Brain tumors can be found in people of both genders and in all ages. According to statistics from the Central Brain Tumor Registry of the United States in 2007-2008, the average annual incidence rate of cancer is 14.3 in 100,000 people in men and 15.1 in 100,000 people in women. Brain tumors are the third leading cause of cancer-related deaths in adults aged 15-34 years. The three pathologies most frequently found in adults are meningioma, glioblastoma multiforme, and astrocytoma, respectively.
In Thailand, the annual incidence rate of benign brain tumors is 5.71 in 100,000 people, and that of malignant brain tumors is 2.07 in 100,000 people (Social Health Insurance and Social Security Office, 2009), and the trend for the incidence of brain tumors appears to be moving upward. According to statistics from the largest tertiary hospital located in Bangkok during 2003-2007, the total numbers of patients who sought treatment for brain tumors were 646, 686, 834, and 714, respectively. Brain tumors cause several health issues, which can be divided into two factors: (a) tumor-related factors, such as the types, locations, sizes, and the affected brain hemisphere (Correa, 2006), and (b) treatment-related factors, including surgery, radiotherapy, chemotherapy, and certain types of medications, such as anticonvulsant or steroids (Byrne, 2005; Correa, 2006). Modern diagnostic and therapeutic methods involve adjuvant treatments offering patients with brain tumor higher survival rates. Nevertheless, the aforementioned treatments do not prevent potential abnormalities after the treatment (Mukand, Blackinton, Crincoli, Lee, & Santos, 2001). As a result, the treatments may inevitably destroy normal parts of the brain during the course of therapy, thereby causing both physical and mental impairments for the patients.
Surgery is the treatment of choice for most patients with brain tumors. The main purpose of surgery is to remove tumors and alleviate the complications and symptoms. However, surgery may be considered a crisis or threatening event for patients (Campeau, 2009). The recovery period after brain surgery is perceived as one of the postoperative crises associated with recovery symptoms as well as adverse psychological and physical functioning. The first few weeks of recovery is critical for patients who need to return home to live independently after hospital discharge.
Brain Tumor Surgery and Recovery Symptoms
Surgery to remove brain tumors causes symptoms during the recovery stage after the treatment of brain tumors. These symptoms include weakness of extremities, visual impairment, loss of sensory perception, urinary and defecation incontinence (Mukand et al., 2001), insomnia, pain, fatigue (Fox, Lyon, & Farace, 2007), cognitive impairment, and problems with speech and communication (Gleason et al., 2007). Previous studies have been conducted in patients who received surgery with other treatments, such as radiation therapy and chemotherapy. However, few studies have been conducted with patients who received only surgery for brain tumor when they were first discharged from the hospital.
Brain Tumor Surgery and Mood State
Postoperative emotional changes generally manifest in the form of depression and mood swings (Ozcan, Evran, Koc, & Saatci, 2008). Gleason and colleagues (2007) have reported that patients tend to have anxiety and depression at all times, including restlessness after a diagnosis with brain tumors. However, no study has examined psychological functioning in Thai patients after surgery for brain tumor.
Brain Tumor Surgery and Physical Functioning
Postoperative functional status of patients with brain tumor has an impact on patients in various aspects. Quality of life is one factor that can be used to measure the functional status of patients after brain tumor surgery. Brain tumor surgery causes impacts on patients' work limitations. For instance, patients are found to be incapacitated with the previous job. Patients with malignant brain tumors at the mean time after diagnosis of 3.8 years were found to have higher work limitations than normal persons (p < .001); decreased problem-solving capabilities (p < .05; Feuerstein, Hansen, Calvio, Johnson, & Ronquillo, 2007); and reduced activities of daily living, for example, transferring problems (requiring assistance with mobility in the home, 64.4%) and stair problems (going up-down stairs, 53.3%; Mukdaprawat, Danaidutsadeekul, Chanruangwanich, & Itthimathin, 2012). Thus, patients who have had brain tumor surgery have reduced functional status, which affects their quality of life. However, few studies have been conducted specifically on the topic of functional status in patients who have had brain tumor surgery after discharge from hospital and when first returning home.
