Brain Surgery

The 1990s were designated the ‘Decade of the Brain’ by U.S. President George H. W. Bush as part of a larger effort involving the Library of Congress, the National Institute of Mental Health, and the National Institutes of Health, “to enhance public awareness of the benefits to be derived from brain research”.This interagency initiative was conducted through a variety of activities. These included publications and programs aimed at introducing members of congress, their staffs, and the general public to cutting-edge research on the brain; thus encouraging public dialog on the ethical, philosophical, and humanistic implications of these emerging discoveries. The 21st century brings with it multiple challenges and opportunities in view of the explosion in information technology, as well as major advances in molecular biology and genetics. Computers in medicine have revolutionised the investigative modalities, as well as diagnosis and treatment paradigms.5 Neuro-imaging, intra-operative neuro-monitoring, neuronavigation, and neuro-modulation are computer-based applications which are now routinely used in standard neurosurgical practice. A 64-slice CT scan with 3D imaging capability is used for vascular reconstructions during aneurysm surgery and for detailed anatomicopathological demonstration for brain tumour surgery.11,12 Functional neuro-imaging is being studied for epilepsy surgery and certain research protocols.13 MRI spectroscopy (metabolic neuro-imaging) is being used to differentiate brain tumours from infections and metastasis.5,11,14 Intraoperative MRI imaging is nowadays being used for rendering maximal safe resection of the brain tumours such as gliomas and pituitary adenomas.15 Neuromodulation with stem cells for neurological functional restoration is currently being utilized for selected patients with spinal cord injury and certain degenerative neurological diseases.16 Although the results are modest, they offer some hope for these debilitated patients; who are otherwise wheel chair bound.11,16 Rehabilitation will assume a crucial role in improving patient quality of life, since stem cell transplantation and neural regeneration would prevent further cell damage. 1,5 In fact, one downside of this could be an upsurge in medico-legal cases due to heightened expectations of treatment and the unpredictable natural course of the disease process. Graphic-interactive cranial surgery comprises of the planning and practice of cranial surgery using instrumentation that reconstructs digital cranial images into a graphic representation of the head and then allows the surgeon to operate by interacting with this graphic rendering. The operating arm system and the medical videoscope are such examples of frameless cranial stereotaxy.17–19 This could lead to a videolibrary demonstrating surgical procedures and techniques which can then be simulated through virtual reality work stations, thus creating a new methodology for training of young consultants in this field.11,20 This will then be translated into real time surgery which will be known as robotic surgery. The use of stereotaxy has opened up the field of neurosurgery to robotics. Robots have been in use for the past 19 years in neurosurgery, but largely remain unknown due to limitations in current robotic systems. The commercial medical robots available in neurosurgery, such as NeuroMate and MKM, remain to be completely adopted by the neurosurgical fraternity. 21 There is a need to develop more integrated systems in which the robots are linked to the imaging and planning software, or directly to the patient anatomy. Robotic biopsy planning facilitates careful preoperative study and optimization of needle trajectory to avoid sulcal vessels, bridging veins, and ventricular penetration.22 The real challenge for the 21st century neurosurgeon will be to assimilate the tremendous advances in neuroscience that have occurred over the last century and then integrate this into the current practice paradigms.5,11 Advances in computer technology should help create large, central databases of neurological ailments which will then provide a reference model for investigation, therapeutics, and further research into the subject.1,4,5,11 Intraoperative image guidance systems provide real-time images, which could increase surgical accuracy. Image guidance navigation in pituitary surgery provides continuous three-dimensional (3D) information regarding anatomical variations of the sphenoid sinus and relationship of tumors to the internal carotid arteries.23 However, the equipment is expensive and requires specific training for the operating room personnel. Stereotactic radiosurgery for primary and metastatic lesions, as well as arteriovenous malformations, can be performed using linear accelerators and refined systems for visualization and guidance.24 They can allow effective and safe treatment of radioresistant neoplasms. 3D-computed tomographic angiography (CTA) using stereo imaging technology allows viewing of multilayer fusion images for neurosurgical procedures in intracranial aneurysms.25 The brain-machine interfaces (BMI) connect machines to the human brain viz. motor neuroprosthetics involves implanting microelectrodes for restoring motor deficits.26The advances in molecular biology and genetics should also change the way a brain tumour, or a degenerative neurological disease, would be treated.11 Genetic microarray would be able to diagnose the type of brain tumour and then suggest relevant molecular targeted therapies. Detection of genetic abnormalities in utero would help the mother to make an informed decision about the future of her pregnancy. Myelomeningocele has been corrected in utero, so-called foetal neurosurgery, although it has been done in an experimental setting. However, its inclusion into routine clinical practice is yet to be accepted worldwide. Infusion of chemotherapeutic agents directly into the tumour bed using nano-technology would be a major advance in this century.11 The applications of nanotechnology in neurosciences include nerve nano-repair, nano-imaging with nano-particles and quantum dots, nano-manipulation of the CNS with surgical nanobots, and nano-neuromodulation with nano-fibres & nano-wires.27,28 The nano-carriers comprise of polymeric nanoparticles, solid lipid nanoparticles, liposomes, micelles, and newer systems, e.g. dendrimers, nano-gels, nano-emulsions and nano-suspensions. These can be effectively transported across various blood-brain-barrier models by endocytosis and/or transcytosis. They have demonstrated early preclinical success in management of brain tumors, HIV encephalopathy, Alzheimer's disease, and acute ischemic stroke.29 Moreover, magnetic nanoparticles (MNPs) conjugated with peptides or antibodies allow direct targeting of the tumor cell surface, and potential disruption of active signaling pathways present in tumor cells.30 Newer strategies permit better delivery of MNPs systemically by direct convection-enhanced delivery to the brain. Direct injection of MNPs into recurrent malignant brain tumors for thermotherapy is being currently explored. The modern-day neurosurgeon, the so called ‘21st century neurosurgeon’, will have to integrate the information technology along with the advances in molecular biology and genetics. 