Neuro-Oncology Practice 219

9(3), 219–228, 2022 | https://doi.org/10.1093/nop/npac013 | Advance Access date 17 February 2022

Assessing mobility in primary brain tumor patients:

A descriptive feasibility study using two established
mobility tests
  

James L. Rogers† , Julianie De La Cruz Minyety†, Elizabeth Vera#, Alvina A. Acquaye#,

Samuel S. Payén, Jeffrey S. Weinberg, Terri S. Armstrong#,‡, and Shiao-Pei S. Weathers‡

Neuro-Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health,
Bethesda, Maryland, USA (J.L.R., J.D.L.C.M., E.V., A.A.A., T.S.A.); Center for Nursing Research, Cizik School of
Nursing, The University of Texas Health Science Center at Houston, Houston, Texas, USA (S.S.P.); Department of
Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (J.S.W.); Department of
Neuro-Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas,
USA (S.S.W.)

†Co-first authors.
‡Co-senior authors.
#These authors were affiliated with The University of Texas MD Anderson Cancer Center during the conduct of this

study.

Corresponding Author: James L. Rogers, BS, Cancer Research Training Award Fellow, Neuro-Oncology Branch, Center for Cancer
Research, National Cancer Institute, National Institutes of Health, 9030 Old Georgetown Rd., Bethesda, MD 20892, USA (rogersjl@
nih.gov).

Abstract
Background. Patients with primary brain tumors (PBT) face significant mobility issues related to their disease and/
or treatment. Here, the authors describe the preliminary utility and feasibility of two established mobility meas-
ures, the Timed-Up-and-Go (TUG) and Five-Times Sit-to-Stand (TSS) tests, in quickly and objectively assessing the
mobility status of PBT patients at a single institution’s neuro-oncology clinic.
Methods. Adult patients undergoing routine PBT care completed the TUG/TSS tests and MD Anderson Symptom
Inventory-Brain Tumor module (MDASI-BT), which assessed symptom burden and interference with daily life,
during clinic visits over a 6-month period. Research staff assessed feasibility metrics, including test completion
times/rates, and collected demographic, clinical, and treatment data. Mann–Whitney tests, Kruskal–Wallis tests,
and Spearman’s rho correlations were used to interrogate relationships between TUG/TSS test completion times
and patient characteristics.
Results. The study cohort included 66 PBT patients, 59% male, with a median age of 47 years (range: 20–77). TUG/TSS
tests were completed by 62 (94%) patients. Older patients (P < .001) and those who were newly diagnosed (P = .024),
on corticosteroids (P = .025), or had poor (≤80) KPS (P < .01) took longer to complete the TUG/TSS tests. Worse activity-
related (work, activity, and walking) interference was associated with longer TUG/TSS test completion times (P < .001).
Conclusions. The TUG/TSS tests are feasible for use among PBT patients and may aid in clinical care. Older age,
being newly diagnosed, using corticosteroids, poor (≤80) KPS, and high activity-related interference were associ-
ated with significant mobility impairment, highlighting the tests’ potential clinical utility. Future investigations are
warranted to longitudinally explore feasibility and utility in other practice and disease settings.

Keywords
clinical cancer research | clinical observations | mobility assessment | symptoms

Published by Oxford University Press 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.
220 Rogers et al. Mobility assessment in neuro-oncology

