bluuebunny/crossref_metadata_2025 huggingface dataset:
The problem of suffering and the principles of assessment in palliative medicine
Authors: Cherny Nathan I.
Published: April 2015

Despite the advances of modern medicine, many illnesses continue to evade cure. Chronic, progressive, incurable illness is a major cause of disability, distress, suffering, and, ultimately, death. This is true for many causes of cancer, progressive neurological disorders, AIDS, and other disorders of vital organs. Progressive chronic diseases of this ilk are most common in late adulthood and old age, but they occur in all ages. When cure is not possible, as often it is not, the relief of suffering is the cardinal goal of medicine. The clinical imperative to relive suffering requires a nuanced understanding of the factors that contribute to suffering and the interaction between the distress of the patient, family members, and health-care providers. This chapter reviews those concepts and offers an approach to the evaluation of suffering for patients requiring palliative care.
The economic challenges of palliative medicine
Authors: Smith Thomas J. , Cassel J. Brian
Published: April 2015

The compelling reasons for palliative care continue to be better symptom management, better advanced care planning and medically appropriate goal setting, and transitions to hospice care. Other new-found compelling reasons include better survival with hospice care, better survival with concurrent palliative care, and lower cost to hospitals and government and insurance funders. In studies to date, hospice and palliative care have been associated with equal or better survival and equal or lower cost. This chapter defines the various types of cost and clinical studies (including cost minimization, cost-effectiveness, cost utility analysis, cost-benefit, cost avoidance) and discusses the available data about the economic challenges of palliative care, how to apply the available data, how to collect and present some useful and useable data, and new directions for research.
Barriers to the delivery of palliative care
Authors: Laird Barry J.A.
Published: April 2015

This chapter discusses several key barriers to the delivery of palliative care, firstly considering the definition of ‘palliative care’. It describes the World Health Organization (WHO) definition and notes that the ideology of palliative care being a concept with which to approach management of patients may still not be fully understood. Furthermore, the differences between generalist and specialist palliative care may also contribute to confusion. Although palliative care as a concept has largely been embraced throughout the world, its implementation into routine clinical care is lacking. Essential to the change from palliative care being a principle available to the few, to being available to all, and a human right, is the need to address the many barriers to the efficient and effective delivery of high-quality palliative care. The chapter argues that the WHO is the key group necessary to develop palliative care worldwide and, together with international palliative care organizations, to help countries advance palliative care services.
Palliative care delivery models
Authors: Higginson Irene J.
Published: April 2015

Palliative care is not integrated into health care in many countries, with a network of services, a medical speciality or sub-speciality, and academic departments. A common distinction exists between generalist and specialist palliative care. Specialist service are dedicated to palliative care, have staff trained in it, and in addition to providing clinical care, engage in education, research, and the measurement of outcomes. Moreover, the patients they care for have more complex needs. Models of service delivery include inpatient palliative care units and hospices, consultation teams (at home, in the community, and in hospitals), day care units, and outpatient services. New models include short-term palliative care services, working in an integrated way with other services. Principles common to all services include a holistic approach (physical, emotional, social, and spiritual), considering the patient and family as the unit of care, and with impeccable attention to listening, communication, and individualized care.
Nursing and palliative care
Authors: Sherman Deborah Witt , Free David C.
Published: April 2015

Nurses, who are educated in palliative care nursing, facilitate the caring process through a combination of science, presence, openness, compassion, mindful attention to detail, and teamwork. As members of the interdisciplinary palliative care team, nurses bring specialized competence and expertise gained through education, credentialing, and experience. With close to 19.4 million nurses globally, nurses have a tremendous potential to reform health care and ensure quality care for seriously ill patients and their families. Through the integration of empirical, aesthetic, personal, and ethical knowledge at the generalist or advance practice levels, nurses reshape societal perspectives regarding illness, dying, and death. By virtue of their numbers, experience, education, time spent at the bedside, and insight into the lived experiences of patients and families, nurses have the potential to play a prominent role in as public health advocates for palliative care at the local, national, and global level.
Communication with the patient and family
Authors: LeBlanc Thomas W. , Tulsky James A.
Published: April 2015