5,31 Surgery is more likely to become minimally invasive until molecular and genetic targeted options provide solutions to major diseases. Clinical neurology will continue to have its own importance in decision making for surgery, however, technology will help refine techniques, achieve precision, and perfection. Neurosurgeons will have to work in conjunction with other specialities including neurologists, psychiatrists, neuro-radiologists, and basic scientists. For example, epilepsy surgery involves close collaboration between neurosurgeons, epileptologists, neuro-psychologists, and psychiatrists. As such, the neurosurgeon will have to be a leader and a task master. They will have to accept responsibility for actions, both their own and the team's, without any arguments.31 They have to be adaptable to suggestions, since treatments for most neurosurgical diseases have become multimodal. They must maintain patience and show perseverance at all times which will help them overcome obstacles in difficult situations. They need to be well versed with computational neurobiology and telemedicine since future consultations and operative surgery will use digital technology. They should have a sound understanding of bioethics and humanity.31 They should have a good knowledge of neuro-anatomy and physiology, and a scientific research based inclination to the subject concerned. Neurologic tumors may involve the brain or spinal cord and are either primary or metastatic. Patients may become increasingly less independent as a re-sult of direct injury of neural structures responsible for motor, sensory, cognitive, and speech functions. The indirect effects of chemotherapy and radiation therapy (RT) add to the functional deficits patients experience. The number of patients involved is quite large. More than 15,000 new cases of primary brain tumor and 4000 new spinal tumors are diagnosed every year (American Cancer Society, 1990). Ap-proximately 2% of all cancer deaths are caused by brain tumors, which account for roughly 11,000 deaths per year (American Cancer Society, 1990). Metastatic lesions from various sites account for 20% to 40% of brain tumors (American Cancer Society, 1990), occur in approximately 15% of cancer pa-tients (Black, 1991), and produce neurologic symp-toms in approximately 85,000 patients each year. Most spinal tumors are extradural and are predomi-nantly metastatic carcinomas, lymphomas, or sarco-mas (Posner and Chernik, 1978). Patients may undergo surgical resection, chemo-therapy, and/or radiation to combat their tumors. It is important to note that significant functional deficits can exist even before treatments. The following signs were noted in 162 patients with cerebral metastases: impaired cognition (77%), hemiparesis (66%), uni-lateral sensory loss (27%), ataxia (24%), and apha-sia (19%) (Caraceni and Martini, 1999a). Spinal cord compression can occur in 5% to 10% of can-cer cases (Barron et al., 1959). Immediate functional consequences can include pain, sensory deficits, mo-tor deficits, neurogenic bowel and bladder, and sex-ual dysfunction. Rehabilitation management of impairments and disabilities is approached in the same manner as in noncancerous neurologic diseases. However, the pathology of the tumor and the anticipated course of disease progression must be considered carefully when developing rehabilitation goals as well as the time frame required to achieve these goals for an in-dividual patient. The purpose of rehabilitation for cancer patients is similar to that for patients with other diseases; emphasis is placed on restoring or maximizing independence with activities of daily liv-ing (ADL), mobility, cognition, and communication. Rehabilitation interventions can be applied in all stages of the disease, although rehabilitation goals change as the stage of illness advances. Preventive re-habilitation maintains maximum functional indepen-dence in patients who undergo treatment and who have potential loss of function. When tumor progres-sion causes a decline in functional skills, or the dis-ease causes fluctuating abilities, rehabilitation as-sumes a supportive role, with goals adjusted to accommodate persistent anatomic and physiologic limitations. During terminal stages of illness, pallia-tive rehabilitation can improve and maintain comfort and quality of life until the end of life. An optimal rehabilitation team consists of a physiatrist, primary physician, nurse, physical therapist, occupational therapist, speech-language therapist, recreational therapist, social worker, case manager, dietitian, and chaplain (Gar-den and Gillis, 1996). Benefits of rehabilitation are noted. It is important to understand that even a small low-grade malignant tumor may cause significant resid-ual functional deficits if it resides in a critical loca-tion. Lesions located near the brain stem can be particularly damaging to motor functions, sensory functions, coordination, and cranial nerves. Primary malignant tumors in adults are mostly gliomas, which account for more than 90% of lesions (Bondy and Wrensch, 1993). Of these, glioblastoma multiforme has the worst prognosis and low-grade astrocytoma, the best (Black, 1991). The location of these tumors may or may not permit resection. Pituitary tumors may result in headaches, bilateral visual loss (due to their central location), and hormonal abnormalities (Black, 1991). With acoustic neuromas, hearing loss and/or vertigo may occur due to their proximity to the cranial nerve. Other symptoms associated with these tumors include facial palsy and numbness, dys-phagia, and hydrocephalus. Visual loss and sexual dysfunction can be present with craniopharyngiomas in adults, and growth failure may occur in children with these tumors. Changes in behavior, appetite, memory, and endocrine function may be seen fol-lowing radiation treatment (Black, 1991). The lung and breast are the most frequent primary sources of metastatic CNS tumors. Other common primary sources are carcinomas from the colon/rectum, kidney, and pancreas, as well as malignant melanomas. These tumors tend to be highly invasive and destructive. Edema is often present and may extend for some distance beyond the tumor. Leptomeningeal metastases with multiple cranial nerve and spinal root involvement may also occur. It is essential to consider the fluctuant nature of dis-ease progression for many of these patients and that the overall prognosis may not be very good when these tumors are present. Rehabilitation interventions should be guided by the evidence regarding the nature and be-havior (aggressive or indolent) of each patient’s tumor, the ongoing clinical course, and the patient’s neuro-logic status. If the prognosis is very limited, or severe cognitive injury impedes patient learning and retention of new information, caregiver education and adapta-tion of the patient’s environment become dominant components of the rehabilitation plan. In cases of ex-pected survival of less than 2 months, primary goals usually shift to injury prevention, safety for patient and caregivers, and ease in performing tasks of hygiene and transfers into and out of bed. Common complications influencing the rehabilitation program for these patients are listed ..With temporal lobe tumors, dysnomia, disturbance of comprehension, and defective hearing and memory may occur (Nelson et al., 1993). Loss of vision, spatial disorientation, memory loss, dressing apraxia, and proprioceptive agnosia may occur with parietal lobe tumors. Behavioral abnormalities can occur with frontal lobe tumors, and these may include person-ality or libido changes, with impulsive behavior, la-bile emotions, and excessive jocularity. Hypona-tremia, as seen in the syndrome of inappropriate diuretic hormone (SIADH), may lead to mental sta-tus changes (Nelson et al., 1993). Fatigue may be-come an issue with radiation treatment. Steroid psy-chosis occasionally complicates the rehabilitation course. With prolonged immobility in bed, supportive care is important. Measures should be taken to prevent pressure ulcers and deep venous thrombosis. Range of motion of all joints should be maintained with daily exercises or passive stretch if paralysis or altered mental status is present. Sensory stimulation should be provided, along with socialization. Corticosteroids, which are commonly used to com-bat peritumoral edema, tend to improve diffuse neu-rologic dysfunction rather than focal deficits. Myopa-thy with proximal muscle weakness often ensues and is very difficult to reverse until steroid doses have been tapered or discontinued. Unfortunately, immo-bility and myopathy frequently create cumulative deficits in strength and