particular became quite passionate about the issue of prognosis and suggested that patients with brain tumours are stigmatized. The fact that not all patients with brain tumours have a very poor prognosis was not considered by rehabilitation services:
I feel there is a bit of stigma attached, people think why bother with rehab because theyre not going to achieve anything . . . for some people their prognosis isnt three months, they could be two years plus . . . and then what are they getting . . . theyre getting very little (PSN 5)

b) Effect on patient behaviours and abilities. Patients with brain tumours often have personality changes, problems with decision making or problem solving or a lack of self-awareness. These issues were identied by ve of the participants as having an eect on their access to rehabilitation services. The fact that patients do not know rehabilitation is available or how it could help was deemed important, and also that patients may not be able to recognize their own needs due to cognitive impairment. It was also suggested that some patients deny rehabilitation services due to issues with self-image or coming to terms with diagnosis:
Hes quite t and well you know and getting on with things, like, he doesnt want any kind of input to remind him of his diagnosis (PSN 2)

Discussion
In this qualitative study, various barriers to accessing rehabilitation for patients with primary brain tumours were identied. All participants showed great interest in the management of brain tumours and there was a general consensus that this patient group are missing out on services, but there was a general feeling of helplessness in knowing what to do to change this. The lack of knowledge about brain tumours and their management may reect on a continued lack of understanding generally about cancer as a disease,25,26 as well as a specic lack of knowledge of brain tumours. The data produced in this study resonate with existing literature. The lack of understanding of the relevance of rehabilitation for this diagnosis was prominent from the healthcare professionals interviewed. This may also reect the general lack of understanding on what rehabilitation can oer cancer patients that has been previously identied.20,2729 Patients knowledge about cancer rehabilitation was not addressed in the current study, although it has been considered previously.30

There was also a suggestion by two participants that rehabilitation could raise unrealistic hope for some patients, which perhaps suggests not only that these professionals would not refer such patients to avoid this issue, but also that they may not fully understand the role of rehabilitation in palliative care:
Sometimes their expectations are when they hear rehab . . . everything is going to be made better

794 There was also the attitude of professionals to assume or expect referrals to rehabilitation services to be carried out by someone else. It is not clear why the participants felt this way, and no similar theme is reported in the current literature, but it could be an interesting area for further research. As identied in this study, the lack of rehabilitation services and specialist rehabilitation sta has previously been documented as a barrier to patients accessing cancer rehabilitation.10,29 The lack of a clear pathway into rehabilitation for these patients is also reected in the literature19,20 and is likely to indicate the diculties in deciding which category these patients t into for rehabilitation services. This study also suggested that a brain tumour diagnosis itself is another barrier to accessing rehabilitation services. It is well known that many primary high-grade brain tumours have a poor prognosis, and therefore services may not be willing to prioritize their limited resources on these patients. In addition, it appears that many professionals may feel these patients will not benet from rehabilitation itself, but the research shows that not only can rehabilitation be eective in improving function and quality of life in these patients,21,31,32 but also that it has been shown to have economic benet.19 Many of the themes overlapped in content, for example the professionals knowledge of the concept of rehabilitation for patients with brain tumours, their knowledge of the AHP role and awareness of services, were all partly dependent on their lack of experience in managing patients with brain tumours. In turn this is directly connected with the low incidence of this diagnosis and the fact that professionals will therefore not regularly deal with these patients. The issues around resources, pathways and prioritization are not necessarily unique to brain tumour rehabilitation, as demand for these services often outstrips supply, but the rapidly changing eects of this particular diagnosis make these issues particularly pertinent. Many solutions to these barriers were oered, from multidisciplinary meetings to education programmes and service directories. Many of these issues could be tackled locally but the general attitude towards brain tumours as a disease may be more successfully tackled through national initiatives. In order to complement this it is necessary for further research into rehabilitation for brain tumour patients, using randomized controlled trials where possible, but also looking at multicentre, longitudinal studies. In particular, it would

Palliative Medicine 25(8) be useful for future research to compare dierent types of rehabilitation interventions for dierent types of primary and secondary brain tumours, in order to be more applicable to clinicians. It would also be benecial to have qualitative studies investigating the views of AHPs in relation to brain tumour rehabilitation and importantly the views of patients with brain tumours in relation to rehabilitation. Local investigation of current access to rehabilitation for these patients would also provide valuable information alongside research that sets some standards for the types and level of rehabilitation that these patients should be receiving. The issues around resources and pathways are something that needs to addressed locally and the local cancer network is aware of the diculties in accessing rehabilitation for this patient group. Possible suggestions have included expanding the remit of existing neurological rehabilitation teams to accept this group of patients or development of a rehabilitation team specically for neuro-oncology patients. These discussions are ongoing but remain a challenge in the current economic climate.