High-quality palliative medicine depends upon communication that is patient-centred, clear, and attends to the central role of emotion in the medical encounter. Good communication leads to a number of improved outcomes including greater adherence to therapy, higher patient satisfaction, decreased anxiety and depression, and care that is more consistent with patients’ goals. Unfortunately, in practice, communication frequently does not meet these standards and opportunities are lost to meet patients’ most basic needs. That said, good communication can be deconstructed and conceptualized as a series of discrete behaviours and skills including assessing patient understanding before entering into difficult conversations, asking permission to discuss tough topics, delivering information in small manageable chunks while checking for understanding, responding to patients’ emotions, eliciting patients’ values, and aligning treatment preferences to their goals. Specific techniques and cognitive roadmaps exist to help navigate these conversations and ought to be in the toolbox of every palliative care clinician.
Talking with families and children about the death of a parent
Authors: Lloyd-Williams Mari , Ellis Jackie
Published: April 2015

Patient and provider outcomes are significantly related to the effectiveness of interprofessional communication Good interprofessional communication includes adopting an attitude of curiosity, recognizing that communication happens at several levels simultaneously, and acknowledging the importance of skilful conflict management. Barriers to good communication among interdisciplinary team members include team organization, provider hierarchy, and professional identity. Optimal communication among palliative consultants and other clinicians requires expert consultation etiquette, and overcoming particular challenges faced by palliative care consultants including the high emotion often accompanying palliative care consultations and the often contrasting assessment of the patient’s needs by the consulting and referring clinicians. The chapter describes how to use structured communication tools, designated forums for discussion, flattened hierarchy, and an open, no-fault culture, along with five core principles for good communication in palliative care consultation: curiosity, humility, transparency, clarity, and judiciousness. Palliative care plays a key role in optimizing interprofessional communication.
Communication between professionals
Authors: deLima Thomas Jane , Moment Amanda , Abrahm Janet , Fitzgerald Katie
Published: April 2015

This chapter discusses the importance of communication between professionals in palliative care. It begins by describing the evidence base that shows that patient and provider outcomes are significantly related to the effectiveness of interprofessional communication. Next it outlines the principles of good interprofessional communication including the importance of adopting an attitude of curiosity, recognizing that communication happens at several levels simultaneously, and acknowledging the importance of skilful conflict management. The following section on communication among members of an interdisciplinary team (IDT) reviews the barriers to good IDT communication, including team organization, provider hierarchy, and professional identity. The next section on communication between palliative consultants and other clinicians discusses consultation etiquette and its evidence base; highlights some of the particular challenges faced by palliative care consultants; and describes strategies for good communication in palliative care consultation. The chapter concludes with a description of future directions in the study and promulgation of interprofessional communication and the role that the field of palliative care can play.
Communications with the public, politicians, and the news media
Authors: Ashpole Barry R.
Published: April 2015

In many countries, the philosophy and practice of palliative medicine is being embraced well beyond the care and support for those living with a terminal illness. This stage in palliative medicine’s evolution is running parallel with a growing elderly population (a global trend), a corresponding increase in the incidence of chronic or long-term illness, and the fiscal challenge facing many governments in sustaining current levels and standards of health care while, at the same time, projecting future demands on both health and social services. This chapter discusses the prevailing communications environment, the language of end-of-life care in public discussion, and engaging in a dialogue with politicians and the news media. Offered is a preparedness plan to enhance existing communications skills and to also assist health professionals in general to engage in advocacy-to facilitate and focus public discussion, and to inform the decision- and policymaking processes.
The measurement of, and tools for, pain and other symptoms
Authors: Ingham Jane M. , Moore Helen M. , Phillips Jane L. , Portenoy Russell K.
Published: April 2015

Symptom assessment is an essential element of good clinical care as it is a key step in the diagnostic process and in the development and implementation of a management plan aimed towards reducing illness burden and suffering. Furthermore, symptom assessment is crucial for testing of therapeutic interventions in clinical research particularly in palliative care research. A number of important factors must be considered, including the subjective nature of symptoms and subtle differences in meaning of symptom descriptors. To aid symptom assessment, an array of instruments has been validated for various symptoms and various patient populations. Instrument selection must be guided by an understanding of the goals of assessment and the practicality, applicability, acceptability, and validity of the instrument in the particular setting and population. This chapter addresses the complexities of symptom assessment and provides an overview of some of the available symptom instruments for consideration for use in palliative care settings.
Validated assessment tools for psychological, spiritual, and family issues
Authors: Emanuel Linda L. , Powell Richard A. , Handzo George , Michelson Kelly Nichole , Dhingra Lara
Published: April 2015