Primary brain tumors (PBT) are typically associated with Center, where they were receiving routine PBT care, to par-
a poor prognosis and significant symptom burden.1,2 ticipate in a large, descriptive study exploring aspects of
Mobility issues, including impaired gait and balance, are symptom burden in the PBT patient population. Research
commonly observed in neuro-oncology clinical practice.3–6 staff reviewed electronic health records (EHRs) to deter-
Other motor deficits, such as weakness and impaired pro- mine patient eligibility, which included: 1) being ≥18 years
prioception, can further compromise quality of life, func- of age; 2) able to read, speak, and write English; and 3) ca-
tional independence, and safety.7 These deficits may arise pable of providing informed consent. Exclusion criteria in-
from the impact on critical neuroanatomy of the tumor cluded: 1) neurological complications of systemic cancer;
and/or related treatment.8 Tumor treatments can com- and 2) inability to complete self-report surveys due to cog-
pound tumor-associated symptoms, leading to worsening nitive deficits, as determined by the clinical team. During
or addition of new symptoms. a clinical evaluation, research staff approached PBT pa-
Regardless of the cause, PBT patients across the disease tients and their caregivers, confirmed study eligibility, and
trajectory are often highly symptomatic and face functional obtained the patient’s written informed consent before
limitations. As many PBT patients report spending a signif- collecting data.
icant portion of their lives feeling ill and unable to perform For statistical analyses, enrolled patients were divided
usual activities, these symptoms and limitations can im- into three groups: 1) newly diagnosed: within one month
pact crucial areas of one’s life, such as returning to work.9–11 of a diagnostic neurosurgical procedure or diagnostic
Symptom burden also has documented clinical relevance. neuroimaging if a surgical intervention could not be per-
For instance, patient-reported activity-related interference, formed; 2) recurrence: recurrent disease and initiated on
including challenges with working or walking, is predictive a new treatment regimen; and 3) long-term survivors: at
of tumor progression.12 least three years out from an initial diagnostic neuro-
Given the prevalence of mobility-related issues in PBT surgical procedure in which a PBT diagnosis was made.
patients and the clinical significance of capturing mobility Additionally, patients were grouped according to treat-
information, neuro-oncology providers require tools to as- ment phase: newly diagnosed, on active treatment, or in
sess their patients’ mobility during clinic visits. Currently, follow-up care. Cross-sectional data collection was con-
several tests enable providers to capture such data, most ducted over a 6-month period. The study’s procedures
prominently the 6-Minute Walk Test (6MWT).13 However, were reviewed and approved by the MDACC Institutional
quicker and more subjective measures, such as the Review Board (IRB) and conform to established clinical re-
Karnofsky Performance Status (KPS) scale, are commonly search standards.
used to assess patients’ mobility. KPS has been plagued
by poor interrater reliability and a weak value in predicting
prognosis when performance status is deemed “good” Study Measures
(KPS ≥ 90%).13–15 Additionally, while more objective mo-
Sociodemographic and clinical variables.—Patients com-
bility measures such as the 6MWT have been used to as-
pleted baseline forms at study entry. From EHRs, research
sess PBT patients’ physical functioning, their use is limited
staff extracted relevant demographic, clinical, and treat-
by restricted space in the clinic.6
ment characteristics, including sex, age, race, ethnicity,
In a recent study by Dulfikar and colleagues (2021),
patient group, treatment phase, World Health Organization
the authors described their clinical use of the Timed-Up-
(WHO) tumor grade, tumor type, KPS, body mass index
and-Go (TUG) test to assess physical functional capacity of
(BMI), tumor location, medication use (corticosteroids and
patients with glioma prior to adjuvant radiation therapy.16
anticonvulsants), and tumor recurrence status.
This mobility test, along with the Five-Times Sit-to-Stand
The description of KPS ≤80 as “poor” was made based
(TSS) test, has previously been identified as clinically rel-
on previous work from our research team which demon-
evant in patient populations with other neurological dis-
strated differences in patient rating of both symptom se-
eases, such as Parkinson’s disease,17,18 multiple sclerosis,19
verity and functional limitations (in terms of self-reported
and stroke,20 and has potential for telehealth application.
activities of daily living) at this cutoff value.1 Additionally,
The TUG and TSS tests have been demonstrated to be im-
those who reported corticosteroid use completed the
portant in predicting fall risk21 and decline in global health
Dexamethasone Symptom Questionnaire-Chronic (DSQ-
and functioning,22 which makes them intriguing poten-
C), an 18-symptom and 4 open-ended item patient self-
tial tests in neuro-oncology. Ultimately, there is a clinical
reported measure of the incidence and severity of side
need in neuro-oncology for a quick, accurate, and objec-
effects associated with their corticosteroid use. Cumulative
tive mobility measure. Therefore, the authors conducted
steroid dose was calculated as dose in milligrams (mg)
an exploratory, cross-sectional study at a single-institution
multiplied by duration (ie, days from self-reported cortico-
to preliminarily describe the utility and feasibility of
steroid start date to mobility test date).
leveraging the TUG and TSS tests, two established mobility
assessments, in routine neuro-oncology clinical practice.

Mobility Tests
Timed-Up-and-Go (TUG) test.—The TUG test is designed
Materials and Methods to assess mobility and balance. During test administra-
Study Cohort Assembly tion, the patient sits in a standard armchair and, on the
instructor’s command of “Go,” rises and walks 3 meters
Patients were recruited from The University of Texas MD (~10 feet) at a comfortable and safe pace using their reg-
Anderson Cancer Center’s (MDACC) Brain and Spine ular footwear and a walking aid, if required (see Figure 1).
 Rogers et al. Mobility assessment in neuro-oncology 221

Practice
Neuro-Oncology
     
Turn

3 m to end marker and 3 m back to chair

Figure 1. The Timed-Up-And-Go (TUG) test is designed to assess

mobility and balance. The patient first sits in a standard armchair.
On the test instructor’s command of “Go,” the patient rises from
the chair and walks 3 meters (m). The patient then turns, walks
back to the chair, and sits down. Timing, using a stopwatch, begins
at the instruction of “Go” and stops when the patient returns to
their initial seated position.
  

