Volume 47 & Number 1 & February 2015 E11

Predictors of Physical Functioning in

Postoperative Brain Tumor Patients
Thitipong Tankumpuan, Ketsarin Utriyaprasit, Prangtip Chayaput, Parunut Itthimathin

ABSTRACT
A cross-sectional predictive design was used to study the relationships among recovery symptoms, mood state,
and physical functioning and to identify predictors of physical functioning in patients who underwent surgery
for brain tumor at the first follow-up visit (2 weeks) after hospital discharge. The sample included 88 patients who
were 18 years or older, had full level of consciousness, and underwent first-time surgery for brain tumor without
other adjuvant treatments from a tertiary hospital in Bangkok, Thailand. Descriptive statistics, Pearson
productYmoment correlation coefficient, and multiple regression were used for data analysis. The results
revealed that most participants were women (75%) with an average age of 45.18 T 11.49 years, having benign
brain tumors (91%) and pathological results as meningioma (48.9%). The most common recovery symptoms
were pain (mean = 3.2, SD = 2.6) and sleep disturbance (mean = 3.1, SD = 3.0). As for mood state,
the problem of confusion was found the most (mean = 4.6, SD = 2.7). The physical functioning problem
found the most was work aspect (mean = 66.3, SD = 13.3). Recovery symptoms had positive relationships
with physical functioning and mood state (r = .406, .716; p G .01), respectively. At the same time, mood state
had positive relationships with physical functioning (r = .288, p G .01). Recovery symptoms, total mood
disturbance, fatigue, and vigor were statistically significant predictors of physical functioning and could
explain variance of postoperative physical functioning in these patients at 2 weeks after discharge by
35%. Total mood disturbance was the strongest predictor of physical functioning followed by vigor, fatigue,
and recovery symptom, respectively. Interventions to improve physical functioning in postoperative brain
tumor patients during home recovery should account for not only recovery symptom management but
also mood state.

Keywords: mood state, patients with brain tumor, physical functioning, recovery symptoms

B
rain tumors can be found in people of both gen- In Thailand, the annual incidence rate of benign brain
ders and in all ages. According to statistics from tumors is 5.71 in 100,000 people, and that of malignant
the Central Brain Tumor Registry of the United brain tumors is 2.07 in 100,000 people (Social Health
States in 2007Y2008, the average annual incidence rate Insurance and Social Security Office, 2009), and the
of cancer is 14.3 in 100,000 people in men and 15.1 in trend for the incidence of brain tumors appears to be
100,000 people in women. Brain tumors are the third moving upward. According to statistics from the largest
leading cause of cancer-related deaths in adults aged tertiary hospital located in Bangkok during 2003Y2007,
15Y34 years. The three pathologies most frequently found the total numbers of patients who sought treatment for
in adults are meningioma, glioblastoma multiforme, brain tumors were 646, 686, 834, and 714, respectively.
and astrocytoma, respectively. Brain tumors cause several health issues, which can be
divided into two factors: (a) tumor-related factors, such
Thitipong Tankumpuan, MNS, is a Full-Time Instuctor, Faculty as the types, locations, sizes, and the affected brain hemi-
of Nursing, Department of Surgical Nursing, Mahidol University,
Bangkok, Thailand.
sphere (Correa, 2006), and (b) treatment-related factors,
including surgery, radiotherapy, chemotherapy, and cer-
Questions or comments about this article may be directed to
Ketsarin Utriyaprasit, PhD, at ketsarin.utr@mahidol.ac.th. She is
tain types of medications, such as anticonvulsant or
an Associate Professor, Faculty of Nursing, Department of Surgical steroids (Byrne, 2005; Correa, 2006). Modern diag-
Nursing, Mahidol University, Bangkok, Thailand. nostic and therapeutic methods involve adjuvant treat-
Prangtip Chayaput, PhD, is an Assistant Professor, Faculty of Nursing, ments offering patients with brain tumor higher survival
Department of Surgical Nursing, Mahidol University, Bangkok, Thailand. rates. Nevertheless, the aforementioned treatments do
Parunut Itthimathin, MD MSc (Neuro Surgery), is a Neurosurgical not prevent potential abnormalities after the treatment
Surgeon, Faculty of Medicine, Department of Surgery, Siriraj Hospital, (Mukand, Blackinton, Crincoli, Lee, & Santos, 2001).
Mahidol University, Bangkok, Thailand. As a result, the treatments may inevitably destroy normal
The authors declare no conflicts of interest. parts of the brain during the course of therapy, thereby
Copyright B 2015 American Association of Neuroscience Nurses causing both physical and mental impairments for the
DOI: 10.1097/JNN.0000000000000113 patients.