Palliative care has a foundational commitment to integrate attention to psychological, spiritual, and family issues with biomedical matters. This requires being able to measure them. A limited number of assessment tools have been subjected to validity studies. Many measures are for service assessment, including assessments made as part of quality improvement; but a range of rigorously developed measures, including patient-reported outcome measures, is available. Those that are multidimensional and feasible in the real world of patient care are fewer. Domain-specific screening and measurement tools that focus on depression, anxiety, and a more generalized state of psychological distress as well as spirituality are described. Additional tools for measuring delirium and adjustment disorders or grief and bereavement are referenced. While rigorous, comprehensive family assessments and measures are not available, multiple measures that focus on particular aspects of family need and function are described.
Fatigue and asthenia
Authors: Yennurajalingam Sriram , Bruera Eduardo
Published: April 2015

Fatigue is the most frequent, complex, multidimensional, and debilitating symptom in patients with advanced medical conditions. In the majority of palliative care patients, the aetiology of fatigue is multifactorial and the most common factors associated with fatigue include anorexia/cachexia, anxiety, depression, shortness of breath, sleep disturbances, anaemia, and inflammation. Routine screening for fatigue is essential for optimal assessment of fatigue and history and investigations should always be individualized. Management should initially aim towards identification and treatment of the reversible/underlying causes; however, if there are no reversible causes identified or if the fatigue is not responsive to specific treatments, symptomatic treatment should be considered. For optimal management the multidimensional components of fatigue should be assessed and future research is needed on the use of non-pharmacological treatment such as physical activity, counselling, and/or pharmacological agents such as a trial of psychostimulants or short course of corticosteroids.
Dyspnoea and other respiratory symptoms in palliative care
Authors: Chan Kin-Sang , Tse Doris M.W. , Sham Michael M.K.
Published: April 2015

Dyspnoea is prevalent among palliative care patients with increased severity over time. There are two patterns of dyspnoea-breakthrough dyspnoea and constant dyspnoea-and three separate qualities of dyspnoea-air hunger, work or effort, and tightness. The measurement of dyspnoea includes three domains: sensory-perceptual experience, affective distress, and symptom impact. The management of dyspnoea includes specific disease management, non-pharmacological intervention, pharmacological treatment, and palliative non-invasive ventilation. Cough is prevalent and disturbing in patients with cancer and chronic lung diseases, and is often associated with airway hypersecretion and impaired mucociliary clearance. Management includes specific treatments for underlying non-cancer and cancer-related causes, symptomatic treatment by antitussives, mucoactive agents, and airway clearance techniques for expectoration and reduction in mucus production. Anticholinergics may be indicated for death rattles to facilitate a peaceful death. Haemoptysis occurs in 30-60% of lung cancer patients and initial management of haemoptysis includes airway protection and volume resuscitation. Localization of the site and source of bleeding may determine the choice of treatment. If a life-threatening haemoptysis occurs, sedation should be given as soon as possible. Support should be given to the family, and debriefing provided to team members.
Oral care
Authors: Davies Andrew N.
Published: April 2015

Oral problems are common in patients with advanced cancer as well as in other groups of patients with life-limiting illnesses (and more generally in patients with chronic illness). Oral problems may be related to direct (‘anatomical’) effect of the primary disease, indirect (‘physiological’) effect of the primary disease, treatment of the primary disease, direct/indirect effect of a coexisting disease, treatment of the coexisting disease, or combinations of these factors. The successful management of oral problems involves adequate assessment, appropriate treatment, and adequate re-assessment. In some cases the most appropriate treatment for a patient with advanced cancer is the same treatment that would be given to a patient with early cancer (or no cancer). Thus, intensive treatment of the oral problem often results in the best palliation of the oral problem. It is not justified to withhold treatment on the grounds that the patient has advanced cancer; however, it may be justified to amend treatment (when appropriate).
Sleep disorders
Authors: Mystakidou Kyriaki , Panagiotou Irene , Parpa Efi , Tsilika Eleni
Published: April 2015

Sleep disturbances represent frequent distressing symptoms in the palliative care setting. The more common disorders include insomnia, excessive daytime sleepiness, and circadian rhythm sleep disorders. The most prevalent sleep disorder, insomnia, includes difficulty initiating and/or maintaining sleep, waking up too early, and non-restorative or poor quality sleep. Primary sleep disturbances are thought to be a disorder of hyperarousal, while a hypothalamic-pituitary-adrenal axis dysfunction has also been confirmed. Secondary sleep disorders have been associated with a large number of potential causes, both physical and psychological. Sleep disturbances in palliative care can be due to either the advanced disease and/or its treatment. Chronic medication use, neurological or psychiatric disorders, as well as environmental factors, can also present contributing factors. This chapter discusses the diagnosis and treatment of sleep disturbances, both pharmacological and non-pharmacological, including cognitive behavioural therapy, the cornerstone of non-pharmacological interventions.
Principles of drug therapy: focus on opioids
Authors: Branford Ruth , Wighton Emily , Ross Joy
Published: April 2015