The patient then turns, walks back, and sits down in the
chair. A stopwatch records the total time spent completing
the test, beginning at the “Go” instruction and stopped Figure 2. The Five-Times Sit-To-Stand (TSS) test is designed to
when the patient returns to the initial seated position.23 assess functional lower extremity strength. The patient sits in the
middle of an armless chair and is instructed to keep their back
Importantly, the TUG test has demonstrated select meas-
straight and feet approximately shoulder-width apart. The patient
ures of interrater reliability24 and validity among elderly crosses their arms (as depicted in the inset image) and on the
patients25,26 and those with Parkinson’s disease27,28 and instructor’s signal of “Go,” rises to a full standing position and then
stroke.25,29 returns to the initial seated position. The patient is instructed to
complete this test sequence 5 times. Research staff monitor the
(TSS) test.—The TSS test is designed to assess functional patient’s performance to ensure proper form. Timing, using a stop-
lower extremity strength.30,31 During test administration, watch, begins at the instruction of “Go” and stops when the patient
returns to their initial seated position after the fifth trial. Reprinted
the patient sits in an armless chair with their back straight,
figure in the public domain from the Centers for Disease Control
feet shoulder-width apart, hands on opposite shoulders, and Prevention, 30-second chair stand assessment handout,
and wrists crossed and held against the chest (see Figure 2). Atlanta, GA. https://www.cdc.gov/steadi/pdf/STEADI-Assessment-
On the instructor’s “Go” signal, the patient rises to a full 30Sec-508.pdf. Accessed on 6 June 2021.
  

standing position and then returns to the initial seated

position. The patient completes this test sequence five
times. Research staff monitor the patient’s performance
to ensure proper form. Similar to the TUG test, a stop- (ie, work, activity, and walking) and mood-related
watch records the total time spent completing the TSS (ie, mood, enjoyment of life, and relations with other
test, beginning at the “Go” instruction and stopped when people) interference data. Higher scores indicate higher
the patient returns to their initial seated position after the symptom severity or interference. For statistical ana-
fifth trial. lyses, symptoms rated ≥5 and interference ≥2 were con-
The TSS test has demonstrated select measures of sidered “moderate-to-severe.”
safety, reliability, and validity in older intensive care unit
patients at discharge32 and community-dwelling elderly
patients.33 Additionally, TSS test administration has report- Feasibility Metrics and Utility
edly high interrater reliability.34
Feasibility was determined by the number/percent of pa-
tients who could complete one or both mobility tests. An
Brain Tumor-Related Symptoms and Interference additional feasibility metric was the time required for each
test to be completed. Importantly, the feasibility of using
Patients also completed the MD Anderson Symptom the TUG/TSS tests assessed in the present study was a sec-
Inventory-Brain Tumor module (MDASI-BT), which ondary, exploratory objective of a larger study conducted
consists of 22 items assessing brain tumor-related at MDACC analyzing changes in PBT patients’ symptom
symptom severity and 6 items assessing interference burden. For this larger study’s primary objectives, a sample
with daily life.1 The symptom severity items measure 6 size of 50 newly diagnosed PBT patients was deemed nec-
underlying symptom factors, including affective, cog- essary to detect an effect size of 0.40 between time points
nitive, focal neurologic deficit, generalized disease, with power of 0.80 using a two-tailed test with an alpha
treatment-related, and gastrointestinal-related symp- of 0.05. This difference between time points was not re-
toms. These symptom items are rated “at their worst” ported in the present manuscript, which had no a priori
on a 0–10 scale (0 = not present; 10 = bad as can be im- thresholds. Utility was defined as how the two mobility
agined). The interference items capture activity-related tests distinguish known groups who would be predicted to
222 Rogers et al. Mobility assessment in neuro-oncology

take longer (eg, elderly patients, those with poor KPS, and   
those on corticosteroids). Table 1. Patient Demographic, Clinical, and Treatment
Characteristics at Baseline

Patient characteristics (N = 66) n (%)

Statistical Analyses
Sex
Descriptive statistics, including means, medians, Female 27 (41%)
standard deviations, and percentages, were used to char- Male 39 (59%)
acterize the patient cohort and report TUG/TSS test com-
Age, median (range) 47 (20–77)
pletion times. For analyses, BMI was divided into three
categories: normal weight (18 ≤ BMI < 25); overweight Race
(26 ≤ BMI < 29); and obese (BMI ≥ 30). TUG/TSS test com- White 57 (86%)
pletion times were evaluated for normality. Because the Black/African American 3 (5%)
distributions of these scores were not normal, differences
Asian 2 (3%)
based on patient demographic, clinical, and treatment
characteristics were evaluated nonparametrically using American Indian/Native Alaskan 1 (2%)
the Mann–Whitney U test for dichotomous variables Missing data 3 (5%)
and Kruskal–Wallis test for variables with ≥3 categories. Ethnicity
Relationships between patient demographic, clinical, and Hispanic 9 (14%)
treatment characteristics and TUG/TSS test completion
Karnofsky performance status (KPS)
times were assessed using Spearman’s rho correlations.
Effect sizes were reported as correlation coefficients and ≤80 (Poor) 18 (27%)
eta squared (η 2). The level of statistical significance was   60 5 (8%)
set at P < .025, adjusting for multiple comparisons of the   70 4 (6%)
two mobility tests.
  80 9 (14%)
≥90 (Good) 48 (73%)
  90 26 (39%)
Results   100 22 (33%)