The Relationships Among Recovery Symptoms, Mood State, and Physical Functioning
Recovery symptoms may be related to functional status in patients with brain tumor. The severity of neurological deficit (Mukdaprawat et al., 2012), pain, sleep disturbance, and fatigue (Fox et al., 2007) are negatively related to activities of daily living and quality of life in patients with brain tumor. Depression has been found to be positively correlated with fatigue and sleep disturbance but negatively correlated with cognitive impairment. Depression has also been found to affect quality of life and functional status of patients (Fox et al., 2007).
It is worth noting that most previous studies have emphasized patients with malignant brain tumor treated by surgery and radiotherapy. The studies were long-term studies conducted in patients over a period of more than 6 months, so some symptoms were not a problem at the time. Furthermore, the studies did not address the problems of patients at the first follow-up visit after hospital discharge. The aforementioned period is in fact important and critical for patients who need to return home to live independently. Understanding the physical and emotional issues faced by patients can help healthcare teams to plan or prepare discharge for patients with greater efficiency. Therefore, the purposes of this study were to explore the relationships among recovery symptoms, mood state, and physical functioning and to identify predictors of physical functioning in patients after brain tumor surgery to implement the data obtained to modify current guidelines on care of patients with brain tumor at the first follow-up visit after hospital discharge.
The research questions were as follows:
1. What are the recovery symptoms, mood states, and physical functioning after brain tumor surgery in Thai patients during the first 2 weeks after hospital discharge?
2. What are the relationships among recovery symptoms, mood state, and physical functioning after brain tumor surgery in Thai patients during the first 2 weeks after hospital discharge?
3. What are the predictors of physical functioning after brain tumor surgery in Thai patients during the first 2 weeks after hospital discharge?
Conceptual Framework of the Study
This study employed the Theory of Unpleasant Symptoms of Lenz, Pugh, Milligan, Gift, and Suppe (1997) to guide the investigation of relationships among recovery symptoms, mood state, and physical functioning after brain tumor surgery in patients at the first follow-up visit after hospital discharge. The Theory of Unpleasant Symptoms involves the following three main components: (a) symptoms, (b) influencing factors, and (c) consequences of symptom experience. The symptoms occurring are influenced by physiological, psychological, and situational factors that affect health conditions. The effects of unpleasant symptoms have impacts on performance in terms of activities, which are functional performance and cognitive performance.
In the current study, the three components of the Theory of Unpleasant Symptoms are explored. First, symptoms are recovery symptoms including physical symptoms, such as headache, nausea, vomiting, fatigue, and so forth. Second, the consequence of symptom experience is functional status, such as physical functioning in patients with brain tumor as related to capacity to perform daily activities, which causes patients to perceive and feel changes from postoperative normal physical function. Thus, patients' experience of unpleasant symptoms related to their postoperative functional status. Finally, influencing factors are psychological factors and mood states such as anxiety, depression, confusion, anger, vigor, and fatigue. These factors are influencing symptoms with potential impact on recovery symptoms.
Materials and Methods
A cross-sectional predictive design was used. The target population of the study consisted of male and female Thai patients who had surgery for brain tumor at the first follow-up visit approximately 2 weeks after hospital discharge. A convenience sample was drawn from surgical units, outpatient departments of a tertiary hospital in Thailand. All participants who met the study inclusion criteria were consecutively approached for recruitment. The criteria for inclusion were as follows: (a) they were at least 18 years old, (b) they had undergone brain surgery for the first time, (c) they came to the hospital for their first follow-up after discharge, and (d) their Glasgow Coma Score was equal to 15. The exclusion criteria were as follows: (a) they had history of psychiatric disorders or existing neurological diseases; (b) they were on the tracheotomy tube; (c) they were unable to perform self-care; and (d) they received other adjuvant treatments with the surgery, such as radiotherapy and chemotherapy, because the combination of treatments has been found to be associated with a slower recovery (Greenberg, Treger, & Ring, 2006).
To estimate the needed sample size for this study, the guidelines suggested by Polit and Beck (2008) were used. Given a conventional level of power of .80, using a two-tailed alpha equal to .05 and moderate effect size of .30 (Mukdaprawat et al., 2012), a sample size of at least 88 subjects was required.