Key principles of clinical pharmacology inform prescribing in palliative care. The use of opioid therapy for pain in populations with serious medical illness exemplifies the relevance of these principles. Concepts include the differences among efficacy, effectiveness, and cost-effectiveness; the nature of a benefit-to-risk analysis; and the meaning of pharmacokinetic variation and pharmacokinetic-pharmacodynamic relationships. This information complements related information about opioid therapy, including best practices during routine care and the role of opioid switching, opioid abuse, and opioid prescribing at the end of life. More extensive information about general pharmacology is available in comprehensive pharmacology textbooks.
Human rights issues
Authors: Brennan Frank , Gwyther Liz
Published: April 2015

Despite significant advances, there are major deficits in the provision of palliative care throughout the world. Issues including inadequate access to essential medications, lack of education of health professionals, absent national policies on palliative care and pain management, poverty, lack of infrastructure, and social and political dislocation all challenge this provision. One response to these deficits has been advocacy stating that palliative care is a basic human right. This chapter examines the history and foundations of this concept, the response of the United Nations and other international bodies, and the practical ways a human rights approach can advance advocacy for, and the provision of, palliative care.
Euthanasia and palliative care
Authors: Materstvedt Lars Johan , Bosshard Georg
Published: April 2015

This chapter focuses on the particular relationship and interconnections between euthanasia and palliative care. Selected key data on assisted dying are presented. Of central importance is the question of how requests for assisted dying should be handled within palliative care, and as part of addressing this question the chapter includes a discussion of the practice in Belgium, where euthanasia is performed within palliative care institutions. Furthermore, the chapter presents the Swiss model, which practises a much clearer separation between assisted dying and both palliative care and clinical medical practice. Statements on assisted dying made by key palliative care organizations are then presented and analysed. The chapter asks whether the palliative care community will be more accepting of euthanasia in the future, following potential new legislation. The concluding remarks consider the current reluctance of doctors to participate, and the pressures they are under to accept a role, in assisted dying.
Disease-modifying therapies in advanced cancer
Authors: Schrijvers Dirk
Published: April 2015

In many situations, anti-cancer therapies may be critical components of a palliative care plan to optimize patient comfort, function, quality of life, and duration of survival. Optimal care often requires the integration of oncological and palliative care and it is important for palliative care clinicians to be familiar with oncological approaches to improve patient well-being, and also the limitations of such approaches. This integrative role requires that palliative care clinicians have a basic literacy regarding anti-cancer therapies and that they be familiar with information resources to update them on new and developing therapeutic options which may be of benefit to their patients.
Cancer-induced bone pain
Authors: Colvin Lesley A. , Fallon Marie
Published: April 2015

Bone is the third most common site of metastatic disease, after liver and lung, with approximately 75% of these patients suffering from related pain. Cancer-induced bone pain (CIBP) is a major clinical problem, with limited options for predictable, rapid, and effective treatment for some of the elements without unacceptable adverse effects. Our understanding of how current therapy acts is based mainly on studies in non-cancer pain syndromes, which are likely to be quite different, not only in clinical presentation, but also in terms of pathophysiology. It can be difficult to study the specific neurobiological changes associated with CIBP, although development of laboratory models of isolated bone metastases has allowed more specific study of pain mechanisms in this syndrome. In order to evaluate our current therapies properly and direct the development of new therapies logically, it is important to understand the underlying mechanisms of CIBP. This chapter discusses pain processing and the mechanisms and management of CIBP.
Management issues in neuropathic pain
Authors: Finnerup Nanna Brix , Jensen Troels Staehelin
Published: April 2015

Neuropathic pain is a common complication to cancer, cancer treatment, HIV, and other conditions that may affect the somatosensory nervous system. Neuropathic pain may be present in up to 40% of cancer patients and may persist independently of the cancer and affect the quality of life in disease-free cancer survivors. Particular surgical treatment and chemotherapy may cause chronic persistent neuropathic pain in cancer survivors. The diagnosis of neuropathic pain can be challenging and requires documentation of a nervous system lesion and pain in areas of sensory changes. The pharmacological treatment may include tricyclic antidepressants, selective serotonin noradrenaline reuptake inhibitors (duloxetine or venlafaxine), calcium channel α‎2↓ agonists (gabapentin or pregabalin), and opioids. Topical lidocaine and capsaicin, NMDA antagonists, carbamazepine, oxcarbazepine, and cannabinoids may be indicated. Due to limited efficacy or intolerable side effects at maximal doses, combination therapy is often required and careful monitoring of effect and adverse reactions is important.
Caring for the patient with advanced chronic obstructive pulmonary disease
Authors: Rocker Graeme M. , Michaud-Young Joanne , Horton Robert
Published: April 2015