endurance. Patients should receive strengthening therapies and exercise pro-grams when steroid therapy is initiated. Patients may have uninhibited bladder due to lack of cortical influence and may require frequent prompting. Behavioral training may be helpful in pa-tients with unimpaired cognition. This involves pro-gressively increasing the time between voiding, often by 10 to 15 minutes every 2 to 5 days until a rea-sonable interval between voiding is obtained. Drugs to inhibit bladder evacuations, such as anticholiner-gic and antispasmodic agents, should be judiciously used. External (condom) catheters may be an option for some male patients. If a diaper is used, it should be changed within 2 to 4 hours to avoid skin break-down. Immobile or sedentary patients become con-stipated easily and may require a bowel program with higher fluid intake, stool softeners, and digital stim-ulation, along with suppositories, laxatives, and enemas.Orthotic devices that support a limb or joint and assistive devices such as walkers and canes may be issued. Use of a wheelchair may be necessary for those with significant weakness and balance impair-ment. Occupational and physical therapists should be consulted early for evaluation and teaching of ADL, ambulation, and strengthening and stretching exer-cises. Speech therapists can assist with the assessment of cognition, linguistic, and communication deficits. They can also determine the presence of swallowing difficulties and recommend therapeutic exercises, compensatory maneuvers, and modified-consistency diets. Seizures and hydrocephalus are complications of brain tumors that often negatively impact the course of rehabilitation through declining functional perfor-mance. Todd’s paralysis and subclinical seizures may mimic other etiologies for declining neurologic sta-tus and prevent participation in a rehabilitation pro-gram. Hydrocephalus may also have a presentation suggestive of other diagnoses, may be acute or chronic in nature, and usually leads to a decline in functional status. It is classically described as a triad of subcortical dementia, incontinence, and gait dis-order. Hydrocephalus should be suspected when changes in mentation occur, when a patient fails to make expected functional gains, or when spasticity, seizures, and emotional problems are present. Work-up may include computed tomography (CT) scan, lumbar puncture, CT cisternography, and radionu-clide cisternography. Neurosurgical consultation for shunt placement should be obtained. Cranial Nerve Deficits Cranial nerve function should be routinely assessed in patients with brain tumors, as appropriate inter-vention may greatly improve functional status. Visual and hearing deficits are frequently seen in menin-giomas, acoustic neuromas, and pituitary adenomas. Ophthalmoplegia and facial pain may also present as symptoms of central nervous system (CNS) tumor (Rowland, 1995). Suprasellar lesions can cause bitemporal hemi-anopsia, but can also cause diminished visual acuity, scotomata, quadrantic deficits, and blindness of one or both eyes. When treating patients with visual deficits, rehabilitation management should include an ophthalmology consultation to quantify the extent of the visual field loss. Training the patient to utilize compensatory techniques such as scanning will im-prove visual spatial awareness. Driving recommen-dations should be given before discharge, with plans for further evaluations as vision improves. Vision im-pairment typically leads to adverse effects on inde-pendent living and must be considered in discharge planning. Patients with double vision can be treated with alternating-eye patching. Facial pain can be very debilitating and may be treated with tricyclic antidepressant, antiepileptic, or analgesic medications, alone or in combination or in combination with mild narcotic medications. Facial and eyelid paralysis may necessitate plastic surgery interventions for corneal protection or cosmesis. Hearing deficits may have a central or peripheral eti-ology. Audiology evaluations will differentiate sen-sorineural from conductive hearing loss. Speech pathology consultation is necessary to establish ap-propriate routes for communication. Balance Abnormalities The neurologic components of human balance are the visual, vestibular, and somatosensory systems. The brain stem and cerebellum process and integrate information about balance from various peripheral receptors, which is then sent onward through corti-cospinal and brain stem pathways. Balance abnor-malities may include dizziness, unsteadiness, vertigo, muscle weakness, and proprioceptive sensory loss. Injuries of the posterior columns of the spinal cord or of the parasagittal or sensory cortex of the brain can lead to these difficulties. Many cancer-related problems and treatments contribute to imbalance, in-cluding poor nutrition, anemia, anxiety, postural hy-potension, and dehydration. Medications such as antiemetics, tranquilizers, opiates, vestibulotoxic an-tibiotics (e.g., aminoglycosides), and diuretics may also cause loss of balance. Radiation therapy that in-cludes the temporal bone and/or the posterior fossa can also lead to intermittent vertigo. While brain tu-mors at many different locations may lead to a sense of vertigo, nystagmus occurs with vestibular or pos-terior cranial fossa tumors. Patients frequently com-pensate by tilting their head to decrease the nystag-mus. Acoustic neuromas can present as Ménière’s disease, where vertigo is associated with hearing loss and tinnitus. Tumors affecting the cerebellum may lead to ataxia and dysdiadochokinesis. Vestibular disturbance can be treated by habitua-tion, which leads to decreased sensitivity of the vestibular response. The goals of rehabilitation are to resolve reversible deficits and to learn compensatory and adaptive techniques for irreversible deficits, thereby improving safety and increasing indepen-dence. Rehabilitation may include training patients to effectively use other sensory input and habituation to control symptoms provoked by activity. Spontaneous resolution can occur and is often related to the sever-ity of the initial insult as well as the possible plastic-ity of the CNS. The Balance Master System is a medical device (NeuroCom International, Clackamas, Oregon) used to quantify and treat balance abnormalities. It utilizes a partially enclosed environment with a monitor screen that changes visual orientation input. It has platforms on which a patient stands (both outside and inside the environment) to measure movements and/or provide tilts or weight shifts. Harnesses are available for safety. Parameters measured include (1) amount of weight bearing on either foot, (2) sway with upper body movement, (3) rhythmic weight shift with body movement in all planes, (4) limits of sta-bility whereby patients are provided a mechanical force toward which they try to shift their weight to compensate to maintain balance, and (5) weight shifts during movements such as transfers from sit-ting to standing and walking. Visual feedback is then given regarding the patient’s position while the ther-apist can give verbal cues. The results are stored for quantitative and graphic analysis. Vestibular and vi-sual components can be isolated by the device’s en-vironment. A custom exercise program can then be developed based on the determined deficits. Propri-oceptive responses may be improved via controlled mobility, improved anterior-posterior weight shifts, increasing trunk strength and range of motion, as well as increasing midline symmetry and transitional movements. Pharmacologic treatments include meclizine and dimenhydrinate, which may cause sedation. Trans-dermal scopolamine patches can also be used and are believed to cause less sedation. Cognition/Speech Deficits Deficits in cognition and speech occur; they vary in type and severity by the location and type of tumor, anticancer treatment, pre-morbid cognitive baseline, and co-morbid medical conditions. Cognitive