Study Cohort Body mass index (BMI)

Normal weight (18 ≤ BMI < 25) 25 (38%)
Baseline demographic and clinical data for the 66 PBT
Overweight (26 ≤ BMI < 29) 14 (21%)
patients in the study cohort are displayed in Table 1.
Obese (BMI ≥ 30) 27 (41%)
Patients were predominantly obese (41%), White (86%)
men (59%) with a median age of 47 years (range: 20–77). Patient group
Half of the cohort had a WHO grade IV PBT (50%), with Newly diagnoseda 19 (29%)
47% of patients diagnosed with glioblastoma according Recurrenceb 18 (27%)
to criteria from the WHO 2016 classification of central
Long-term survivorsc 29 (44%)
nervous system (CNS) tumors. Regarding phase along
the disease trajectory at the time of study enrollment, Treatment phase
29% were newly diagnosed, 27% were in recurrence, and Newly diagnosed 19 (29%)
44% were in the long-term survivorship period. Most pa- On treatment 25 (38%)
tients had a good (≥90) KPS (73%; range: 60–100) and a
In follow-up 22 (33%)
frontal (39%) or temporal (33%) lobe tumor. Additionally,
WHO tumor grade
while the majority of patients were taking anticonvul-
sants (n = 56, 30 of whom were on levetiracetam), far I 1 (2%)
fewer were taking corticosteroids (n = 23, 22 of whom II 14 (22%)
were on dexamethasone). III 18 (27%)
IV 33 (50%)
Tumor typed
Feasibility Findings
Glioblastoma (Grade IV) 31 (47%)
Nearly all (94%) patients completed the two mobility tests. Astrocytoma (Grade I, II, or III) 20 (30%)
Four patients could not complete the TUG/TSS tests be- Oligodendroglioma (Grade II or III) 7 (11%)
cause they were unable to stand (n = 3) or walk without e
Other 8 (12%)
assistance (n = 1). Therefore, 62 PBT patients were con-
sidered in our analyses. Patients took 5–40 s to complete Tumor locationf
the TUG test, with an average time of 13 s, and 4–67 s to Frontal lobe 26 (40%)
complete the TSS test, with an average time of 15 s. Almost Temporal lobe 22 (34%)
all patients (97%) completed the five required TSS test
Parietal/occipital lobe 11 (17%)
trials, with one patient completing only one trial and an-
other completing just three trials. Multiple lobes involved 6 (9%)
 Rogers et al. Mobility assessment in neuro-oncology 223

Practice
Neuro-Oncology
   statistical significance. Importantly, 1 patient had a tumor
Table 1. Continued in the corpus callosum and was excluded from the univar-
iate test for tumor location.
Patient characteristics (N = 66) n (%)
Medication use
Corticosteroid 23 (35%) Medication Usage: Corticosteroids and
  Dexamethasone 22 (96%) Anticonvulsants
  Prednisone 1 (4%) Twenty-three patients (35%) reported using corticoster-
Anticonvulsant 52 (79%) oids, including dexamethasone (n = 22) and prednisone
  Levetiracetam 30 (58%) (n = 1). The mean dexamethasone dose taken was 7 mg
(median = 4 mg, SD = 5 mg, range: 2–18 mg), while the
  Otherd 22 (42%)
one patient on prednisone took a 20 mg dose. A statisti-
Tumor recurrence cally significant difference in TUG test completion times
Yes 29 (45%) was found based on corticosteroid use. Those on cortico-
No 36 (55%) steroids took longer to complete the TUG test than those
not currently on corticosteroids (median = 12.0 seconds vs.
aPatients within one month of a diagnostic neurosurgical procedure 10.0 s, r = 0.28, P = .025).
or diagnostic neuroimaging if surgical intervention could not be Among patients who reported corticosteroid use and
performed. completed the DSQ-C (n = 21), there was no statistically
bPatients who had experienced a recurrence and were initiated on a significant association between DSQ-C score and TUG
new treatment regimen. (r = −0.23, P = .342) or TSS (r = 0.16, P = .492) test comple-
cPatients who were at least three years from their initial diagnostic
tion times. However, a larger cumulative steroid dose was
neurosurgical procedure in which a primary brain tumor diagnosis associated with longer TUG test completion time. For the
was made. 12 patients (19%) who provided a start date for their cor-
dTumor type is according to the WHO 2016 classification of central
ticosteroid use, cumulative steroid dose positively correl-
nervous system tumors.
e“Other” tumor types represented in this patient cohort include: ated with TUG (n = 11, r = 0.80, P = .003) but not TSS (n = 10,
oligoastrocytoma, gliosarcoma, diffuse glioma, high-grade glioma, r = 0.62, P = 0.059) test completion times. Finally, no statis-
infiltrating glioma, and pilocytic astrocytoma. “Other” anticonvul- tically significant differences in test completion times were
sants include: phenytoin (2), carbamazepine (1), sodium valproate (3), found based on anticonvulsant drug use.
phenobarbital (1), lamotrigine (1), and other (18).
fAdditionally, 1 patient had a tumor in the corpus callosum.

