Neurologic Complications in Adult Cancer Survivorship.

Over the past decade, the improvement in cancer diagnostics and therapeutics has extended the overall survival of patients diagnosed with cancer including brain cancer. However, despite these unprecedented medical successes, patients continue to experience numerous neurologic complications after treatment that interfere with their independence, functionality, and overall quality of life. These include, among others, cognitive impairment, endocrinopathies, peripheral and cranial neuropathies, and vasculopathy. This article describes the long-term neurologic complications cancer survivors commonly experience to increase awareness of these complications and discuss treatments when available. Further research is necessary to understanding of mechanisms of neurologic injury and advance diagnosis and treatment. Effective patient education, monitoring, and managing neurologic issues after cancer treatment may improve independence, functionality, and quality of life during survivorship.

Surveillance of long-term complications after treatment of adult brain tumor survivors-review and evidence-based recommendations.

As a result of treatment and diagnosis, adults with primary or metastatic brain tumors experience comorbidities that impacts their health and well-being. The Children's Oncology Group has guideline recommendations for childhood survivors of brain tumors; however, guidelines for monitoring long-term sequela among adult brain tumor survivors are lacking. The purpose of this review is to present the screening recommendations for the long-term complications after brain tumor treatment from a multidisciplinary panel of healthcare professionals. Chronic complications identified include cognitive dysfunction, vasculopathy, endocrinopathy, ophthalmic, ototoxicity, physical disability, sleep disturbance, mood disorder, unemployment, financial toxicity, and secondary malignancy. We invited specialists across disciplines to perform a literature search and provide expert recommendations for surveillance for long-term complications for adult brain tumor survivors. The Brain Tumor Center Survivorship Committee recommends routine screening using laboratory testing, subjective assessment of symptoms, and objective evaluations to appropriately monitor the complications of brain tumor treatments. Effective monitoring and treatment should involve collaboration with primary care providers and may require referral to other specialties and support services to provide patient-centered care during neuro-oncology survivorship. Further research is necessary to document the incidence and prevalence of medical complications as well as evaluate the efficacy of screening and neuro-oncology survivorship programs.

Evaluation of Cognitive Symptoms Following Concussion.

The assessment of cognitive symptoms following concussion has evolved over the last several decades as a distinct focus in research and an essential component of clinical decision making and management. The aims of this paper are to (1) identify issues related to assessment of postconcussion cognitive functioning and (2) provide a review of common self-report and performance-based measures, including computerized-based assessments (CBAs), and, more traditional, comprehensive neuropsychological evaluations. We conclude that (1) there has yet to emerge one cognitive-symptom measurement method that can be considered the "gold standard" for all settings, (2) the usefulness of cognitive symptoms assessment findings in the clinical management decisions rests a great deal on the background of the practitioner, and (3) cognitive-symptom assessment needs to be considered in the context of a broader evaluation of other postconcussion symptoms.

Cognition, cognitive dysfunction, and cognitive rehabilitation in multiple sclerosis.

This article focuses on approaches and techniques for effective cognitive rehabilitation with people who have multiple sclerosis (MS). The patterns of preserved versus disrupted neuropsychological functions are reviewed. The relevant brain anatomy and physiology that underlie the common neurocognitive and neurobehavioral changes are described. The essential role is highlighted of comprehensive neuropsychological, speech language pathology, and clinical evaluations in the design and refinements of cognitive retraining treatment. The functional impact of cognitive problems expected with MS is emphasized, accompanied by examples of cognitive retraining approaches used to manage them and improve day-to-day performance.

Traumatic brain injury and pain.

The co-occurrence of traumatic brain injury (TBI) and pain is quite frequent and presents a number of challenges to the medical practitioner. The distinct nature and extent of these challenges calls for considering the co-existence of TBI and pain a unique medical entity. Clearly, from a research standpoint, the area is in its infancy. The clinician is often left with adapting standard techniques effective for evaluating and treating pain in patients without TBI. Such adaptations require a readiness to recognize how pain affects the presence and course of TBI-related symptoms and, in turn, how TBI symptoms affect the presence and course of pain. Given the myriad factors that can affect outcome, effective evaluation and treatment of this co-occurring problem need to rely on a biopsychosocial model, which encourages consideration of a broad perspective of possible causes and care approaches as well as use of multiple disciplines.

Trial of amitriptyline for relief of pain in amputees: results of a randomized controlled study.

OBJECTIVE: To evaluate whether amitriptyline is more effective than placebo in improving phantom limb pain or residual limb pain. DESIGN: Randomized controlled trial of amitriptyline for 6 weeks. SETTING: University hospital. PARTICIPANTS: Thirty-nine persons with amputation-related pain lasting more than 6 months. INTERVENTION: Six-week trial of amitriptyline (titrated up to 125 mg/d) or an active placebo (benztropine mesylate). MAIN OUTCOME MEASURES: Analyses were conducted to examine whether there was a medication group effect on the primary outcomes (average pain intensity) and secondary outcome measures (disability, satisfaction with life, handicap). RESULTS: No significant differences were found between the treatment groups in outcome variables when controlling for initial pain scores. CONCLUSIONS: Our findings do not support the use of amitriptyline in the treatment of postamputation pain.