The final sample consisted of 88 participants (66 women and 22 men). The mean age of the subjects was 45.18 years (SD = 11.49 years, range = 18-72 years). Most subjects (71.6%) were married, more than half (55.7%) had elementary education, almost all (97.7%) were Buddhists, and a little more than one fourth (27.3%) were agriculturists. In terms of health risks, more than half of the sample group had never used cigarettes and liquor, and 27.3% of them had. In addition, nearly 60% of the sample group had good health with no chronic diseases. The most frequent comorbid disease in the sample group was hypertension, followed by diabetes mellitus. When considering income, more than 1 in 3 subjects had income less than 1,000 baht per month (1 US dollar = 31 Baht), and three quarters of them (75%) used the universal health coverage rights in seeking treatments.
Instrument
The questionnaire used to elicit demographic data of age, gender, educational attainment, marital status, religion, occupation, history of substance abuse, illness history, patient income, and payment coverage and clinical profile of diagnosis, tumor sites, time from early symptoms, type of surgery, time after surgery to the date of data collection, time after discharge from hospital to the date of first follow-up, and length of hospital stay was developed by the researcher.
Recovery symptoms were measured by the M.D. Anderson Symptom Inventory Brain Tumor of Armstrong and colleagues (2006), which is a questionnaire on existing symptoms after treatment for brain tumors. The 28-item questionnaire was reduced to 22 items because those items were related to cognitive function, and the inclusion criteria of the participants in this study required Glasgow Coma Score equal to 15, which they were able to communicate well. The rating scales valued from 0 to 10, and the subjects were asked to describe the severity of symptoms that happened in the past 24 hours. A total score was calculated by summing the item scores. Higher score indicated more severe symptoms, and vice versa. Cronbach's alpha coefficient revealed that the reliability of the instrument was equal to .86 in this study.
Mood state was assessed by using the Profile of Mood State-Brief Thai constructed by McNair, Lorr, and Dropplemen (1992). This standard instrument was composed of 65 questions. McNair and colleagues revised the instrument into the Profile of Mood State-Brief with 30 questions to assess six dimensions of mood state as follows: anxiety/tension, depression/dejection, confusion/bewilderment, anger/hostility, vigor/activity, and fatigue/inertia. The mood states of patients were assessed by a five-level scale ranging from 0 = "none" to 4 = "severe" according to the feelings of each patient. The scores could be calculated for each aspect and overall score for the individual's mood state. High total scores indicated increasingly fluctuating mood states, and vice versa. Cronbach's alpha coefficient revealed that the reliability of the instrument was equal to .81 in this study.
Physical functioning was measured by using the Sickness Impact Profile developed by Bergner, Bobbitt, Carter, and Gilson (1981) who used the instrument to assess functional status. The theoretical background of this instrument was based on behavioral changes of a person because of illness and the ultimate goal of healthcare service to reduce sickness or impacts of illnesses on ability to perform various activities. In completing the questionnaire, each section allowed patients to answer "yes" or "no." In interpreting scores, high scores indicated high degrees of sickness impacts or impaired capacity for performing duties, thereby reflecting poor functional status and vice versa. Cronbach's alpha coefficient revealed that the reliability of the instrument was equal to .82 in this study.
Procedure
Once the researcher had received permission from Siriraj Institutional Review Board (number Si 586/2011) to collect data, the researcher introduced himself to the director, head nurse, and staff of surgical unit to explain the research objectives and the details of research procedures and requested cooperation in data collection. During the first 2 weeks after discharge from the hospital, a list of patients who met the study criteria was prepared by the staff nurse and given to the researcher. Patients were approached consecutively by the researcher on the day of the first following visit at the surgical unit (outpatient department) while they were waiting for the physician or when the physician and nurse had completed the routine procedure. The researcher met the eligible patients to introduce himself and explain the research objectives, data collection procedures, risks and benefits of the research, and protection of the rights of the research subjects. The researcher also asked the patients for participation in the study. The subjects were asked to sign the informed consent form to indicate their willingness to participate in the research. The researcher then explained to the subjects how to complete the questionnaires and gave them opportunity to respond to the questionnaires on their own. In cases the subjects had reading difficulties or visual impairments, the researcher would read for them and allow them to fill out the questionnaires on their own. Data collection began with the demographic and clinical profile data questionnaire, the recovery symptoms questionnaire, and the physical functioning questionnaire and ended with the mood state questionnaire, respectively. It took the subjects approximately 45-60 minutes to complete all of the questionnaires.