deficits arise from tissue injury caused by the tumor itself, surgical resection, and the acute effects of radiation and chemotherapy (Silberfarb, 1983). The neu-ropsychiatric side effects of both steroid and anti-convulsant therapy should also be considered in cog-nitive assessment (Lewis and Smith, 1983). Emotional sequelae such as depression and anxiety are com-mon, may worsen cognitive functions, or are over-looked in the presence of cognitive deficits. Coexist-ing medical conditions such as hypothyroidism are treatable and should be considered in the differential diagnosis of cognitive impairment.Cognitive deficits are most often seen in areas in-volving memory, attention, initiation, and psychomo-tor retardation. Primary interventions for memory im-pairment include memory aids and the use of visual imagery. Cognitive remediation programs teach pa-tients adaptive strategies and compensatory tech-niques. Psychostimulants have been reported to be useful in treating psychomotor retardation, depres-sion, and opioid-induced drowsiness (Bruera et al., 1989; Weitzner et al., 1996). Dopamine agonists and stimulating antidepressants improve attentional dys-function, particularly distractibility and difficulty fo-cusing, in higher level patients (Gualtieri et al., 1989). Bromocriptine can be effective for motor aphasias and neglect in some patients (Grujic et al., 1998). Carba-mazepine, tricyclic antidepressants, trazodone, aman-tadine, and -blockers have been prescribed to man-age agitation in patients with traumatic brain injury (Brooke et al., 1992; Mysiw et al., 1988; Whyte, 1988).Aphasia is a language disorder, whereas dysarthria is an articulation disorder. In contrast to aphasia, naming, fluency, repetition, and comprehension are normal in dysarthric conditions, and dysarthric pa-tients can read and write without errors. The sever-ity of aphasia correlates significantly with communi-cation difficulty. Other disorders such as apraxia, visual constructive difficulties, and neglect need to be considered in the differential diagnosis of communi-cation dysfunction.Myelopathy may occur due to tumor involvement, ir-radiation, and intrathecal chemotherapy. Metastatic tumors may involve the spine or spinal cord. Back pain is a frequent symptom and in 10% of cases may be due to spinal instability (Gilbert et al., 1977; Portenoy et al., 1987; Rodichok et al., 1981). Any tu-mor can metastasize to the spine and cause sufficient destruction to produce spinal instability. The thoracic spine is the segment most commonly involved, fol-lowed by lumbosacral and then cervical vertebral lev-els (Casciato and Lowitz, 1983; Schlicht and Smelz, 1994). Spinal cord compression eventually occurs in ap-proximately 5% of patients with cancer (Casciato and Lowitz, 1983). Abrupt neurologic deterioration from spinal cord involvement may occur from rapidly growing lesions in the extradural space. Infarction of the vertebral blood supply can cause cord injury. Radiculopathy at any level is also possible (Gilbert et al., 1977; Rodichok et al., 1981). By the time treat-ment is pursued, as many as 50% of patients may not be able to ambulate, and 10% to 30% may be para-plegic (Shapiro and Posner, 1983; Shaw et al., 1980). Symptoms include weakness, incoordination, gait abnormality, spinal or radicular pain, paresthesias, sensory disturbances, autonomic disturbances, as well as bowel or bladder problems. Pinprick and deep pain sensation is often retained until later in the course of the disease. Motor involvement typi-cally occurs before sensory involvement with epidural extension (Galasko, 1999). With radiation treatment alone, ambulation is maintained in 79% of patients if they were ambulatory before treatment and in 42% with paraparesis. In 20% to 25% of patients, significant neurologic deterioration was noted dur-ing the course of treatment with radiation alone (Findlay, 1984). Significant neurologic deterioration and progres-sive spinal instability require a neurosurgical con-sultation. High-dose steroids are used in the acute phase to control neurologic damage. Tetraplegia, whether complete or incomplete, occurs with spinal cord involvement at T1 or above. Below this level, injuries more commonly result in paraplegia, conus medullaris syndrome, or cauda equina syndrome. Local pain is typically described as constant and aching, whereas radicular pain is classically sharp and shooting. Referred pain can be either aching or sharp and at a location distant to the involved site. Pain can also occur with epidural involvement; this pain worsens with Valsalva maneuvers, coughing, and neck and back flexion (Gilbert et al., 1978; Ger-ber and Vargo, 1998). Functional prognostic factors are listed . With use of radiation treatment and posterior laminectomy, the overall results were that complete paraplegia patients rarely recovered, but those who were ambulatory remained ambulatory and approxi-mately one-half of patients with incomplete paraple-gia regained ambulation (Posner, 1995). Recovery tends to occur first in the area of sensory disturbance, followed by motor abnormalities (Casciato and Lowitz, 1983; Schlicht and Smelz, 1994). Radiation-Related Myelopathies The detrimental effects of radiation are multifactorial and cannot be entirely attributed to dosage, site, or technique. Such myelopathy may be transient or de-layed (Dropcho, 1991). With transient myelopathy, peak onset is at 4 to 6 months (Dropcho, 1991). Clin-ical onset may involve symmetric paresthesia or shock-like sensations in a nondermatomal pattern from spine to extremities (Leibel et al., 1991). Radi-ologic studies are usually normal. Symptoms typically resolve in 1 to 9 months (Dropcho, 1991). Con-versely, delayed myelopathy is irreversible, has a la-tency period of 9 to 18 months, and generally occurs within 30 months (Dropcho, 1991). The incidence is reported at 1% to 12%. The latency period is de-creased with increased radiation dose and in children (Leibel et al., 1991). The onset of symptoms begins with lower extremity paresthesias and is followed by sphincter disturbance. Partial Brown-Séquard syn-drome (motor weakness on one side and some sen-sory changes on the contralateral side) may occur below the level of injury. In cases of myelopathy or significant radiculopathy, physical and occupational therapists should be con-sulted early to address ADLs and ambulation and to provide adaptive equipment and strengthening ex-ercises. When spinal metastasis has occurred, other bony areas may also be affected, particularly the pelvis, femur, ribs, and skull. When there is skull involvement, compromise of adjacent neurologic structures can occur. Use of orthoses to limit spinal mobility, such as sternal-occipital-mandibular im-mobilization (SOMI), may be required for spinal stability for patients with tumors affecting the spine. Rigid thoracic-lumbar-sacral orthoses with a “clamshell” design can provide good external sup-port but may not be tolerated by patients with painful rib or iliac crest bony involvement or by those with fragile skin due to steroids or chemo-therapy (Garden and Gillis, 1996). The rehabilita-tion team must consider metastatic disease as a pos-sible etiology for new pain or weaknesses that arise during the course of therapy. Adequate pain con-trol is essential and enables patients to participate in therapy. Pain Management; Pain (see later in this chapter and Chapter 23) may be both acute and chronic. Pharmacologic options include opiates, nonsteroidal anti-inflammatory agents, tricyclic antidepressants, various antiepilep-tics, steroids, and other medications such as -block-ers and -adrenergic agonists. Use of modalities such as heat, cold, and transcutaneous electrical nerve stimulation (TENS) should be considered. Nontradi-tional interventions such as acupuncture have also been used with success. In patients with spinal hard-ware, worsening pain could indicate malfunction or loosening of hardware or infection in the surround-ing tissues. Bladder