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
E12 Journal of Neuroscience Nursing

Surgery is the treatment of choice for most patients Mukdaprawat, Danaidutsadeekul, Chanruangwanich,
with brain tumors. The main purpose of surgery is to & Itthimathin, 2012). Thus, patients who have had
remove tumors and alleviate the complications and brain tumor surgery have reduced functional status,
symptoms. However, surgery may be considered a which affects their quality of life. However, few studies
crisis or threatening event for patients (Campeau, 2009). have been conducted specifically on the topic of
The recovery period after brain surgery is perceived as functional status in patients who have had brain tumor
one of the postoperative crises associated with recov- surgery after discharge from hospital and when first
ery symptoms as well as adverse psychological and returning home.
physical functioning. The first few weeks of recovery
is critical for patients who need to return home to live The Relationships Among Recovery
independently after hospital discharge. Symptoms, Mood State, and Physical
Functioning
Brain Tumor Surgery and Recovery Recovery symptoms may be related to functional status
Symptoms in patients with brain tumor. The severity of neurological
Surgery to remove brain tumors causes symptoms during deficit (Mukdaprawat et al., 2012), pain, sleep distur-
the recovery stage after the treatment of brain tumors. bance, and fatigue (Fox et al., 2007) are negatively
These symptoms include weakness of extremities, vi- related to activities of daily living and quality of life in
sual impairment, loss of sensory perception, urinary and patients with brain tumor. Depression has been found to
defecation incontinence (Mukand et al., 2001), insom- be positively correlated with fatigue and sleep distur-
nia, pain, fatigue (Fox, Lyon, & Farace, 2007), cognitive bance but negatively correlated with cognitive impair-
impairment, and problems with speech and communi- ment. Depression has also been found to affect quality of
cation (Gleason et al., 2007). Previous studies have life and functional status of patients (Fox et al., 2007).
been conducted in patients who received surgery with It is worth noting that most previous studies have
other treatments, such as radiation therapy and chemo- emphasized patients with malignant brain tumor treated
therapy. However, few studies have been conducted by surgery and radiotherapy. The studies were long-term
with patients who received only surgery for brain tumor studies conducted in patients over a period of more
when they were first discharged from the hospital. than 6 months, so some symptoms were not a problem
at the time. Furthermore, the studies did not address
Brain Tumor Surgery and Mood State the problems of patients at the first follow-up visit after
Postoperative emotional changes generally manifest hospital discharge. The aforementioned period is in fact
in the form of depression and mood swings (Ozcan, important and critical for patients who need to return
Evran, Koc, & Saatci, 2008). Gleason and colleagues home to live independently. Understanding the physical
(2007) have reported that patients tend to have anxiety and emotional issues faced by patients can help healthcare
and depression at all times, including restlessness after teams to plan or prepare discharge for patients with
a diagnosis with brain tumors. However, no study has greater efficiency. Therefore, the purposes of this study
examined psychological functioning in Thai patients were to explore the relationships among recovery symp-
after surgery for brain tumor. toms, mood state, and physical functioning and to
identify predictors of physical functioning in patients
Brain Tumor Surgery and Physical after brain tumor surgery to implement the data obtained
Functioning to modify current guidelines on care of patients with
Postoperative functional status of patients with brain brain tumor at the first follow-up visit after hospital
tumor has an impact on patients in various aspects. discharge.
Quality of life is one factor that can be used to measure The research questions were as follows:
the functional status of patients after brain tumor surgery.
Brain tumor surgery causes impacts on patients’ work 1. What are the recovery symptoms, mood states, and
limitations. For instance, patients are found to be inca- physical functioning after brain tumor surgery in
pacitated with the previous job. Patients with malig- Thai patients during the first 2 weeks after hospital
nant brain tumors at the mean time after diagnosis of discharge?
3.8 years were found to have higher work limitations 2. What are the relationships among recovery symp-
than normal persons (p G .001); decreased problem- toms, mood state, and physical functioning after
solving capabilities (p G .05; Feuerstein, Hansen, Calvio, brain tumor surgery in Thai patients during the first
Johnson, & Ronquillo, 2007); and reduced activities 2 weeks after hospital discharge?
of daily living, for example, transferring problems 3. What are the predictors of physical functioning
(requiring assistance with mobility in the home, 64.4%) after brain tumor surgery in Thai patients during the
and stair problems (going upYdown stairs, 53.3%; first 2 weeks after hospital discharge?

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
 Volume 47 & Number 1 & February 2015 E13