Data Analysis
Data analysis was performed as follows: data regarding demographic characteristics, clinical profile, recovery symptoms, physical functioning, and mood state of the subjects were analyzed by means of frequency distribution, percentage, mean, and standard deviation. Analysis of correlations among recovery symptoms, mood state, and physical functioning at the first follow-up visit after hospital discharge was performed using Pearson's product-moment correlation coefficient. Predictors of physical functioning were tested by using multiple regression. Before analysis, data were examined for missing data points, outliners, normality, and linearity. Descriptive statistics were used to summarize the demographic, clinical profile, recovery symptoms, physical functioning, and mood state of participants. Pearson's correlation coefficient was used to determine the relationships among recovery symptoms, mood state, subscale of mood state (vigor, confusion, fatigue, anxiety, anger, depression), and physical functioning. Predictors of physical functioning were examined using a multiple regression analysis; all variables were examined for normality and homoscedasticity to avoid a multicollinearity effect. Although all independent variables had a multicollinearity, the tolerance test and the VIF are in acceptable values (tolerance score not less than 0.1, VIF not more than 10).
Results
With regard to the subjects' clinical profiles, most subjects (90%) had benign brain tumors, with the pathological examination results showing that the most frequently encountered pathology was meningioma brain tumors (48.9%), followed by pituitary adenoma (11.4%) and glioblastoma multiforme (8.0%), respectively. The mean period for which patients had symptoms before receiving surgery was during the first 3 and 3-6 months equally (30.7%). Moreover, the mean time after surgery to the date of data collection was 19.94 days (SD = 5.88 days), and the mean time from hospital discharge to the date of first follow-up treatments was 13.45 days (SD = 4.58 days). Finally, the mean length of hospital stay was 8.13 days (SD = 3.79 days).
Table 1 displays the frequency of recovery symptoms during the first follow-up visit after hospital discharge. The most common recovery symptom had the mean overall score of 30.57 points (SD = 23.22 points) with pain being the most severe symptom, followed by disturbed sleep, vision problems, and numbness, respectively. Symptoms of seizures were the least severe.
Table 2 shows total mood disturbance (TMD) score with the mean score equal to 4.68 points (SD = 15.13 points). When mood state was considered in terms of individual aspects, positive mood states (e.g., vigor) had the highest mean score. The mean score of negative mood state in the aspect of confusion was found to be the highest, followed by fatigue, anxiety, anger, and depression, respectively.
Table 3 displays physical functioning. The mean Sickness Impact Profile score was 26.22 points (SD = 7.64 points). The sample group was found to have the most problems with working (problems returning to previous occupations), followed by home management (housework such as sweeping, mopping, doing laundry, etc.), sleep and rest (difficulty sleeping and frequent wakening), and mobility (problems in traveling to various places), respectively. The problem least frequently encountered was being concerned with communication (conversations with surrounding persons).
Table 4 shows the relationships among recovery symptoms, mood state, and physical functioning of postoperative brain tumor patients during the period after discharge from hospital at the first follow-up visit after treatment as calculated by Pearson's product-moment correlation coefficient. According to the findings, recovery symptoms were found to be positively related to physical functioning at a moderate level (r = .406, p < .01). Mood state was positively related to physical functioning at a low level (r = .288, p < .01). Moreover, recovery symptoms were found to be positively related to mood state at a high level (r = .716, p < .01).
The correlations of the recovery symptoms, TMD, vigor, confusion, fatigue, anxiety, anger, depression, and physical functioning are shown in Table 4. As can be seen, all correlations, except for three variables between confusion, anxiety, anger, and physical activity, were not statistically significant. Therefore, recovery symptoms, TMD, depression, fatigue, and vigor were used in a standard regression analysis to predict physical functioning (Table 5). The prediction model was statistically significant, F(5, 88) = 8.83, p < .001, and accounted for approximately 35% of the variance of physical functioning (R2 = .35, adjusted R2 = .31). Recovery symptoms, TMD, fatigue, and vigor were statistically significant predictors of physical functioning and could explain variance of physical functioning in postoperative brain tumor patients during 2 weeks after discharge by 35%. The regression equation for physical functioning was therefore 31.63 + .38 (recovery symptoms) - .83 (TMD) + .45 (fatigue) - .49 (vigor). The results indicated that TMD was the strongest predictor to physical functioning in postoperative brain tumor patients during 2 weeks after discharge, followed by vigor, fatigue, and recovery symptom, respectively. However, depression was not significantly predicted to the outcome measure.