Management Patients with myelopathy can develop detrusor-sphinc-terdyssynergia (DSD), a condition in which the bladder contracts but the bladder outlet (sphincters) fails to relax in a timely manner, leading to impaired emp-tying and increased bladder pressure. Patients may at-tempt to void on their own; however, postvoid resid-ual volumes must be checked on multiple occasions to confirm complete emptying. If incomplete emptying oc-curs (i.e., residual volume 100 to 150 cc), inter-mittent catheterization should be performed every 4 hours. The goal is to have no more than 350 to 400 cc of urine in the bladder at any time to avoid overdis-tension, detrusor muscle injury, and retropropulsion of urine into the ureters. With chronically increased bladder volumes, bladder flaccidity may occur sec-ondary to detrusor muscle injury. The amount of urine produced is affected by the volume of fluid intake, medications, and hormonal abnormalities, such as SIADH, which may be seen particularly with lung malignancies and pituitary adenomas. Certain types of foods and drinks may also act as diuretics. Fluid intake should initially be re-stricted to 2 L per day if other medical concerns per-mit. The frequency of bladder catheterization may at first be kept at every 4 to 6 hours and can be adjusted so that bladder volumes do not exceed 400 cc. Pa-tients should not restrict fluid intake simply to avoid catheterization. The intermittent catheterization pro-gram (ICP) should be taught to patients and care-takers. Patients with a cord injury at C7 or below can usually learn to independently perform such a pro-gram. Condom catheters may be used by men with hyperactive bladder (without dyssynergia) or those with normal bladder function but with incontinence due to impaired cognition or mobility. Indwelling catheters may be needed in women who cannot per-form ICP and in men who cannot wear condom catheters or who have contraindications to ICP. Bowel Management A bowel program (more details follow in a later sec-tion) with fiber, stool softeners, and digital stimula-tion, along with judicious use of suppositories, laxa-tives, and enemas should be started. Warm fluids may be given after meals to supplement the gastrocolic re-flex. Patients should be allowed to sit on a commode at regular times to facilitate bowel movements. Es-tablishment of a set pattern (daily or every other day) for evacuation will minimize constipation and incon-tinence. Management of Autonomic Dysreflexia Autonomic dysreflexia is a medical emergency that occurs when a patient manifests a massive sympathetic discharge in response to a noxious stimulus. The clinical presentation is that of an anxious patient with paroxysmal hypertension, nasal congestion, sweating above the level of lesion, facial flushing, piloerection, and reflex bradycardia. Autonomic dysre-flexia typically occurs with a spinal cord injury at the level of T6 or above. Most commonly, the noxious stimulus is a distended bladder or bowel. Other causes include enemas, tight clothing, infection, deep venous thrombosis, ingrown toenails, bladder catheterization, and pressure ulcers. Treatment fo-cuses on eliminating the underlying noxious stimu-lus, such as emptying of the distended bladder or bowel. Such measures usually resolve the episode quickly; however, if a cause cannot be found promptly, treatment with antihypertensives must be initiated to prevent complications of rising blood pressure. Chemotherapy can enhance the radiation-induced in-jury in irradiated tissue and decrease the latency pe-riod for development of plexopathy. Predominant symptoms are pain and paresthesias. Clinical signs in-clude sensory loss, decreased or absent reflexes, and weakness. Brachial Plexopathy Plexus lesions can result from compression or infil-tration by tumor lying in contiguous tissues or may be seen after RT for breast and lung cancers. Char-acteristic differences between neoplastic and post-radiation plexopathies are listed . Pain typically occurs in the shoulder, elbows, hand, and fourth/fifth digits, whereas sensory disturbance occurs in the axilla with C8, T1, and T2 involvement. Breast cancer in particular may affect the upper bra-chial plexus, where pain referral is to the paraspinal region, shoulders, biceps, elbow, and hand. Burning dysesthesias in the index finger or thumb are com-mon. A hallmark of this syndrome is the neuropathic character of the pain, with numbness, paresthesias, allodynia, and hyperesthesia complaints. All patients with brachial plexopathy should have a scan of the contiguous paravertebral region before RT because extension of disease is common in this area. Epidural invasion can occur in some patients with brachial plexopathy. Imaging of the epidural space is essen-tial when a patient develops Horner’s syndrome, panplexopathy, or vertebral body erosion or if a paraspinal mass is detected on CT scan. With radia-tion dosages exceeding 60 Gy, or large fractions of 190 cGy/day, fibrosis of the plexus can occur. Lumbosacral Plexopathy Pelvic malignancies, including bladder, uterus, prostate, and/or lung cancer or melanoma can lead to lumbosacral plexopathy. Retroperitoneal tumors, including sarcomas and metastatic nodal tumors, may affect the lumbosacral plexus or its roots more prox-imally (Table 22–7). The presenting symptom is usu-ally pain in the buttocks or legs, and it often precedes other symptoms by weeks or months. Other symp-toms include numbness, weakness, and later edema. Pain is usually of an aching or pressure-like quality, rarely burning (Caraceni and Martini, 1999b). Lesions most commonly occur in the lower plexus (L4–S1) with an incidence of 50%, followed by up-per lumbar plexus (L1–L4) at 33%. Panplexopathy involving two sites is less common at 20% (Jaeckle et al., 1985). Pain management may require tricyclic antide-pressants, antiepileptic agents such as gabapentin and carbamazepine, along with epidural catheters and neurosurgical approaches in more resistant cases. Neuropathic pain may also respond to radiation treat-ment. After acute inflammation and pain subside, low-resistance weight exercises and functional activities should be encouraged. Neck exercises and range of motion programs should be included in the treatment of brachial plexopathy, especially with injury to the upper portion of the plexus, to avoid functionally dev-astating contractures in that area. A sling should be given to prevent glenohumeral subluxation. With lower extremity involvement, assistive devices for am-bulation, such as a cane, may be required by those patients with weakness and proprioceptive feedback loss. Orthoses and splints may be required for joint or limb support or to enable function and prevent injury. WITH NEUROPATHIES Peripheral polyneuropathy may occur as a result of direct tumor invasion, as part of a paraneoplastic syn-drome, or with chemotherapy (see Chapter 17). Para-neoplastic neuropathy may be related to an autoim-mune process and may be sensorimotor in nature (see Chapter 19). Chemotherapy-associated periph-eral neuropathies are generally distal and symmetric. Most frequently these neuropathies occur with Vinca alkaloid, taxane, or platinum-based therapies (Amato and Collins, 1998). Symptoms include numbness, paresthesias, and occasionally severe neuropathic pain. Tricyclic antidepressants and antiepileptics should be given to manage pain. Adaptive strategies such as energy conservation, orthotics, and assistive and adaptive devices are prescribed. With sensory loss in the lower extremity, preventive measures such as those used for management of diabetic neuropathy and neuropathic ulcers should be instituted. Educa-tion, nonconstricting footwear, and daily inspection of feet are important in such cases. Patients with acute inflammatory demyelinating polyneuropathy benefit from a resistive exercise program. LEPTOMENINGEAL DISEASE Leptomeningeal disease is also known as carcinoma-tous meningitis or meningeal carcinomatosis (see Chapter 16). It is caused by