  
Symptom Burden and Interference
The top-5 most commonly reported moderate-to-severe
Patient Demographics symptoms were fatigue (24%), difficulty remembering
(24%), feeling drowsy (24%), disturbed sleep (20%), and
Table 2 includes select associations between patient char- pain (17%). Additionally, many patients reported moderate-
acteristics and mobility test completion times. Age im- to-severe overall (38%), activity-related (38%), and mood-
pacted the time patients took to complete the mobility related (35%) interference. Those reporting higher overall
tests. TUG/TSS test completion times correlated positively symptom interference took significantly longer to com-
with age (TUG: r = 0.53, P < .001; TSS: r = 0.50, P < .001). No plete the TUG (r = 0.50, P < .001) and TSS (r = 0.53, P < .001)
statistically significant differences in mobility test comple- tests. This relationship was particularly strong for activity-
tion times were identified based on any other patient dem- related interference (TUG: r = 0.58; TSS: r = 0.56).
ographic, such as sex or BMI.

Comparison to Normative Data

Clinical and Treatment Characteristics
Previous studies have described cutoff time values to iden-
Patient performance status impacted mobility test comple- tify patients at risk for falling. The cutoff values for the TUG
tion times, with those with poor (≤80) KPS taking longer test are >13.5 s for community-dwelling adults and >11.5 s
than those with good (≥90) KPS to complete the TUG (me- for patients with Parkinson’s disease. Based on these
dian = 17.5 s vs. 10.0 s, r = 0.52, P < .01) and TSS tests (me- values for TUG completion times, 24–34% (depending on
dian = 17.5 s vs. 12.0 s, r = 0.36, P < .01). Patients’ phase the comparison population) of our patient sample would
along the disease trajectory impacted only TSS test com- be at risk for falling. In addition, cutoff time values for the
pletion times, with newly diagnosed patients taking longer TSS test are >12 s for community-dwelling adults and
than those with recurrent disease (median = 15.0 s vs. >16 s for patients with Parkinson’s disease. Based on these
11.0 s, η2 = 0.09, P = .024). In contrast, there was no sta- cutoff time values for the TSS test, 18–50% (depending on
tistically significant difference in test completion times by the comparison population) of our patient sample would
treatment phase, history of tumor recurrence, WHO tumor be at risk for falling.
grade, or tumor location. While PBT patients with frontal When comparing the mobility test completion times
lobe tumors had the shortest completion times on both from this study’s patient sample to data from previously
tests, this difference did not reach the designated level of published studies, it was found that PBT patients took, on
224 Rogers et al. Mobility assessment in neuro-oncology

  
Table 2. Associations Between Select Patient Characteristics and Mobility Test Completion Times