Conceptual Framework of the Study used. Given a conventional level of power of .80, using
This study employed the Theory of Unpleasant Symp- a two-tailed alpha equal to .05 and moderate effect size
toms of Lenz, Pugh, Milligan, Gift, and Suppe (1997) of .30 (Mukdaprawat et al., 2012), a sample size of at
to guide the investigation of relationships among reco- least 88 subjects was required.
very symptoms, mood state, and physical functioning The final sample consisted of 88 participants (66
after brain tumor surgery in patients at the first follow-up women and 22 men). The mean age of the subjects was
visit after hospital discharge. The Theory of Unpleasant 45.18 years (SD = 11.49 years, range = 18Y72 years).
Symptoms involves the following three main compo- Most subjects (71.6%) were married, more than half
nents: (a) symptoms, (b) influencing factors, and (c) (55.7%) had elementary education, almost all (97.7%)
consequences of symptom experience. The symptoms were Buddhists, and a little more than one fourth
occurring are influenced by physiological, psychological, (27.3%) were agriculturists. In terms of health risks,
and situational factors that affect health conditions. more than half of the sample group had never used
The effects of unpleasant symptoms have impacts on cigarettes and liquor, and 27.3% of them had. In ad-
performance in terms of activities, which are functional dition, nearly 60% of the sample group had good
performance and cognitive performance. health with no chronic diseases. The most frequent
In the current study, the three components of the comorbid disease in the sample group was hyper-
Theory of Unpleasant Symptoms are explored. First, tension, followed by diabetes mellitus. When consid-
symptoms are recovery symptoms including physical ering income, more than 1 in 3 subjects had income
symptoms, such as headache, nausea, vomiting, fatigue, less than 1,000 baht per month (1 US dollar = 31 Baht),
and so forth. Second, the consequence of symptom ex- and three quarters of them (75%) used the universal
perience is functional status, such as physical function- health coverage rights in seeking treatments.
ing in patients with brain tumor as related to capacity to
perform daily activities, which causes patients to perceive Instrument
and feel changes from postoperative normal physical The questionnaire used to elicit demographic data of
function. Thus, patients’ experience of unpleasant symp- age, gender, educational attainment, marital status,
toms related to their postoperative functional status. religion, occupation, history of substance abuse, illness
Finally, influencing factors are psychological factors history, patient income, and payment coverage and
and mood states such as anxiety, depression, confusion, clinical profile of diagnosis, tumor sites, time from
anger, vigor, and fatigue. These factors are influencing early symptoms, type of surgery, time after surgery to
symptoms with potential impact on recovery symptoms. the date of data collection, time after discharge from
hospital to the date of first follow-up, and length of
Materials and Methods hospital stay was developed by the researcher.
A cross-sectional predictive design was used. The target Recovery symptoms were measured by the M.D.
population of the study consisted of male and female Anderson Symptom Inventory Brain Tumor of Armstrong
Thai patients who had surgery for brain tumor at the and colleagues (2006), which is a questionnaire on
first follow-up visit approximately 2 weeks after hos- existing symptoms after treatment for brain tumors.
pital discharge. A convenience sample was drawn from The 28-item questionnaire was reduced to 22 items
surgical units, outpatient departments of a tertiary hos- because those items were related to cognitive function,
pital in Thailand. All participants who met the study and the inclusion criteria of the participants in this
inclusion criteria were consecutively approached for study required Glasgow Coma Score equal to 15, which
recruitment. The criteria for inclusion were as follows: they were able to communicate well. The rating scales
(a) they were at least 18 years old, (b) they had under- valued from 0 to 10, and the subjects were asked to
gone brain surgery for the first time, (c) they came to describe the severity of symptoms that happened in
the hospital for their first follow-up after discharge, and the past 24 hours. A total score was calculated by
(d) their Glasgow Coma Score was equal to 15. The summing the item scores. Higher score indicated more
exclusion criteria were as follows: (a) they had history severe symptoms, and vice versa. Cronbach’s alpha
of psychiatric disorders or existing neurological di- coefficient revealed that the reliability of the instrument
seases; (b) they were on the tracheotomy tube; (c) they was equal to .86 in this study.
were unable to perform self-care; and (d) they received Mood state was assessed by using the Profile of
other adjuvant treatments with the surgery, such as ra- Mood State-Brief Thai constructed by McNair, Lorr,
diotherapy and chemotherapy, because the combina- and Dropplemen (1992). This standard instrument was
tion of treatments has been found to be associated with composed of 65 questions. McNair and colleagues
a slower recovery (Greenberg, Treger, & Ring, 2006). revised the instrument into the Profile of Mood State-
To estimate the needed sample size for this study, Brief with 30 questions to assess six dimensions of
the guidelines suggested by Polit and Beck (2008) were mood state as follows: anxiety/tension, depression/

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
E14 Journal of Neuroscience Nursing