Physical findings in patients with chronic intractable benign pain of the neck and/or back.

Chronic intractable benign pain (CIBP) is defined as non-neoplastic pain of greater than 6 months duration without objective physical findings and known nociceptive peripheral input. To test the CIBP concept, 283 consecutive chronic pain patients were examined independently by a neurosurgeon and physiatrist and only congruent physical findings were coded. Because they did not fit the CIBP definition, patients with the following primary treatment diagnoses were eliminated: degenerative disease of the spine and spinal stenosis; degenerative disease of the hips; radiculopathy; malignancy; deafferentation pain; and miscellaneous. Eliminated, also, were patients with any one finding indicative of a root compression syndrome, leaving 90 low back and 34 neck patients. These patients had abnormal physical findings in 7 categories: tender points/trigger points; decreased ranges of motion in back or neck; non-anatomical sensory loss; rigid musculature; decreased range of hip motion; gait disturbance; and miscellaneous non-neurologic signs. Low back CIBP patients had the following distribution among the 7 categories: 0% had findings of all 7; 1.1% had 6; 13.3% had 5; 24.4% had 4; 25.6% had 3; 26.7% had 2; 8.9% had 1; and 0% had none. Neck CIBP patients, in which only the first 4 categories of physical findings were applicable had the following distribution: 2.9% had 4; 41.2% had 3; 35.3% had 2; 20.6% had 1; and 0% had none. It was concluded that CIBP patients do have abnormal physical findings indicative of musculoskeletal disease: possibly fibrositis and/or specific myofascial syndromes, as sources of peripheral nociception. These findings question the validity of the CIBP concept and point to the need for a careful, all-inclusive physical examination as a basic initial requirement in the classification of chronic pain patients.

Münchausen syndrome presenting with chronic pain: case report.

A factitious disorder is one that has been fabricated or simulated by the patient. Münchausen syndrome is a subtype of factitious disorder. This syndrome has not previously been described in relationship to chronic pain/chronic pain treatment units. Such a patient is presented, and the clues to the identification of this syndrome within chronic pain patients are presented.

Compensation and non-compensation chronic pain patients compared for DSM-III operational diagnoses.

Two hundred and eighty-three mixed chronic pain patients, consecutive admissions, were diagnostically evaluated as per DSM-III, Axis I, Axis II or personality type psychiatric operational criteria. Controlling for primary organic treatment diagnosis, age and race, statistical comparisons were made between male compensation patients (n = 93) and male non-compensation patients (n = 23) and between female compensation patients (n = 38) and female non-compensation patients (n = 28) for all DSM-III diagnoses. Male compensation patients were significantly overrepresented for these diagnostic groups: conversion disorder (somatosensory type); combined personality disorders; and passive-aggressive personality disorder. Male non-compensation patients were significantly overrepresented for these diagnostic groups: no diagnosis on Axis I; combined personality types; and compulsive personality type. Female compensation patients were significantly overrepresented for conversion disorder (somatosensory) only. Female non-compensation patients were significantly overrepresented for generalized anxiety disorder and combined anxiety syndromes. Compensation chronic pain patients may be at risk for some psychiatric disorders not previously identified: conversion disorder (somatosensory), and personality disorders.

Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria.

Two hundred and eighty-three chronic pain patients, consecutive admissions to the Comprehensive Pain Center of the University of Miami School of Medicine, received an extensive psychiatric evaluation based upon the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria and flowsheets. All patients received the following type of diagnoses: DSM-III axis I; DSM-III axis II, and personality type. The distribution of assigned diagnoses for the entire patient sample was reviewed and a statistical comparison between male and female patients was performed with regards to the prevalence of each diagnosis. Anxiety syndromes and depression of various diagnostic types were the most frequently assigned axis I diagnoses with over half the patient sample receiving each of these diagnoses. Males were significantly overrepresented in the axis I diagnoses of intermittent explosive disorders, adjustment disorders with work inhibitions, and alcohol abuse and other drug dependence, while females were significantly overrepresented in disorders of current depression of various diagnostic types and somatization disorders. 58.4% of the patients fulfilled criteria for axis II personality disorder diagnoses. The most frequently personality disorders found in the patient group were dependent (17.4%), passive aggressive (14.9%), and histrionic (11.7%). Males were significantly overrepresented in paranoid and narcissistic disorders while females were overrepresented in histrionic disorder. The most frequent personality types found in the patient group were compulsive (24.5%) and dependent (10.6%). All personality types were similarly distributed between the sexes. The results of the present study were compared to a previous study of DSM-III diagnoses in chronic pain patients and are discussed in terms of the prevalence of DSM-III diagnoses in the general population. Questions are raised as to the applicability of certain DSM-III diagnoses in the chronic pain population.