dissemination of can-cerous cells throughout the subarachnoid space. Life expectancy is usually very short, often only 3 to 6 months with treatment (Sause et al., 1988; Siegal et al., 1994). Both central and peripheral nervous sys-tem involvement can occur, along with cerebrospinal fluid flow obstruction leading to hydrocephalus. Symptoms can include mental status changes, polyradiculopathy with radicular pain, and cauda equina syndrome. Rehabilitation management is sim-ilar to that outlined earlier, based on the sites involved and the deficits encountered. The rehabilitation goals should include supportive and safety concerns and reflect the generally poor prognosis. MUSCULOSKELETAL PROBLEMS Primary and metastatic nervous system cancers and their treatments can cause multiple musculoskeletal problems. These problems can significantly compro-mise normal function. They require an accurate diagnosis, assessment of functional impairments, and implementation of appropriate rehabilitation inter-ventions. Corticosteroid-Induced Myopathy Myopathies are a group of muscle diseases whose common principal symptom is weakness, usually in the proximal muscles of the shoulder and hip joints. Steroid myopathies most commonly occur in patients who undergo high-dose, long-term corticosteroid therapy. These patients generally show recovery after decreasing or discontinuing medication. Myopathy patients usually present with difficulty climbing stairs, rising from chairs, and performing transfers. Inpa-tient rehabilitation is sometimes necessary to regain strength, learn to perform ADLs safely, and use am-bulatory aids. In the most severe cases, patients may require a wheelchair for all mobility and ADLs, but can achieve independence in those functions despite the use of a wheelchair. In such cases, adaptive equip-ment (e.g., transfer board, raised toilet seat, bathtub bench) is necessary for them to perform ADLs safely. As patient strength improves, gait training under the supervision of a physiatrist and physical therapist can continue on an outpatient basis. Avascular Necrosis and Osteoporosis Avascular necrosis and osteoporosis frequently occur in cancer patients. These problems are diagnosed ra-diographically and may be asymptomatic until the in-volved bone is subject to fracture or infection. Most avascular necrosis is attributable to the direct effects of RT or to the systemic effects of corticosteroids, al-though these effects appear to be dose dependent (Zizic, 1991). In addition to RT and steroids, avas-cular necrosis in cancer patients has been anecdo-tally associated with single-agent cyclophosphamide or methotrexate, as well as cyclophosphamide in combination with methotrexate and 5-fluorouracil (Pizzo and Poplack, 1997). Like avascular necrosis, osteoporosis has been re-lated to steroids and to RT (Duthie and Katz, 1998; Tefft et al., 1976). Glucocorticosteroids inhibit new bone formation and calcium absorption and increase bone resorption and renal calcium excretion. Steroid-induced hypogonadism contributes to the problem in both men and women. More than 50% of patients tak-ing long-term steroids develop some degree of os-teoporosis (Goroll et al., 1995). The risk of devel-oping steroid-induced osteoporosis can be reduced by using a short-acting preparation at the lowest pos-sible dose in an alternate-day regimen, by maintain-ing physical activity, and by ensuring adequate daily intake of calcium and vitamin D. Treatments for os-teoporosis include 1. Therapies used to slow down bone involution and prevent contracture formation and postural deviations: weight-bearing exercises, upper and lower extremity muscle strengthening, balance training, back extension and chest expansion ex-ercises, pectoralis muscle stretching, posture correction, and proper lifting techniques 2. Cessation or tapering of glucocorticoid intake 3. Hormone replacement therapy for men and women who do not have contraindications 4. Thiazide therapy for hypercalcemia 5. Vitamin D and calcium supplementation when appropriate 6. Bisphosphonate therapy 7. Environmental modification: proper footwear, adjustment of medications that may contribute to falling; assistive devices 8. Education of patients regarding risk factors such as smoking Compression fractures may ensue with only minor trauma once sufficient structural integrity is lost. Pain may be managed with analgesic and anti-inflamma-tory medications and the use of spinal orthoses. Sur-gical fixation is sometimes necessary to attain stabil-ity. Early weight-bearing and limited immobilization should be encouraged to minimize continued bone loss. Contracture of Joints A limitation of passive joint range of motion, con-tracture commonly results from a restriction in con-nective tissue, tendons, ligaments, muscles, and joint elements. Contractures are most often related to spas-ticity, bed rest, localized heterotopic ossification, bleeding, infection, trauma, and edema. Prevention is achieved by minimizing the duration of bed rest and encouraging daily range of motion exercises. Heterotopic Ossification Heterotopic ossification is the formation of mature, lamellar bone in soft tissues. The variable incidence of heterotopic ossification has been reported in spinal cord injury patients (20% to 25%) and in head in-jury patients (10% to 20%) (An et al., 1987; Brooker et al., 1973; Evans, 1991; Garland, 1988; Ishikawa et al., 1982; Jensen et al., 1988; Stoikovic et al., 1955; Storey and Tegner, 1955; Stover et al., 1975). This condition has been observed in patients who require a prolonged ICU stay and is rarely seen in the cancer population. The chief symptoms of heterotopic ossi-fication are joint and muscle pain and compromised range of motion. A triple-phase bone scan is able to detect heterotopic ossification at an early stage. Ther-apies include bisphosphonates, nonsteroidal anti-inflammatory drugs, RT, and physical therapy. Pas-sive joint mobilization helps to maintain or increase joint mobility without promoting heterotopic ossification. Matured heterotopic ossification can be sur-gically excised. Shoulder Pain This problem often occurs in neurologically impaired populations. Shoulder pain may originate from rota-tor cuff tears, bicipital tendinitis, adhesive capsulitis, and subdeltoid bursitis. Other causes of shoulder pain in the hemiplegic population include excessive shoul-der capsule stretch secondary to paresis of shoulder musculature, sympathetically maintained pain (reflex-sympathetic-dystrophy, shoulder-hand syndrome), and thalamic syndrome. Management is diagnosis dependent. Immobilization syndrome may occur during recovery from operative or other treatments, be caused by medical complications, or result from the neurologic sequelae of cancer. It negatively impacts multiple body systems and often causes a decline in the pa-tient’s functional status. Immobilization can contrib-ute to intellectual, emotional, and behavioral distur-bances, decreased muscle strength and endurance, poor coordination, and contracture of joints. Car-diovascular and pulmonary deconditioning may pres-ent with orthostatic hypotension, deep vein thrombo-sis, decreased vital capacity, and impairment of the cough mechanism. Anorexia, constipation, electrolyte disturbances, and pressure ulcers are also manifes-tations of immobilization (Hoffman et al., 1998). The best management of this syndrome is through pre-vention. Physical therapy should begin early, empha-sizing progressive mobilization, starting with passive range of motion if necessary; progressing to assisted active range of motion; then to active range of mo-tion. When postural hypotension is pronounced or when patients have been or are expected to be bed bound for more than one week, tilt-table use should begin as soon as the patient is stable. This device is beneficial for cardiovascular and respiratory recon-ditioning and can also help prevent osteoporosis. Once the patient tolerates a 70-degree angle for 30 minutes, standing and ambulation