dejection, confusion/bewilderment, anger/hostility, began with the demographic and clinical profile data
vigor/activity, and fatigue/inertia. The mood states questionnaire, the recovery symptoms questionnaire,
of patients were assessed by a five-level scale ranging and the physical functioning questionnaire and ended
from 0 = ‘‘none’’ to 4 = ‘‘severe’’ according to the with the mood state questionnaire, respectively. It took
feelings of each patient. The scores could be calculated the subjects approximately 45Y60 minutes to complete
for each aspect and overall score for the individual’s all of the questionnaires.
mood state. High total scores indicated increasingly
fluctuating mood states, and vice versa. Cronbach’s Data Analysis
alpha coefficient revealed that the reliability of the Data analysis was performed as follows: data regarding
instrument was equal to .81 in this study. demographic characteristics, clinical profile, recovery
Physical functioning was measured by using the symptoms, physical functioning, and mood state of
Sickness Impact Profile developed by Bergner, Bobbitt, the subjects were analyzed by means of frequency
Carter, and Gilson (1981) who used the instrument to distribution, percentage, mean, and standard devia-
assess functional status. The theoretical background tion. Analysis of correlations among recovery symp-
of this instrument was based on behavioral changes toms, mood state, and physical functioning at the first
of a person because of illness and the ultimate goal of follow-up visit after hospital discharge was performed
healthcare service to reduce sickness or impacts of using Pearson’s productYmoment correlation coeffi-
illnesses on ability to perform various activities. In cient. Predictors of physical functioning were tested
completing the questionnaire, each section allowed by using multiple regression. Before analysis, data were
patients to answer ‘‘yes’’ or ‘‘no.’’ In interpreting examined for missing data points, outliners, normality,
scores, high scores indicated high degrees of sickness and linearity. Descriptive statistics were used to summa-
impacts or impaired capacity for performing duties, rize the demographic, clinical profile, recovery symptoms,
thereby reflecting poor functional status and vice versa. physical functioning, and mood state of participants.
Cronbach’s alpha coefficient revealed that the reliability Pearson’s correlation coefficient was used to deter-
of the instrument was equal to .82 in this study. mine the relationships among recovery symptoms,
mood state, subscale of mood state (vigor, confusion,
Procedure fatigue, anxiety, anger, depression), and physical func-
Once the researcher had received permission from tioning. Predictors of physical functioning were
Siriraj Institutional Review Board (number Si 586/ examined using a multiple regression analysis; all var-
2011) to collect data, the researcher introduced himself iables were examined for normality and homoscedas-
to the director, head nurse, and staff of surgical unit to ticity to avoid a multicollinearity effect. Although all
explain the research objectives and the details of re- independent variables had a multicollinearity, the tol-
search procedures and requested cooperation in data erance test and the VIF are in acceptable values (tol-
collection. During the first 2 weeks after discharge erance score not less than 0.1, VIF not more than 10).
from the hospital, a list of patients who met the study
criteria was prepared by the staff nurse and given to the Results
researcher. Patients were approached consecutively by With regard to the subjects’ clinical profiles, most sub-
the researcher on the day of the first following visit at jects (90%) had benign brain tumors, with the patho-
the surgical unit (outpatient department) while they logical examination results showing that the most
were waiting for the physician or when the physician frequently encountered pathology was meningioma
and nurse had completed the routine procedure. The brain tumors (48.9%), followed by pituitary adenoma
researcher met the eligible patients to introduce him- (11.4%) and glioblastoma multiforme (8.0%), respec-
self and explain the research objectives, data collec- tively. The mean period for which patients had symp-
tion procedures, risks and benefits of the research, and toms before receiving surgery was during the first 3 and
protection of the rights of the research subjects. The 3Y6 months equally (30.7%). Moreover, the mean time
researcher also asked the patients for participation in after surgery to the date of data collection was 19.94 days
the study. The subjects were asked to sign the in- (SD = 5.88 days), and the mean time from hospital
formed consent form to indicate their willingness to discharge to the date of first follow-up treatments was
participate in the research. The researcher then ex- 13.45 days (SD = 4.58 days). Finally, the mean length
plained to the subjects how to complete the question- of hospital stay was 8.13 days (SD = 3.79 days).
naires and gave them opportunity to respond to the Table 1 displays the frequency of recovery symp-
questionnaires on their own. In cases the subjects had toms during the first follow-up visit after hospital dis-
reading difficulties or visual impairments, the re- charge. The most common recovery symptom had the
searcher would read for them and allow them to fill mean overall score of 30.57 points (SD = 23.22 points)
out the questionnaires on their own. Data collection with pain being the most severe symptom, followed

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
 Volume 47 & Number 1 & February 2015 E15

TABLE 1. Mean and Standard Deviation TABLE 2. Range, Mean, and Standard
Categorized by Recovery Deviation Categorized by
Symptoms of Sample (n = 88) Mood State of Sample (n = 88)
Recovery Symptoms Range Mean SD Mood State Range Mean SD
Pain 0Y10 3.20 2.62 Positive mood state
Disturbed sleep 0Y10 3.13 3.06 Vigor 3Y20 13.32 3.90
Vision problems 0Y10 2.90 3.42 Negative mood state
Numbness 0Y10 2.36 2.98 Confusion 0Y14 4.67 2.73
Distressed 0Y10 2.26 3.31 Fatigue 0Y18 4.27 3.72
Fatigued 0Y8 2.20 2.37 Anxiety 0Y14 3.76 3.85
Dry mouth 0Y10 2.18 2.57 Anger 0Y15 2.90 3.51
Lack of appetite 0Y10 1.67 2.53 Depression 0Y16 2.40 3.50
Drowsy 0Y9 1.36 2.27 Total mood disturbance score j16 to 65 4.68 15.13
Irritability 0Y10 1.25 2.23
Weakness 0Y10 1.23 2.30
Sadness 0Y10 1.22 2.33 Table 4 shows the relationships among recovery
Nausea 0Y10 1.11 2.21 symptoms, mood state, and physical functioning of
Shortness of breath 0Y9 0.92 1.99 postoperative brain tumor patients during the period
Change in appearance 0Y10 0.80 1.91
after discharge from hospital at the first follow-up visit
after treatment as calculated by Pearson’s productY
Change in bowel pattern 0Y10 0.73 1.81
moment correlation coefficient. According to the find-
Loss of memory 0Y7 0.58 1.44 ings, recovery symptoms were found to be positively
Difficulty speaking 0Y5 0.45 1.16 related to physical functioning at a moderate level
Difficulty concentration 0Y5 0.35 0.94 (r = .406, p G .01). Mood state was positively re-
Difficulty understanding 0Y5 0.33 0.94 lated to physical functioning at a low level (r = .288,
Vomiting 0Y10 0.31 1.32 p G .01). Moreover, recovery symptoms were found
Seizure 0Y2 0.03 0.23 to be positively related to mood state at a high level
Total 0Y125 30.57 23.22
(r = .716, p G .01).