Strengths and limitations

This study was exploratory in nature and aimed to highlight some of the barriers that may prevent patients with primary brain tumours from accessing rehabilitation from AHPs. It is acknowledged that generalizations cannot be made but that these ndings provide more insight into the behaviours of healthcare professionals, which may well be relevant more widely. As the interviews were carried out by the main researcher, this may have aected the interview style and also may have introduced some bias, as one professional interviewed was known to the researcher. However, as this participants views were similar to other participants it is not thought that this introduced serious implications for the research ndings. The study was limited in its recruitment to only three groups of healthcare professionals and to those who had been involved in caring for a patient with a primary high-grade brain tumour within the last two years. This may have discounted some valuable professional experiences, but it was essential to target professionals with relevant experience and to gain views that were relevant to current services and systems. It may also have been relevant and interesting to include discussion of low-grade tumours within the study, as the symptoms and problems are often similar. However, the study focused on high-grade

McCartney et al. tumours as this was the authors area of interest, coming from a specialist palliative care background where low-grade tumours were rarely dealt with. In addition, it was the lack of access to rehabilitation for patients with high-grade tumours for whom deterioration is often much faster and therefore input more urgent, that was of key relevance. However, many of the ndings may well be applicable to issues for patients with low-grade tumours. Acknowledgement
The authors would like to thank all the healthcare professionals who generously gave their time to be interviewed.

795
10. Kirshblum S, ODell MW, Ho C and Barr K. Rehabilitation of persons with central nervous system tumors. Cancer 2001; 92: 10291038. 11. NCHSPCS. Fulfilling lives: rehabilitation in palliative care. London: National Council for Hospice and Specialist Palliative Care Services, 2000. 12. National Institute for Health and Clinical Excellence. Improving supportive and palliative care for adults with cancer. London: NICE, 2004. 13. National Institute for Health and Clinical Excellence. Service guidance for improving outcomes for people with brain and other central nervous system tumours. London: NICE, 2006. 14. Holley S and Borger D. Energy for living with cancer: preliminary findings of a cancer rehabilitation group intervention study. Oncol Nurs Forum 2001; 28: 13931396. 15. Bredin M, Corner J, Krishnasamy M, Plant H, Bailey C and AHern R. Multicentre randomized controlled trial of nursing intervention for breathlessness in patients with lung cancer. Br Med J 1999; 318: 901904. 16. Corner J, Plant H, Ahern R and Bailey C. Non pharmacological management for breathlessness in lung cancer. Palliat Med 1996; 10: 299305. 17. Berglund G, Bolund C, Gustafsson UL and Sjoden PL. One year follow up of the Starting Again group rehabilitation programme for cancer patients. Eur J Cancer 1994; 30A: 17441751. 18. Cramp F and Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev (Online) 2008; 2: CD006145. 19. Sherer M, Meyers CA and Bergloff P. Efficacy of postacute brain injury rehabilitation for patients with primary malignant brain tumors. Cancer 1997; 80: 250257. 20. Huang ME, Cifu DX and Keyser-Marcus L. Functional outcome after brain tumor and acute stroke: a comparative analysis. Arch Phys Med Rehabil 1998; 79: 13861390. 21. ODell MW, Barr K, Spanier D and Warnick RE. Functional outcome of inpatient rehabilitation in persons with brain tumors. Arch Phys Med Rehabil 1998; 79: 15301534. 22. Patton MQ. Qualitative research and evaluation methods, 3rd ed. CA: Sage Publications, 2002. 23. Rubin HJ and Rubin IS. Qualitative interviewing the art of hearing data. CA: Sage Publications, 1995. 24. Ezzy D. Qualitative analysis: practice and innovation. London: Routledge, 2002. 25. Corner J, Hopkinson J and Roffe L. Experience of health changes and reasons for delay in seeking care: A UK study of the months prior to the diagnosis of lung cancer. Soc Sci Med 2006; 62: 13811391. 26. Miller M, Kearney N and Smith K. Measurement of cancer attitudes: a review. Eur J Oncol Nurs 2000; 4: 233245. 27. Rodriguez-Bigas MA, Chang GJ and Skibber JM. Barriers to rehabilitation of colorectal cancer patients. J Surg Oncol 2007; 95: 400408.

Funding
This research received no specic grant from any funding agency in the public, commercial or not-forprot sectors.

Competing interests
The authors declare that they have no competing interests.

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