Discussion
Recovery Symptoms in Postoperative Brain Tumor Patients
In the current study, pain was found to have the highest mean score, followed by sleep disturbances, visual problems, numbness, distressed, and fatigue, respectively. Such findings differed from findings of a previous study of Armstrong and colleagues (2009) that found fatigue to have the highest mean score followed by sleep disturbances, drowsiness, and pain, respectively. In addition, Fox and colleagues (2007) have reported that sleep disturbances had the highest mean score, followed by fatigue, distress, and pain, respectively. The possible reason for such differences in the findings may be because of the fact that both studies were conducted with patients with malignant brain tumor who were treated with a combination of methods such as surgery, radiotherapy, and chemotherapy. Hence, most of the symptoms were the results of combined treatments rather than direct effects of the surgery alone. Moreover, surgery caused damage to the brain tissues, that is, the dura, brain tissue, nerve endings, and blood vessels. The consequence was pain, which was localized and which could be alleviated by taking pain relief medication. Generally, symptoms of pain can stabilize and disappear within 2 weeks (Gee, Ishaq, & Vijayan, 2003; Lovely, 2004). This finding was found to be in agreement with the study conducted with patients at approximately 2 weeks after hospital discharge.
Regarding visual problems, most patients had problems ranging from double vision to blindness, which were also reported by Mukand and colleagues (2001) who studied symptoms of patients with brain tumor after receiving various methods of treatment and found 53% of the patients to have visual impairment. Problems with numbness are caused by loss of sensory cortex function, which receives feelings from various parts of the body. In addition, sensory pathways may have been damaged, causing discontinuous neurological transmissions. Hence, patients lose their sense of feeling and become numb (Hickey, 2009).
The findings of the current research, however, were found to be contradictory to findings of past studies conducted on symptoms of patients with high-grade glioma and malignant brain tumor after receiving treatments for brain tumors by various methods, such as surgery, radiotherapy, and chemotherapy. Patients who had received treatments for more than a year were most frequently found to have symptoms of fatigue, followed by sleep disturbances, visual impairments, and pain, respectively (Fox et al., 2007), perhaps because patients with high-grade glioma and malignant brain tumor have abnormal formations of cytokines, such as tumor necrosis factor-[alpha], interleukin-1-[beta], interleukin-6, and interferon-[gamma], thereby causing loss of appetite as well as weight loss with protein and fat breakdown (Stasi, Abriani, Beccaglia, Terzoli, & Amadori, 2003). Furthermore, abnormal cytokines also have impacts on mitochondria, leading to loss of functional balance in generating aerobic and anaerobic energy, which in turn causes insufficient formation of adenosine triphosphate with impacts on the creation of protein cells and lactic acid (Berger, Gerber, & Mayer, 2012). Moreover, there are many factors more than the type of tumor that can cause fatigue in patients such as adjuvant treatment and the period after treatment. Therefore, patients with high-grade glioma and malignant brain tumor experience the most fatigue. Such findings were different from the findings of this study, which was carried out with patients with brain tumor during the first 2 weeks after hospital discharge, in that most patients were found to have benign tumors rather than malignant tumors. Hence, pain was the most frequently encountered symptom.
Mood State in Postoperative Brain Tumor Patients
Mood state refers to feelings expressed by persons or feelings expressed by persons in response to situations (Utiyaprasit & Moore, 2005). In this study, mood state refers to feelings expressed by patients after brain tumor surgery, that is, anxiety, depression, confusion, anger, vigor, fatigue, and TMD.
For the negative mood disturbance, this study found the sample group to most frequently experience confusion, followed by fatigue, anxiety, anger, and depression, respectively, which differed from findings of previous studies conducted with patients with brain tumor in the western culture using the same instruments because this study found depression to be the most frequently encountered emotional problem (Shaw et al., 2006). The differences in these findings may be because of diversity in terms of religious and cultural beliefs. This is because most of the population in Thailand are Buddhists who believe that religion is the source of their spiritual strength and feel that compliance with religious principles will help improve their lives (Lundberg, 2000). They also believe in the Law of Karma that their disease is in fact caused by actions in their past. Therefore, they are able to accept a condition that no one can change (Lundberg & Thrakul, 2012). This was found to be consistent with the mood states of patients with cancer in Taiwan where most of the population are also Buddhists and patients were found to experience more confusion than depression (Lin, Lai, & Ward, 2003). One the contrary, people in Western cultures have the belief that all persons are capable of managing their own lives and can change or improve their lives on their own.