should begin. Signs and symptoms of hypercalcemia, pressure ulcer, uri-nary tract infection, and pneumonia should be watched for vigilantly. Venous Thromboembolism Deep venous thrombosis (DVT) has a high incidence in stroke patients (30% to 50%) (Gibberd et al., 1976), in spinal cord injury patients (Merli et al., 1993; Weinmann and Salzman, 1994), after hip arthroplasty (Imperiale and Speroff, 1994), in pa-tients with cancer (Marik et al., 1997), and in im-mobilized patients (Giuntini et al., 1995). Elastic hosiery and sequential compression pumping of the calves should be continued until mobilization is un-derway. In spinal cord-injured and hemiplegic pa-tients, administration of subcutaneous low-molecu-lar-weight heparin is recommended. Exceptions are made for patients following intracranial surgery to avoid devastating hemorrhage. Patients with throm-bocytopenia, especially those with hematologic ma-lignancies and hemorrhagic tumors, require individ-ualized assessment, and their anticoagulation risks should be addressed with the primary oncology team. A consensus on the optimal duration of prophylactic anticoagulation has not yet been reached. A high index of suspicion for thrombosis should be maintained for patients with recent surgery or anesthesia, smoking history, current or recent pro-longed bed rest, prior history of DVT, cardiac dis-ease, obesity, extremity trauma, neoplasm, and in the elderly. If DVT is suspected, Doppler ultrasound and venography can be used to confirm the diagnosis. Once the clinical diagnosis of DVT is seriously con-sidered or confirmed, intravenous heparin can be started, followed by oral anticoagulation therapy for a 3 month period. When a pulmonary embolism has occurred, 6 months of treatment is usually suggested (Bone et al., 1998). Spasticity Spasticity is a motor disorder characterized by a velocity-dependent resistance to movement associ-ated with exaggerated phasic stretch reflexes (tendon jerks), representing one component of the upper mo-tor neuron syndrome. Tone is the sensation of resis-tance felt by the examiner as passive range of motion is tested. Spasticity can be caused by a wide variety of disorders that damage descending motor tracts at the cortical, subcortical, brain stem, or spinal cord Spasticity can be quantified by using the Modified Ashworth Scale (Table 22–8). Only those patients whose spasticity interferes with present function or potential future function, or whose condition is painful, should be treated. Spasticity treatment should begin with the least invasive techniques and advance as needed. Basic treatment includes a daily stretch-ing program, use of proper positioning, and avoid-ance of noxious stimuli. Topical cold may provide short-term benefit. Casting and splinting techniques can improve the range of motion in hypertonic joint contractures. Oral medications (Table 22–9) to treat spasticity should be combined with basic treatment and are only effective in mild to moderate cases. Chemical neurolysis, such as phenol block, injec-tions, epidural infusion of medications, botulinum toxin via an implantable pump, and surgery are op-tions for severe spasicity management. Pain: Distinguishing whether pain (see Chapter 23) is acute or chronic in nature can assist in selecting appropri-ate management. Pain tends to be less prominent in patients with brain tumors, but may be significant with spinal column and cord involvement. In patients with spinal stabilization using hardware, increasing pain should prompt an evaluation of the construct’s in-tegrity. Headaches occur in 48% to 71% of patients with brain tumors. These are usually mild to moderate and can resemble tension headaches but may increase with changes in position (Forsyth and Posner, 1993; Suwanwela et al., 1994; Caraceni and Martini, 1999b). Increasing severity or accompanying nausea and vom-iting may signify increasing intracranial pressure, which often responds to steroids (Caraceni and Mar-tini, 1999b). Medical management typically includes non-steroidal anti-inflammatory agents (NSAIDS) and non-narcotic and narcotic analgesics. Neuropathic pain, which may be seen with spinal cord involve-ment, can be managed with tricyclic antidepressants, anticonvulsants, steroids, and occasionally opiates. Tricyclic agents may potentiate opiate analgesia. An-tihistamine agents such as hydroxyzine may help with analgesia and provide antiemetic effects, but these usually occur only with relatively high parenteral dosages (Beaver and Feise, 1976). Benzodiazepines may be helpful in managing anxiety or muscle spasms but are not useful for analgesia (Beaver et al., 1966). Short-term administration of high-dose corticos-teroids can provide significant pain relief in patients with bony or neural structure involvement. Dosage of steroids should be tapered as alternative means are implemented (Ettinger and Portenoy, 1988; Bruera et al., 1985). Bisphosphonates should be considered for patients with refractory bone pain (Payne, 1989). An-ticholinergic drugs like scopolamine should be con-sidered for refractory pain from bowel obstruction. Neurostimulants such as methylphenidate and dex-troamphetamine can be analgesic in low doses (Bruera et al., 1987). Physical medicine modalities for pain control can serve as an adjunct to cancer pain management (U.S. Department of Health and Human Services, 1994). Cold modalities are generally safe. Heat modalities can be superficial or deep (usually ultrasound) and may increase circulation to the involved area. How-ever, this method may increase the potential for met-astatic spread, and application of ultrasound over malignant tissues is generally contraindicated. Tran-scutaneous electrical stimulation (TENS) is particu-larly helpful in the management of radiculopathy or incisional pain. Conventional high-frequency settings are usually effective, but expertise in electrode place-ment may be required to attain pain relief. Trigger point injections can help myofascial pain. Nerve blocks, epidural injections, and ablative surgical pro-cedures may also be useful for treating acute pain. Appropriate use of orthotics can be invaluable. Ex-amples include shoulder support with a sling in pa-tients with malignant brachial plexopathy or gleno-humeral subluxation with brain tumor; or use of cervical, thoracic, and lumbosacral orthoses for pa-tients with metastatic spinal involvement. Psycholog-ical approaches including hypnosis, relaxation train-ing, and distraction techniques may be considered. Acupuncture has also been useful in acute pain management. Delirium and Dementia Alterations in consciousness may occur during the rehabilitation evaluation or treatment course and re-quire accurate diagnoses and intervention to maxi-mize functional outcome. Delirium (see Chapter 27) is a confusional state with an acute onset, manifest-ing as a global impairment of mental function. It oc-curs frequently in elderly cancer patients (Breitbart and Cohen, 1998). The causes of delirium include a variety of drugs, primary intracranial diseases, sys-temic diseases secondarily affecting the brain, with-drawal from alcohol or sedative-hypnotic medica-tions, metabolic disorders such as hyponatremia and hypoglycemia, infections, and seizures. Determina-tion of the causative agent or factor and removal or correction of the cause is the primary treatment. Detecting dementia is important for rehabilitation decision-making. Rehabilitation is based on a pa-tient’s ability to learn and retain information. Mod-erately or severely demented patients have limited re-habilitation potential due to their difficulty retaining new information. A brief trial of rehabilitation may still be justified in such situations to train caregivers and to clarify learning abilities. Too often, mental sta-tus observations in the acute hospital setting under-estimate the patient’s cognitive function in a more supportive and stimulating environment and their function following resolution of acute illness. Dis-charge planning for