TABLE 3. Range, Mean, and Standard

by disturbed sleep, vision problems, and numbness, Deviation Categorized by
respectively. Symptoms of seizures were the least severe. Physical Functioning of Sample
Table 2 shows total mood disturbance (TMD) score (n = 88)
with the mean score equal to 4.68 points (SD = 15.13 Physical Functioning Range Mean SD
points). When mood state was considered in terms of Working 7.18Y70.10 66.37 13.35
individual aspects, positive mood states (e.g., vigor)
Home management 0Y98.65 58.36 25.63
had the highest mean score. The mean score of negative
Sleep and rest 0Y90.18 57.20 21.21
mood state in the aspect of confusion was found to be
the highest, followed by fatigue, anxiety, anger, and de- Mobility 0Y88.04 38.86 19.31
pression, respectively. Emotional behaviors 0Y58.87 22.92 15.89
Table 3 displays physical functioning. The mean Recreation and pastime 0Y27.29 15.47 5.38
Sickness Impact Profile score was 26.22 points (SD = Ambulation 0Y53.80 14.96 12.61
7.64 points). The sample group was found to have the Social interactions 0Y31.45 11.60 7.23
most problems with working (problems returning to Eating 0Y39.15 9.12 8.69
previous occupations), followed by home manage- Body care and movement 0Y58.51 8.62 11.87
ment (housework such as sweeping, mopping, doing
Alertness behaviors 0Y39.64 5.97 8.45
laundry, etc.), sleep and rest (difficulty sleeping and
frequent wakening), and mobility (problems in trav- Communication 0Y43.03 5.21 9.11
eling to various places), respectively. The problem least Total Sickness Impact 4.02Y45.81 26.22 7.64
frequently encountered was being concerned with com- Profile score
munication (conversations with surrounding persons).

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
E16 Journal of Neuroscience Nursing

TABLE 4. The Relationships Among Recovery Symptoms, Mood State, and Physical
Functioning of Sample by Pearson’s ProductYMoment Correlation Coefficient
(n = 88)
Variables 1 2 3 4 5 6 7 8 9
1. Physical 1
functioning
2. Recovery .406** 1
symptoms
3. Mood state .288** .716** 1
(total mood
disturbance)
4. Vigor j.421** j.241* j.446** 1
5. Confusion .051 .490** .694** .014 1
6. Fatigue .322** .645** .833** j.277** .655** 1
7. Anxiety (tension) .140 .607** .814** j.201 .511** .588** 1
8. Anger j.037 .388** .661** j.028 .466** .464** .442** 1
9. Depression .276** .697** .838** j.279** .505** .601** .723** .479** 1

*p G .05 (two tailed). **p G .01 (two tailed).

The correlations of the recovery symptoms, TMD, Such findings differed from findings of a previous
vigor, confusion, fatigue, anxiety, anger, depression, study of Armstrong and colleagues (2009) that found
and physical functioning are shown in Table 4. As can fatigue to have the highest mean score followed by
be seen, all correlations, except for three variables be- sleep disturbances, drowsiness, and pain, respectively.
tween confusion, anxiety, anger, and physical activity, In addition, Fox and colleagues (2007) have reported
were not statistically significant. Therefore, recovery that sleep disturbances had the highest mean score,
symptoms, TMD, depression, fatigue, and vigor were followed by fatigue, distress, and pain, respectively.
used in a standard regression analysis to predict phys- The possible reason for such differences in the find-
ical functioning (Table 5). The prediction model was ings may be because of the fact that both studies were
statistically significant, F(5, 88) = 8.83, p G .001, and conducted with patients with malignant brain tumor
accounted for approximately 35% of the variance of
physical functioning (R2 = .35, adjusted R2 = .31).
Recovery symptoms, TMD, fatigue, and vigor were sta- TABLE 5. Summary of Multiple
tistically significant predictors of physical functioning Regression Analysis of
and could explain variance of physical functioning Recovery Symptoms and
in postoperative brain tumor patients during 2 weeks Mood State on Physical
after discharge by 35%. The regression equation for Functioning in Postoperative
physical functioning was therefore 31.63 + .38 (re- Brain Tumor Patients (n = 88)
covery symptoms) j .83 (TMD) + .45 (fatigue) j .49 Variables B SEB Beta p
(vigor). The results indicated that TMD was the strongest
Recovery symptoms .13 .05 .38 .01
predictor to physical functioning in postoperative brain
Total mood disturbance j.42 .14 j.83 .00
tumor patients during 2 weeks after discharge, followed
by vigor, fatigue, and recovery symptom, respectively. Depression .64 .41 .29 .12
However, depression was not significantly predicted Fatigue .92 .37 .45 .01
to the outcome measure. Vigor j.96 .21 j.49 .00

Discussion Note. Predictors: recovery symptoms, total mood disturbance,

Recovery Symptoms in Postoperative Brain depression, fatigue, and vigor. Dependent variable: physical
functioning. B = unstandardized regression coefficient;
Tumor Patients SEB = standard error of unstandardized regression coefficient;
In the current study, pain was found to have the highest Beta = standardized regression coefficient; R2 = squared multiple
correlation of y with x.
mean score, followed by sleep disturbances, visual R2 = .35, F = 8.83, p G .001.
problems, numbness, distressed, and fatigue, respectively.