Culture is also a significant factor in managing stress during illnesses. Patients in Thailand usually receive good physical, psychological, and economical care from relatives until their conditions have improved. Moreover, in Thai society, extended families are more common, so caregivers of sick family members are easily procured for issues in providing care, for example, food, medication adherence, exercise support, and transportation to hospital (Lundberg & Thrakul, 2012). On the contrary, Western society is primarily self-reliant, so patients are susceptible to depression when they become ill. In this study, therefore, the Thai patients with brain tumor in the sample group had mean scores of depression and anxiety that were lower than the mean score of confusion.
The high confusion scores obtained in this study may have been caused by the fact that patients were in the postoperative period and the period during the first 2 weeks after hospital discharge. The period when patients come back to the hospital for their first follow-up on treatments is a period for recovering cerebral function after surgery. Hence, the cerebral function of patients is not in a normal condition. In this study, some patients explained that they continued to experience confused feelings and blurriness at certain times, including the performance of activities without a purpose and experiencing forgetfulness. Furthermore, during that period, the patients remained unable to return to their daily lives and had to stop working, which caused uncertainty about their chances of returning to a normal life. Furthermore, most patients indicated that they performed activities without normal efficiency. The fact that most of the subjects were women may have caused them to have many roles in families and society, such as marital roles, maternal roles, and so forth, so they felt confused with their lives, and high confusion scores were found in this study.
For positive mood state, vigor got the highest score in postoperative brain tumor patients. Vigor was referred to feeling that someone possesses physical strength, emotional energy, and cognitive illness, a set of interconnected affective experiences that relate to individual energetic resources (Shirom, Toker, Berliner, Shapira, & Melamed, 2008). The positive mood in postoperative Thai patients may be described by the family structure, culture, and religious belief (as mentioned above).
Physical Functioning in Postoperative Brain Tumor Patients
The sample group was found to have low mean scores of problems with physical functioning during the first 2 weeks after hospital discharge. One plausible explanation for such finding is that this study was conducted with patients whose Glasgow Coma Scale score was 15 points, reflecting their normal levels of consciousness. Furthermore, more than 90% of the patients had benign tumors, thus constituting a group of patients with brain tumor without severe neurological changes. As a result, they had a tendency toward good physical functioning. Furthermore, nearly 50% of the sample had meningioma brain tumors, so they had nearly normal physical functioning after undergoing surgery. Generally, patients with meningioma have better physical functioning than patients with glioma and patients with cerebral hemorrhage. This is because patients with meningioma have less cerebral tissue destruction and require less complex surgery than other diseases. In addition, most of the subjects were patients who had undergone surgery to remove brain tumors for the first time, and they had never received other treatments, such as radiotherapy, chemotherapy, and so forth. Patients who have received more than one surgery and patients who have received radiotherapy with chemotherapy are likely to experience more neurological complications, thereby causing patients to have worse neurological changes (Byrne, 2005; Chang et al., 2003; Correa, 2006; Greenberg et al., 2006).
Scores on the physical functioning of patients with brain tumor during the period after discharge from hospital during the first 2 weeks after hospital discharge were considered in terms of all 12 aspects, that is, body care and movement, mobility, ambulation, social interactions, alertness behaviors, emotional behaviors, communication, recreation and pastime, working, home management, sleep and rest, and eating. The top five physical functioning with problems were work (the ability to return to work normally), home management (housework), sleep and rest, mobility (trips to various places), and emotional behaviors, respectively. The cause for the most problematic work-related issues is that most patients with brain tumor have limitations regarding work capacity. Thus, patients are unable to perform the work they have been accustomed to performing, and some patients have to leave work and lose income because of factors concerning various aspects, for example, capacity to confront stress, thinking process and decision making to resolve the problems, fatigue, cognitive function of patients, and so forth, when they are compared with normal and healthy persons (Feuerstein et al., 2007).
