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).