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
 Volume 47 & Number 1 & February 2015 E17

who were treated with a combination of methods such most patients were found to have benign tumors rather
as surgery, radiotherapy, and chemotherapy. Hence, than malignant tumors. Hence, pain was the most fre-
most of the symptoms were the results of combined quently encountered symptom.
treatments rather than direct effects of the surgery alone.
Moreover, surgery caused damage to the brain tissues, Mood State in Postoperative Brain Tumor
that is, the dura, brain tissue, nerve endings, and blood Patients
vessels. The consequence was pain, which was localized Mood state refers to feelings expressed by persons or
and which could be alleviated by taking pain relief feelings expressed by persons in response to situations
medication. Generally, symptoms of pain can stabi- (Utiyaprasit & Moore, 2005). In this study, mood
lize and disappear within 2 weeks (Gee, Ishaq, & state refers to feelings expressed by patients after brain
Vijayan, 2003; Lovely, 2004). This finding was found tumor surgery, that is, anxiety, depression, confusion,
to be in agreement with the study conducted with pa- anger, vigor, fatigue, and TMD.
tients at approximately 2 weeks after hospital discharge. For the negative mood disturbance, this study found
Regarding visual problems, most patients had prob- the sample group to most frequently experience con-
lems ranging from double vision to blindness, which fusion, followed by fatigue, anxiety, anger, and de-
were also reported by Mukand and colleagues (2001) pression, respectively, which differed from findings
who studied symptoms of patients with brain tumor of previous studies conducted with patients with brain
after receiving various methods of treatment and found tumor in the western culture using the same instruments
53% of the patients to have visual impairment. Problems because this study found depression to be the most
with numbness are caused by loss of sensory cortex frequently encountered emotional problem (Shaw et al.,
function, which receives feelings from various parts 2006). The differences in these findings may be be-
of the body. In addition, sensory pathways may have cause of diversity in terms of religious and cultural
been damaged, causing discontinuous neurological beliefs. This is because most of the population in
transmissions. Hence, patients lose their sense of feel- Thailand are Buddhists who believe that religion is
ing and become numb (Hickey, 2009). the source of their spiritual strength and feel that com-
The findings of the current research, however, were pliance with religious principles will help improve
found to be contradictory to findings of past studies their lives (Lundberg, 2000). They also believe in the
conducted on symptoms of patients with high-grade Law of Karma that their disease is in fact caused by
glioma and malignant brain tumor after receiving treat- actions in their past. Therefore, they are able to accept
ments for brain tumors by various methods, such as a condition that no one can change (Lundberg &
surgery, radiotherapy, and chemotherapy. Patients who Thrakul, 2012). This was found to be consistent with
had received treatments for more than a year were most the mood states of patients with cancer in Taiwan where
frequently found to have symptoms of fatigue, followed most of the population are also Buddhists and patients
by sleep disturbances, visual impairments, and pain, were found to experience more confusion than depres-
respectively (Fox et al., 2007), perhaps because pa- sion (Lin, Lai, & Ward, 2003). One the contrary, peo-
tients with high-grade glioma and malignant brain ple in Western cultures have the belief that all persons
tumor have abnormal formations of cytokines, such as are capable of managing their own lives and can change
tumor necrosis factor-", interleukin-1-$, interleukin-6, or improve their lives on their own.
and interferon-,, thereby causing loss of appetite as Culture is also a significant factor in managing stress
well as weight loss with protein and fat breakdown during illnesses. Patients in Thailand usually receive
(Stasi, Abriani, Beccaglia, Terzoli, & Amadori, 2003). good physical, psychological, and economical care
Furthermore, abnormal cytokines also have impacts from relatives until their conditions have improved.
on mitochondria, leading to loss of functional balance Moreover, in Thai society, extended families are more
in generating aerobic and anaerobic energy, which in common, so caregivers of sick family members are
turn causes insufficient formation of adenosine triphos- easily procured for issues in providing care, for exam-
phate with impacts on the creation of protein cells and ple, food, medication adherence, exercise support, and
lactic acid (Berger, Gerber, & Mayer, 2012). More- transportation to hospital (Lundberg & Thrakul, 2012).
over, there are many factors more than the type of On the contrary, Western society is primarily self-
tumor that can cause fatigue in patients such as adju- reliant, so patients are susceptible to depression when
vant treatment and the period after treatment. There- they become ill. In this study, therefore, the Thai pa-
fore, patients with high-grade glioma and malignant tients with brain tumor in the sample group had mean
brain tumor experience the most fatigue. Such find- scores of depression and anxiety that were lower than
ings were different from the findings of this study, the mean score of confusion.
which was carried out with patients with brain tumor The high confusion scores obtained in this study
during the first 2 weeks after hospital discharge, in that may have been caused by the fact that patients were

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
E18 Journal of Neuroscience Nursing