patients with dementia needs to include caregiver education to ensure awareness of the individual’s cognitive strengths and weaknesses and instructions for how to handle potential behav-ioral problems. Community resources and educa-tional materials can be very helpful to caregivers. The incidence of dementia is higher in the cancer patient population for the following reasons: 1. Occurrence of leukoencephalopathy secondary to chemotherapy such as intrathecal chemo-therapy, especially the combination of irradia-tion and methotrexate (Abrey et al., 1998) 2. Slowly progressing viral infections (Manuelidis et al., 1988) 3. Radiation-related dementia characterized either by dementia alone or by dementia with gait abnormalities and incontinence. A small num-ber of patients will also have hydrocephalus and benefit by ventricular-abdominal shunting (Asai et al., 1989) Parkinsonism The major clinical features of Parkinson’s disease are recognized as a symptom complex manifested by any combination of six cardinal features: tremor at rest, rigidity, bradykinesia-hypokinesia, flexed posture, loss of postural reflexes, and the freezing phenome-non. At least two of these features, with at least one being either tremor at rest or bradykinesia, must be present for a diagnosis of Parkinson’s disease. The biochemical pathology in this disorder is decreased dopaminergic neurotransmission in the basal ganglia. Parkinsonism can occur in cancer patients for the following reasons 1. Use of dopamine antagonists and depleting agents 2. Radiation injury, including radiation necrosis 3. Hydrocephalus/normal pressure hydro-cephalus 4. CNS hypoxia 5. Following encephalitis 6. Parathyroid dysfunction 7. Tumor 8. Multi-infarct state 9. Idiopathic Parkinson’s disease co-existing in the cancer population The clinical features of tremor, rigidity, and flexed posture are referred to as positive phenomena; bradykinesia, loss of postural reflexes, and freezing are negative phenomena. In general, the negative phe-nomena are more disabling. Bradykinesia results in difficulty with speech, swallowing, ADL, and mobility. Walking, transferring, and even bed mobility can be affected. Severe bradykinesia prevents these patients from driving due to slowed foot movement between the accelerator and the brake pedal. Loss of postural reflexes leads to increased risk of falls and a high in-cidence of hip fractures in parkinsonian patients. Af-fected patients also have cognitive and behavioral signs such as decreased attention span, visuospatial impairment, and personality changes. They are often more fearful, indecisive, and passive, as well as de-pressed, than is normal (Dropcho, 1991). Autonomic disturbances are also encountered. Patients may ex-perience constipation, urinary retention, hypoten-sion, and/or erectile dysfunction.Treatment is aimed at controlling symptoms through use of standard antiparkinsonian medica-tions and rehabilitation interventions. Physical and occupational therapies play an important role in maintaining ADL and muscle strength and slowing de-velopment of contractures and the accompanying characteristically stooped posture. Functional deficits often worsen disproportionately with periods of im-mobility; thus mobility should be preserved as much as possible despite intercurrent illnesses. Rehabilita-tion also involves treatment of dysphagia, manage-ment of bowel and bladder problems, and assistance with psychosocial difficulties caused by declining cognition. Psychological Issues Psychological symptoms can include reactive anxiety and depression, major depression, and organic brain disorder. The incidence of these disorders is gener-ally greater with higher levels of disability and ad-vanced illness (Breitbart et al., 1998). Symptoms of depression may include anorexia, insomnia, fatigue, weight loss, dysphoric mood, hopelessness, worthlessness, excessive guilt, and suicidal ideation (Massie and Holland, 1990). Symptoms are initially likely to be reactive to the diagnosis of a malignancy and then depressive as the functional deficits caused by neurologic impairments are manifested. Endicott (1984) suggested substitution criteria for making the diagnosis of depression, as somatic symptoms of de-pression might be unreliable and nonspecific in can-cer patients. Anxiety is frequently encountered during the course of rehabilitation. Recognition of anxiety can be challenging in the face of neurologic disease, use of corticosteroids, and other medications. Common signs and symptoms include restlessness, jitteriness, vigilance, insomnia, distractibility, dyspnea, numb-ness, apprehension, autonomic hyperactivity, and worry. Physical symptoms may be more prevalent than psychological or cognitive ones. Sexual Dysfunction Sexual dysfunction may be due to a malignancy or its related treatments. It can be affected by changes in nervous, vascular, endocrine, as well as psychological function. Along with depression, patients may feel less sexually attractive. Frontal lobe brain tumors can cause libido changes. Endocrine changes may occur with pituitary involvement and with hormonal treat-ments for prostate cancer. Hormonal treatments re-duce sexual desire and function in most cases. Che-motherapy can cause changes in testosterone production, spermatogenesis, and premature meno-pause with associated symptoms. Problems include low sexual drive, dry orgasm, vaginal mucosal changes leading to dyspareunia, erectile dysfunction, and decreased pleasure with orgasm (Schover et al., 1993; Gerber and Vargo, 1998). Neuropathies can amplify all of these problems. Because psychological adjustment is an impor-tant determinant of sexual function, counseling should be provided. Patients should be encouraged to pursue intimacy and physical closeness, focus-ing on various aspects of an intimate relationship. Hormonal replacement therapy should be given for premature menopause when no contraindica-tions are present, along with water-based lubri-cants. Regular douching should be encouraged to avoid odor. A peer-support system can also be of benefit (Gerber and Vargo, 1998; Garden and Gillis, 1996). Family Interaction Lack of an adequate support system can be a barrier to successful rehabilitation. Family interventions in-clude counseling, education, and identifying addi-tional support frameworks for the caregiver. Both ed-ucation and counseling interventions significantly improve caregiver knowledge. Specific techniques for care should be taught, including1. Performing physical functions such as trans-fers, mobility, and other ADL2. Encouraging patients to perform any activity that he or she is capable of doing3. Coping and compensatory strategies to deal with cognitive deficits4. Preventing complicationsCommon teaching points can include maintaining bowel and bladder function, administering medica-tions, swallow training with appropriate dietary mod-ifications, maintenance of nutrition and hydration, safety training, and a home exercise program.Equipment/Orthosis Needs Patient equipment needs are usually assessed when they approach discharge or experience a sudden de-cline in function. Equipment available for in-home medical management includes ventilators, suctioning devices, supplemental oxygen, and tube feeding de-vices. Mobility equipment includes wheelchairs, walk-ers, crutches, and canes. Rehabilitation professionals choose devices according to the patient’s functional level. Assistive devices help to achieve an improved level of independence in ADLs and include transfer boards, tub/shower chairs, raised toilet seats, long-handled reachers, sock-aids, elastic shoelaces, dressing sticks, modified eating utensils, and bath and grooming aids. Orthoses are prescribed for support, alignment, and protection. Four important functions of the upper limb—reaching, carrying, prehension, and release—should be taken into account when con-sidering an orthosis for the upper extremity. Lower extremity orthoses are primarily to assist with safety in weight bearing.