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.