in the postoperative period and the period during the other treatments, such as radiotherapy, chemotherapy,
first 2 weeks after hospital discharge. The period when and so forth. Patients who have received more than one
patients come back to the hospital for their first surgery and patients who have received radiotherapy
follow-up on treatments is a period for recovering ce- with chemotherapy are likely to experience more neu-
rebral function after surgery. Hence, the cerebral func- rological complications, thereby causing patients to
tion of patients is not in a normal condition. In this have worse neurological changes (Byrne, 2005; Chang
study, some patients explained that they continued to et al., 2003; Correa, 2006; Greenberg et al., 2006).
experience confused feelings and blurriness at certain Scores on the physical functioning of patients with
times, including the performance of activities without a brain tumor during the period after discharge from
purpose and experiencing forgetfulness. Furthermore, hospital during the first 2 weeks after hospital dis-
during that period, the patients remained unable to charge were considered in terms of all 12 aspects, that
return to their daily lives and had to stop working, is, body care and movement, mobility, ambulation,
which caused uncertainty about their chances of return- social interactions, alertness behaviors, emotional be-
ing to a normal life. Furthermore, most patients in- haviors, communication, recreation and pastime, work-
dicated that they performed activities without normal ing, home management, sleep and rest, and eating. The
efficiency. The fact that most of the subjects were top five physical functioning with problems were work
women may have caused them to have many roles in (the ability to return to work normally), home manage-
families and society, such as marital roles, maternal ment (housework), sleep and rest, mobility (trips to
roles, and so forth, so they felt confused with their lives, various places), and emotional behaviors, respectively.
and high confusion scores were found in this study. The cause for the most problematic work-related issues
For positive mood state, vigor got the highest score is that most patients with brain tumor have limitations
in postoperative brain tumor patients. Vigor was re- regarding work capacity. Thus, patients are unable to
ferred to feeling that someone possesses physical perform the work they have been accustomed to per-
strength, emotional energy, and cognitive illness, a forming, and some patients have to leave work and
set of interconnected affective experiences that re- lose income because of factors concerning various
late to individual energetic resources (Shirom, Toker, aspects, for example, capacity to confront stress, think-
Berliner, Shapira, & Melamed, 2008). The positive ing process and decision making to resolve the problems,
mood in postoperative Thai patients may be described fatigue, cognitive function of patients, and so forth,
by the family structure, culture, and religious belief when they are compared with normal and healthy per-
(as mentioned above). sons (Feuerstein et al., 2007).
The second most important problem was home
management. This may be because most of the sub-
Physical Functioning in Postoperative Brain jects were married women. In the Thai culture, women
Tumor Patients are expected to carry out different roles, burdens, and
The sample group was found to have low mean scores duties of managing various activities inside the home,
of problems with physical functioning during the first such as house cleaning, cooking, childrearing, and so
2 weeks after hospital discharge. One plausible ex- forth (Klunklin & Greenwood, 2005), as evidenced
planation for such finding is that this study was con- by high scores of home management. Furthermore,
ducted with patients whose Glasgow Coma Scale score most patients also had problems with sleep and rest
was 15 points, reflecting their normal levels of con- because they were unable to sleep or were awakened
sciousness. Furthermore, more than 90% of the pa- frequently during the night and had difficulty returning
tients had benign tumors, thus constituting a group of to sleep. Such findings could be explained that the
patients with brain tumor without severe neurological subjects were in the postoperative period and continued
changes. As a result, they had a tendency toward good to experience pain. Such findings were in agreement
physical functioning. Furthermore, nearly 50% of the with the findings of this study in terms of recovery
sample had meningioma brain tumors, so they had symptoms because pain was found to be the most fre-
nearly normal physical functioning after undergoing quently encountered problem during the postoperative
surgery. Generally, patients with meningioma have period. Pain-related insomnia is defined as secondary
better physical functioning than patients with glioma insomnia, which differs from primary insomnia, that is,
and patients with cerebral hemorrhage. This is be- pain for which no causes can be determined. There-
cause patients with meningioma have less cerebral tis- fore, if we can manage pain, symptoms of insomnia
sue destruction and require less complex surgery than are likely to improve. Besides, pain severity can predict
other diseases. In addition, most of the subjects were insomnia severity (Tang, Goodchild, Hester, & Salkovskis,
patients who had undergone surgery to remove brain 2012). With regards to problems with mobility, most
tumors for the first time, and they had never received of the subjects were found to have spent most of their

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
 Volume 47 & Number 1 & February 2015 E19