The second most important problem was home management. This may be because most of the subjects were married women. In the Thai culture, women are expected to carry out different roles, burdens, and duties of managing various activities inside the home, such as house cleaning, cooking, childrearing, and so forth (Klunklin & Greenwood, 2005), as evidenced by high scores of home management. Furthermore, most patients also had problems with sleep and rest because they were unable to sleep or were awakened frequently during the night and had difficulty returning to sleep. Such findings could be explained that the subjects were in the postoperative period and continued to experience pain. Such findings were in agreement with the findings of this study in terms of recovery symptoms because pain was found to be the most frequently encountered problem during the postoperative period. Pain-related insomnia is defined as secondary insomnia, which differs from primary insomnia, that is, pain for which no causes can be determined. Therefore, if we can manage pain, symptoms of insomnia are likely to improve. Besides, pain severity can predict insomnia severity (Tang, Goodchild, Hester, & Salkovskis, 2012). With regards to problems with mobility, most of the subjects were found to have spent most of their time at home and had not left their house areas because patients had recently had surgery with surgical incisions on their head, and they experience various symptoms, such as pain, fatigue, and so forth. Therefore, most patients decided to stay at home rather than perform activities outside the house.
Predictors of Physical Functioning in Postoperative Brain Tumor Patients
Recovery symptoms, TMD, fatigue, and vigor were statistically significant predictors of physical functioning and could explain variance of physical functioning in postoperative brain tumor patients during 2 weeks after discharge by 35%. The results indicate that TMD is the strongest predictor to physical functioning in postoperative brain tumor patients during 2 weeks after discharge, followed by vigor (negative direction), fatigue, and recovery symptom, respectively.
The correlation between recovery symptoms and physical functioning is consistent with the study hypothesis and could be explained in relation to the concept of the Theory of Unpleasant Symptoms (Lenz et al., 1997), which maintains that the severity of unpleasant symptoms has impacts on the physical functioning of patients. According to this study, recovery symptoms were found to be positively related to physical functioning at a moderate level (r = .406, p < .01). To put in another way, if patients had severe recovery symptoms, physical functioning would be decreased. Fox and colleagues (2007) explored the symptoms of patients with malignant brain tumor with impact on functional status and quality of life of patients. They found that pain, fatigue, and sleep disturbances were negatively related to functional status (r = -.355, -.522, and -.517, respectively; p < .01). Rocha-Filho and colleagues (2008) explored the impacts of pain from craniotomy on patient functional status and found that headache frequency led to poor functional status, which agrees with the study findings of Mukdaprawat and colleagues (2012) who explored severity of long-term neurological deficit for more than 2 months after brain tumor treatments, for example, strength of limbs, levels of consciousness, and visual problems. They found that these symptoms had impacts on physical functioning of postoperative brain tumor patients, and neurological deficit was negatively related to physical functioning (r = -.405, p < .01). Moreover, Feuerstein and colleagues (2007) discovered that fatigue and sleep disturbances resulted in limitations in the patients' ability to return to work.
In this study, psychological factors were also explored. According to the study findings, mood state was positively related to physical functioning at a low level (r = .288, p < .01). This means that patients with high emotional distress were more likely to have decreased functional capacity. When subscale of mood state was considered in relation to physical functioning, depression was found to be positively related to physical functioning at a low level (r = .276, p < .01). In addition, fatigue was positively related to physical functioning at a high level (r = .655, p < .01). Vigor was negatively related to physical functioning at a moderate level (r = -.421, p < .01).
Psychological factors also influenced physical functioning through symptoms because recovery symptoms were found to be related to mood state, which was in compliance with the Theory of Unpleasant Symptoms that states that symptoms occurring will be influenced by influencing factors, for example, physiological factors, psychological factors, and situational factors. In this study, only psychological factors were addressed. In this study, recovery symptoms were found to be positively related to mood state at a high level (r = .716, p < .01). That is, severe recovery symptoms caused emotional distress. This finding was found to be consistent with the finding of the study conducted by Fox and colleagues (2007) that fatigue and sleep disturbances were positively related to depression (r = .561 and .490, respectively; p < .01). Therefore, it is possible to confirm the Theory of Unpleasant Symptoms of Lenz and colleagues (1997) that recovery symptoms may be influenced by factors that have an influence on symptoms such as mood state, which in turn may affect physical functioning.