Patient Characteristic Timed-Up-And-Go Five-Times Sit-To-Stand

N Median Mean SD Sig. Effect sizea N Median Mean SD Sig. Effect sizea
Sex Male 37 10.0 12.5 6.5 0.270 0.14 37 12.0 13.7 5.9 0.494 0.09
Female 25 11.0 13.6 7.2 25 13.0 17.4 14.2
Karnofsky performance Poor (≤80) 14 17.5* 19.1 8.1 <0.001 0.52 14 17.5* 20.9 12.4 0.005 0.36
status (KPS)
Good (≥90) 48 10.0* 11.2 5.2 48 12.0* 13.5 8.9
Body mass index (BMI) Normal weight 22 10.0 10.9 3.3 0.167 0.03 23 12.0 13.5 5.8 0.579 −0.02
Overweight 14 9.0 12.6 6.3 14 11.0 19.6 19.0
Obese 26 12.5 14.9 8.6 25 14.0 14.2 4.6
Patient group Newly diagnosed 17 11.0 14.5 7.7 0.051 0.07 18 15.0 17.1 7.0 0.032 0.08
On treatment 23 12.0 13.9 7.6 22 12.0 16.3 15.1
In follow-up 22 9.0 10.8 4.5 22 12.0 12.5 4.6
Treatment phase Newly diagnosed 17 11.0 14.5 7.7 0.198 0.02 18 15.0* 17.1 7.0 0.024 0.09
Recurrence 17 11.0 13.4 7.9 16 11.0* 14.5 14.3
Long-term survivors 28 10.0 11.8 5.4 28 12.0 14.3 9.3
WHO tumor grade I–II 15 10.0 10.9 3.4 0.031 0.09 15 11.0 12.3 4.2 0.155 0.03
III 17 10.0 11.5 5.8 16 12.0 14.4 11.4
IV 29 12.0 15.0 8.1 30 14.0 17.0 11.6
Tumor location (lobe) Frontal 22 10.0 10.6 3.2 0.375 0.02 23 12.0 12.3 4.0 0.401 0.02
Temporal 22 11.0 14.8 9.7 21 13.0 15.5 10.4
Parietal/occipital 11 11.0 13.5 5.9 11 13.0 18.1 17.1
Corticosteroid use Yes 6 14.0* 13.7 3.8 0.025 0.28 6 15.5 17.3 8.2 0.058 0.24
No 41 10.0* 12.6 7.7 41 12.0 13.8 8.3
Anticonvulsant use Yes 50 11.0 13.6 7.2 0.067 0.23 49 13.0 15.9 11.1 0.306 0.13
No 12 9.0 10.4 3.9 13 12.0 12.3 5.2
Tumor recurrence Yes 28 12.0 13.8 7.1 0.23 0.15 27 13.0 16.0 13.7 0.526 0.08
No 33 11.0 12.4 6.6 34 12.5 14.6 6.4

Note: all median, mean, and standard deviation (SD) values reported in this table are mobility test completion times measured in seconds.
Additionally, 1 patient had a tumor in the corpus callosum and was excluded from the univariate test for tumor location.
*Bolded text indicates statistically significant differences in the median mobility test completion times (ie, P < .025).
aEffect sizes: correlation coefficient (r; sex, Karnofsky Performance Status (KPS), corticosteroid use, anticonvulsant use, and tumor recurrence);

eta squared (η 2; Body Mass Index (BMI), patient group, treatment phase, WHO tumor grade, and tumor location (lobe)).
  

average, longer to complete both the TUG and TSS tests assessments in a neuro-oncology clinic. To assess feasi-
than community-dwelling adults.25 Additionally, PBT pa- bility, we used metrics of test completion times and rates.
tients took less time, on average, on the TUG and TSS Research staff administered the TUG/TSS tests with a 94%
tests compared to patients from a study of patients with completion rate. In considering salient patient characteris-
Parkinson’s disease.17 Conversely, when comparing our tics, we identified that older age, being newly diagnosed,
sample with a different Parkinson’s disease patient group,18 using corticosteroids, having poor (≤80) KPS, and reporting
PBT patients took more time, on average, to complete both high activity-related interference were associated with mo-
mobility tests. Finally, patients also took longer to com- bility impairment, highlighting the tests’ potential clinical
plete the TUG test than those in another glioma patient utility. Therefore, our preliminary data suggest a possible
population recently described by Dulfikar and colleagues role for using the TUG/TSS tests in routine neuro-oncology
(2021) in which patients took a median of 7 s to complete clinical practice.
the test.35

The Impact of Age, Sex, and Body Mass Index

(BMI) on Mobility Test Completion Times
Discussion
Both TUG and TSS test completion times increased di-
This descriptive, cross-sectional study outlines the pre- rectly with age. Ibrahim and colleagues (2017) report sim-
liminary feasibility of using two established mobility ilar findings related to age in their cohort of older adults.36
 Rogers et al. Mobility assessment in neuro-oncology 225