time at home and had not left their house areas be- functional capacity. When subscale of mood state was
cause patients had recently had surgery with surgical considered in relation to physical functioning, depres-
incisions on their head, and they experience various sion was found to be positively related to physical func-
symptoms, such as pain, fatigue, and so forth. There- tioning at a low level (r = .276, p G .01). In addition,
fore, most patients decided to stay at home rather than fatigue was positively related to physical functioning
perform activities outside the house. at a high level (r = .655, p G .01). Vigor was nega-
tively related to physical functioning at a moderate
Predictors of Physical Functioning in level (r = j.421, p G .01).
Postoperative Brain Tumor Patients Psychological factors also influenced physical func-
Recovery symptoms, TMD, fatigue, and vigor were tioning through symptoms because recovery symptoms
statistically significant predictors of physical function- were found to be related to mood state, which was in
ing and could explain variance of physical functioning compliance with the Theory of Unpleasant Symptoms
in postoperative brain tumor patients during 2 weeks that states that symptoms occurring will be influenced
after discharge by 35%. The results indicate that TMD by influencing factors, for example, physiological fac-
is the strongest predictor to physical functioning in tors, psychological factors, and situational factors. In
postoperative brain tumor patients during 2 weeks after this study, only psychological factors were addressed.
discharge, followed by vigor (negative direction), In this study, recovery symptoms were found to be
fatigue, and recovery symptom, respectively. positively related to mood state at a high level (r =
The correlation between recovery symptoms and .716, p G .01). That is, severe recovery symptoms
physical functioning is consistent with the study hy- caused emotional distress. This finding was found to
pothesis and could be explained in relation to the be consistent with the finding of the study conducted
concept of the Theory of Unpleasant Symptoms (Lenz by Fox and colleagues (2007) that fatigue and sleep
et al., 1997), which maintains that the severity of disturbances were positively related to depression (r =
unpleasant symptoms has impacts on the physical .561 and .490, respectively; p G .01). Therefore, it is
functioning of patients. According to this study, recov- possible to confirm the Theory of Unpleasant Symp-
ery symptoms were found to be positively related toms of Lenz and colleagues (1997) that recovery
to physical functioning at a moderate level (r = .406, symptoms may be influenced by factors that have an
p G .01). To put in another way, if patients had severe influence on symptoms such as mood state, which in
recovery symptoms, physical functioning would be turn may affect physical functioning.
decreased. Fox and colleagues (2007) explored the On the other hand, Lenz and her colleagues (1997)
symptoms of patients with malignant brain tumor with who presented the updated version of the model pro-
impact on functional status and quality of life of pa- pose that decreased levels of performance can have a
tients. They found that pain, fatigue, and sleep dis- feedback loop to the influential factors. The current
turbances were negatively related to functional status study found that vigor and fatigue could predict phys-
(r = j.355, j.522, and j.517, respectively; p G .01). ical functioning directly in postoperative brain tumor
Rocha-Filho and colleagues (2008) explored the patients. This finding corresponds with parallel research
impacts of pain from craniotomy on patient functional on postoperative brain tumor patients by Armstrong
status and found that headache frequency led to poor and colleagues (2006), who reported that performance
functional status, which agrees with the study findings status was the strongest predictor of fatigue severity,
of Mukdaprawat and colleagues (2012) who explored with those patients with poor performance status being
severity of long-term neurological deficit for more almost likely to report moderate-to-severe fatigue. How-
than 2 months after brain tumor treatments, for exam- ever, the participants in their study (66%) had high-
ple, strength of limbs, levels of consciousness, and grade tumor, which differs from the current study
visual problems. They found that these symptoms had wherein most of the participants (90%) had benign
impacts on physical functioning of postoperative brain tumor. Likewise, Fox and colleagues (2007) have found
tumor patients, and neurological deficit was negatively depression to be negatively related to functional status
related to physical functioning (r = j.405, p G .01). (r = j.757, p G .01). Furthermore, Feuerstein and
Moreover, Feuerstein and colleagues (2007) discov- colleagues (2007) discovered that depression resulted
ered that fatigue and sleep disturbances resulted in in limitations of patients’ ability to return to work.
limitations in the patients’ ability to return to work. Vigor was negatively related to physical functioning
In this study, psychological factors were also explored. (negative direction). Vigor represents a positive affec-
According to the study findings, mood state was pos- tive state denoting active and pleasurable engagement
itively related to physical functioning at a low level with physical health benefit (Shirom et al., 2008).
(r = .288, p G .01). This means that patients with high Although there was a statistically significant bivariate
emotional distress were more likely to have decreased correlation between depression and physical functioning,

Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
E20 Journal of Neuroscience Nursing

this did not contribute significantly to a regression the impacts on various aspects of capabilities. Accord-
model. The reason for the lack of a significant effect ing to this study, recovery symptoms after brain tumor
could be the fact that depression is related to physical surgery have impacts on physical functioning of the
functioning at a low level (r = .276, p G 0.01) and had patients, and physical functioning can have retroactive
a multicollinearity to all independent variables. effects on influencing factors such as mood state. There-
For nursing implication, the results in this study fore, intervention to improve physical activity in Thai
indicate that TMD is the strongest predictor to phys- postoperative brain tumor patients should be tailored to
ical functioning in postoperative brain tumor patients both recovery symptoms and mood states.
during 2 weeks after discharge, followed by vigor There are some limitations of this study. First, the
(negative direction), fatigue, and recovery symptom, researcher examined only postoperative brain tumor
respectively. Therefore, when planning for manage- patients with full levels of consciousness, which may
ment of various symptoms that are problematic for not be able to reflect problems in other patient groups
postoperative brain tumor patients and that have impacts with brain tumor. Second, this study aimed at examin-
on the functional status of these patients, nurses should ing recovery symptoms, mood state, and physical func-
not overlook mood states of the patients; otherwise, they tioning of patients during the first 2 weeks after hospital
may not be able to achieve their goals in providing care. discharge with only one assessment or measurement.
In addition, future research that addresses intervention Longitudinal studies should be conducted to shed more
to improve physical activity in Thai postoperative brain light on the long-term impacts of brain tumor surgery
tumor patients is recommended. Such studies should on patients and families, including duration of post-
focus on interventions aimed at decreasing TMD or operative recovery. Third, convenience sampling was
fatigue or reliving symptoms such as pain and in- used. The lack of random sampling may contribute to
creasing positive mood state such as vigor. Interven- sample selection bias and limits the generalization of
tions to improve physical activity in Thai postoperative the findings.
brain tumor patients might include music therapy,
meditation, family support, or walking exercise. Acknowledgment
In conclusion, according to the findings of this study, This study was funded in part by the scholarship in
which was conducted with patients undergoing brain Celebration of the 84th birthday anniversary of His
tumor surgery during the period of approximately Majesty King Bhumibol Adulyadej, Faculty of Nurs-
2 weeks after hospital discharge, most of the subjects ing, Mahidol University, in the academic year of 2011.
were married middle-aged women who had low edu-
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