On the other hand, Lenz and her colleagues (1997) who presented the updated version of the model propose that decreased levels of performance can have a feedback loop to the influential factors. The current study found that vigor and fatigue could predict physical functioning directly in postoperative brain tumor patients. This finding corresponds with parallel research on postoperative brain tumor patients by Armstrong and colleagues (2006), who reported that performance status was the strongest predictor of fatigue severity, with those patients with poor performance status being almost likely to report moderate-to-severe fatigue. However, the participants in their study (66%) had high-grade tumor, which differs from the current study wherein most of the participants (90%) had benign tumor. Likewise, Fox and colleagues (2007) have found depression to be negatively related to functional status (r = -.757, p < .01). Furthermore, Feuerstein and colleagues (2007) discovered that depression resulted in limitations of patients' ability to return to work. Vigor was negatively related to physical functioning (negative direction). Vigor represents a positive affective state denoting active and pleasurable engagement with physical health benefit (Shirom et al., 2008).
Although there was a statistically significant bivariate correlation between depression and physical functioning, this did not contribute significantly to a regression model. The reason for the lack of a significant effect could be the fact that depression is related to physical functioning at a low level (r = .276, p < 0.01) and had a multicollinearity to all independent variables.
For nursing implication, the results in this study indicate that TMD is the strongest predictor to physical functioning in postoperative brain tumor patients during 2 weeks after discharge, followed by vigor (negative direction), fatigue, and recovery symptom, respectively. Therefore, when planning for management of various symptoms that are problematic for postoperative brain tumor patients and that have impacts on the functional status of these patients, nurses should not overlook mood states of the patients; otherwise, they may not be able to achieve their goals in providing care. In addition, future research that addresses intervention to improve physical activity in Thai postoperative brain tumor patients is recommended. Such studies should focus on interventions aimed at decreasing TMD or fatigue or reliving symptoms such as pain and increasing positive mood state such as vigor. Interventions to improve physical activity in Thai postoperative brain tumor patients might include music therapy, meditation, family support, or walking exercise.
In conclusion, according to the findings of this study, which was conducted with patients undergoing brain tumor surgery during the period of approximately 2 weeks after hospital discharge, most of the subjects were married middle-aged women who had low educational attainments, held agricultural occupations with low income, and had never had the disease before. The subjects experienced pain as the most frequently encountered recovery symptom, which differed from previous studies conducted with patients with high-grade glioma. With regards to mood state, the subjects most frequently had problems with confusion, which also differed from previous studies on mood state conducted in western countries. Concerning physical functioning, returning to work was found to be the most frequently encountered problem. The study findings regarding the relationships among the study variables and predictors of physical functioning including recovery symptoms, TMD, fatigue, and vigor during the first follow-up (2 weeks after discharge from hospital) yielded support to the Theory of Unpleasant Symptoms of Lenz and her colleagues (1997), which points out that symptoms are caused by the fact that a person has to face at least one incident, consequently leading to physiological, psychological, and behavioral impacts on the person. Symptoms may occur simultaneously or singularly. Each symptom interacts with others in that, when a symptom occurs, that symptom may cause other symptoms to subsequently follow or may exacerbate the severity of existing symptoms while greatly increasing the impacts on various aspects of capabilities. According to this study, recovery symptoms after brain tumor surgery have impacts on physical functioning of the patients, and physical functioning can have retroactive effects on influencing factors such as mood state. Therefore, intervention to improve physical activity in Thai postoperative brain tumor patients should be tailored to both recovery symptoms and mood states.
There are some limitations of this study. First, the researcher examined only postoperative brain tumor patients with full levels of consciousness, which may not be able to reflect problems in other patient groups with brain tumor. Second, this study aimed at examining recovery symptoms, mood state, and physical functioning of patients during the first 2 weeks after hospital discharge with only one assessment or measurement. Longitudinal studies should be conducted to shed more light on the long-term impacts of brain tumor surgery on patients and families, including duration of postoperative recovery. Third, convenience sampling was used. The lack of random sampling may contribute to sample selection bias and limits the generalization of the findings.
Acknowledgment
This study was funded in part by the scholarship in Celebration of the 84th birthday anniversary of His Majesty King Bhumibol Adulyadej, Faculty of Nursing, Mahidol University, in the academic year of 2011.
References