Practice
Neuro-Oncology
Gomes and colleagues (2015) also report increasing TUG recurrent disease. This finding contrasts with previous
times with older age.37 Among healthy elderly individuals, studies demonstrating that patients with recurrent disease
Mangano and colleagues (2020) used data from a wear- report more motor deficits and worse physical functioning
able inertial sensor to support the postulation that longer than newly diagnosed patients.47,48 However, in these two
TUG test completion times among older adults result from studies, Osoba and colleagues (1997 and 2000) did not uti-
difficulty with the turning portion of the test.38 Elderly in- lize objective mobility tests. The longer TSS test comple-
dividuals are also more likely to be frail,39 contributing tion times found among newly diagnosed patients in our
to impaired mobility and highlighting the importance of cohort may be accounted for by perioperative deficits in
incorporating comprehensive geriatric assessments into these patients that improve after their tumor burden is di-
routine neuro-oncology practice.40 minished and subsequent treatment is initiated.
Interestingly, we found no statistically significant differ- Despite this difference between newly diagnosed and
ences in mobility test completion times based on sex or recurrent patients, a history of recurrence did not impact
BMI. In contrast, in their sample of community-dwelling TUG/TSS test completion times. This finding could be ex-
adults, Bohannon and colleagues (2007) demonstrated plained by those long-term survivors with no history of
that weight and BMI were significantly correlated with TSS recurrence who were grouped with newly diagnosed pa-
test completion times.41 In their regression models, they tients. Long-term survivorship is heterogenous, with pa-
showed that age and BMI explained 43.7% of the variance tients potentially falling into distinct symptom cohorts with
in TSS test completion times, prompting their conclusion differing physical functioning and symptom complaints.49
that TSS test times should be considered in light of pa- In neuro-oncology, functional deficits result both from
tients’ age and BMI. Given that increased BMI can disrupt the tumor’s anatomical location and associated treat-
balance and postural control, we expected to detect find- ments.8 However, we did not observe a statistically sig-
ings similar to those reported by Bohannon and colleagues nificant difference in test completion times based on
in our cohort, which had a fairly even distribution of BMI tumor location. While patients with frontal lobe tumors
(see Table 1). However, we did not find such significant as- had slightly shorter test completion times, the difference
sociations, suggesting the need for further investigations was not statistically significant. These findings may be ex-
into the relationship between BMI and mobility test com- plained by compensation of function; while frontal lobe
pletion times in the PBT patient population. areas (eg, primary motor and premotor cortices) are im-
portant for motor functioning, other brain regions asso-
ciated with gait and mobility may compensate for frontal
Karnofsky Performance Status and Mobility Test lobe tumor-related motor impairments.
Completion Times
Patients with poor (≤80) KPS took longer to complete both
mobility tests than those with good (≥90) KPS. This finding
The Relationship Between Corticosteroid and
was to be expected as KPS is an indication of a patient’s
Anticonvulsant Drug Use and Mobility Test
performance status and is associated with functional mo-
Completion Times
bility. Therefore, our study suggests congruency between a Corticosteroid use was reported in 35% (n = 23/66) of our
subjective mobility measure and objective mobility assess- cohort, with most patients on dexamethasone (n = 22,
ments. Such congruency has been described previously in 96%). Patients on corticosteroids took longer to com-
a retrospective study of cancer patients seeking geriatric plete the TUG test than those not on such medications. In
evaluation where poor (≤80) KPS and TUG test perfor- neuro-oncology, corticosteroids are frequently prescribed
mance were directly associated with a history of falls.42 as adjuncts to tumor-directed therapies and to manage
Assessing a patient’s performance status is clinically im- peritumoral edema. Importantly, corticosteroids have been
portant and provides prognostic information. It has been independently associated with significantly shorter overall
established that poor (≤80) KPS is associated with an in- survival and frequently result in severe side effects.50,51
creased risk of mortality among patients with CNS tumors.43 As outlined previously, patients in our study who were
Similarly, in non-CNS cancers, functional mobility assess- on corticosteroids completed the DSQ-C instrument, self-
ments like the TUG test appear to be associated with prog- reporting side effects related to their corticosteroid use.
nosis, with longer test completion times associated with This specific measure was selected as members of our
poor prognosis.44–46 Thus, our study results suggest that, group previously demonstrated its utility and associated
similar to what has been reported in other cancer popula- signs and symptoms in a PBT patient population.52
tions, subjective performance status, and objective mobility Notable side effects of corticosteroids include steroid-
tests, when used in tandem, provide comprehensive clinical induced myopathy, musculoskeletal complications, and
information on a patient’s general health status. proximal muscle weakness.53 Importantly, PBT patients
typically remain on corticosteroids for long periods of
The Impact of Phase Along the Disease Trajectory time, often until death.54 Studies have reported an in-
and Tumor Location and Grade on Mobility Test creased likelihood of side effects with prolonged or higher
Completion Times doses of corticosteroid use.51
Therefore, with functionally significant and highly prev-
Patients’ phase along the disease trajectory was associ- alent side effects related to corticosteroid use, particu-
ated with differential performance on the TSS test, with larly with long exposure periods and/or high dosages,
newly diagnosed patients taking longer than those with we expected to see increased TUG/TSS test completion
226 Rogers et al. Mobility assessment in neuro-oncology

times among those PBT patients with high DSQ-C scores. Limitations
Interestingly, we found no statistically significant relation-
ship between these variables. However, when considering This study has several limitations worth noting. First, our
the relationship between cumulative steroid dose and predominantly White cohort was derived from only one
mobility test completion times, larger cumulative ste- large, tertiary academic medical center in the United States
roid doses were associated with significantly longer TUG (ie, MDACC). Thus, findings have potentially limited gener-
test completion times. As first outlined by Arvold and col- alizability. As only 27% of patients (n = 18/66) had a poor
leagues (2017), while previous studies of corticosteroid use (≤80) KPS, larger studies considering the performance
in neuro-oncology have reported idiosyncratic side effects, of these individuals on the mobility tests are warranted.
proximal muscle weakness increases in a predictable “cor- Given that MDACC has hundreds of oncology clinical trials
ticosteroid dose x time” dependent manner. Our findings with typically stringent study inclusion criteria, it is unsur-
support Arvold’s claim, highlight the clinical utility of the prising that the majority of our cohort had a good (≥90)
TUG test in detecting proximal muscle weakness among KPS.57,58
PBT patients, and underscore the need for steroid-sparing Additionally, patients were all either newly diagnosed, in
therapies in neuro-oncology. recurrence, or long-term survivors. Therefore, certain pa-
Additionally, 52 patients (n = 52/66, 79%) were on anti- tient populations, for instance those within one year of di-
convulsants, with no significant impact on mobility test agnosis without disease recurrence, were not considered.
completion times. These null findings were unsurprising This convenience sampling issue further limits the gener-
given that, for PBT patients prone to seizures, anticonvul- alizability of our findings. Certainly, some clinical factors
sants mitigate the uncontrolled electrical activity that could also occur more commonly in specific patient groups. For
compromise mobility and balance.55 Future clinical studies instance, in this study, newly diagnosed patients were
assessing mobility among PBT patients should further more likely to be on corticosteroids. However, a robust
characterize the anticonvulsant drugs and dosages used, analysis of differences between treatment groups was lim-
considering, for example, the impact of taking multiple or ited by our small sample size. Longitudinal research will be
high doses of anticonvulsant medications on mobility test crucial to consider possible interactions with demographic
completion times and rates. and other salient patient characteristics. Such longitudinal
work will also highlight how use of the TUG/TSS tests is
impacted as patient conditions change throughout the dis-
Symptom Burden and Interference ease trajectory. In the present study, our limited sample
size resulted in comparisons of small groups, although
Higher symptom interference, particularly activity-related we attempted to address this concern with use of multiple
interference, was associated with longer mobility test comparison adjustments, tests for normality, and appro-
completion times. This finding was to be expected as the priate inferential tests. Effect sizes should be considered
patient-reported outcome of activity-related interference when interpreting the results presented in this manuscript.
encompasses activity and walking. Furthermore, previous Our study cohort also had a median age of 47 years.
studies have identified that patient-reported symptoms are Since the TUG/TSS tests were originally designed for frail
associated with functional status.56 Additionally, the symp- elderly individuals, these tests may not have been sensi-
toms of fatigue, difficulty remembering, feeling drowsy, tive enough for use among nongeriatric patients. Again,
disturbed sleep, and pain commonly reported by patients longitudinal research is needed to understand the clinical
in the present study are similar in severity to those symp- utility and sensitivity of these mobility tests across the life-
toms observed in other PBT patient samples.2 span. Also, we were unable to explore associations with
the individual items of the MDASI-BT in this small study.
Future studies exploring associations with specific symp-
The Potential for Assessing Mobility During toms will be undertaken with a larger sample size, using
Telehealth Visits: A New Frontier multiple comparison adjustments, and with a priori hy-
The coronavirus disease-2019 (COVID-19) global pandemic potheses as to which specific symptoms to evaluate.
significantly altered clinical practice and impaired access to Lastly, it is important to consider that PBT patients are a
health care. However, telehealth visits frequently replaced unique population, essentially suffering from both cancer
in-person consultations, offering an essential opportunity and a neurological disease.59 Thus, in our study, it was dif-
to provide remote medical care to diverse, underserved ficult to parse out the relative impact on mobility issues
patient communities during this public health emergency. of the cancer, neurological symptoms, and associated
Importantly, we believe telehealth has promise in cancer treatments.
far beyond the COVID-19 pandemic. Future studies should
consider how feasible using the TUG/TSS tests are in
telehealth. Certainly, caretakers will be required to guide
patients as they complete the mobility tests and provide
Conclusions
safety and aid should a fall occur. Unlike the TUG test or Our preliminary study sought to determine if using the
6MWT, which require extensive physical space, the TSS TUG/TSS tests was feasible among PBT patients in a
test may be particularly well-suited for telehealth given the neuro-oncology clinic and whether larger studies of these
limited space required for test administration, which also tests are warranted. Secondary objective results from our
ensures patients remain in the computer’s frame of view larger study indicate that the TUG/TSS tests are feasible
for the test administrator during the assessment. and clinically sensitive to important patient characteristics,
 Rogers et al. Mobility assessment in neuro-oncology 227

Practice
Neuro-Oncology
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