The global prevalence of chronic obstructive pulmonary disease (COPD) is high and rising. Patients and families living with advanced disease often experience biopsychosocial symptom burdens over a long trajectory, leaving them housebound when they require support the most. Current models of care, by placing a disproportionate focus on the provision of acute and facility-based services, do little to address the complex needs of those vulnerable patients and families who struggle to easily access primary care services. This chapter provides an overview of conventional COPD treatments and highlights some newer understandings and management approaches for patients living with high symptom burden despite optimized conventional treatments, including the use of opioids. It provides some concrete examples of models of care that employ interventions and holistic approaches to care that can improve patient and family outcomes. The move towards an integrated care approach to COPD will help patients and their families reach informed decisions about their care throughout the trajectory of COPD.
Advanced heart disease
Authors: Pantilat Steven Z. , Steimle Anthony E. , Davidson Patricia M.
Published: April 2015

Heart disease is the leading cause of death in the developed world and causes significant morbidity and repeated hospitalization. Optimal medical management and targeted use of devices can improve survival and quality of life for people with heart failure (HF). Despite optimal management of HF symptoms including breathlessness, pain, fatigue and oedema may persist and palliative care interventions may be needed. Palliative care specialists must be aware that referral to HF specialists may be necessary for patients with advanced HF. The risk of sudden death at every stage of HF means that palliative care treatments should be integrated into care for all patients. Palliative care should enhance communication among clinicians and with the patient and family, and should provide options for treatment of symptoms and deactivation of devices. Integrating palliative care alongside HF care can increase quality of life, decrease suffering and health-care costs, and improve quality of care.
Sedation at the end of life
Authors: Krakauer Eric L.
Published: April 2015

Palliative sedation is a well-accepted therapy that should be considered in the rare situations when a terminally ill patient whose overriding goal is comfort experiences severe suffering that is refractory to all available standard palliative interventions. Typically, such suffering is caused by physical or neuropsychiatric symptoms such as pain, dyspnoea, vomiting, seizures, agitated delirium, anxiety, or depression. The level of sedation should be proportional to an individual patient’s suffering and should be just deep enough to provide the desired relief. In some cases, sedation to unconsciousness is necessary. The intention of palliative sedation should be only to relieve suffering, never to hasten death. Informed consent must be obtained, and clinicians should demonstrate their intentions by documenting the regimen used and the patient’s response. Ideal medications have a rapid onset of action and a short duration of action that facilitate titration to the desired effect. The best agents are barbiturates such as pentobarbital and anaesthetic induction agents such as propofol.
Research in palliative care
Authors: Kaasa Stein , Forbes Karen
Published: April 2015

Research in palliative care is essential for maintaining standards and advancing knowledge and improving practice. It is challenging, sometimes daunting, often frustrating, but always exciting and rewarding when a study is successfully completed, whether the outcome is positive or negative. This chapter discusses a wide range of topics that will help those who are new to research to get started, to proceed and complete it, and contribute to improving outcomes for patients with advanced disease. Topics include, among others, collaborative and translational research, research governance, controlled clinical trials, evidence-based palliative care, and trial planning (including methodology, randomization, statistical considerations, protocol, access to patients, finance, administration, monitoring, and publication).
Clinical audit in palliative medicine
Authors: Higginson Irene J.
Published: April 2015

Audit approaches and methods are now well advanced in palliative care, especially in clinical audit. This chapter discusses these approaches and methods, and addresses such questions as ‘Why perform clinical audit in palliative medicine?’ and ‘How do we assess the quality of palliative care?’ It discusses the evolving terms of audit, quality improvement, and governance, and how to apply clinical audit to palliative medicine. Audit requires resources, and so it must be sure to benefit patients and families, be kept as simple and efficient as possible, and have a strong educational component. There is also a need to develop and test methods of audit in developing countries. If palliative approaches extend backwards to include patients earlier in care, rather than those just near to death, then the audit could become a means for clinical dialogue and education between specialties.
Constipation and diarrhoea
Authors: Sykes Nigel P.
Published: April 2015

Constipation is far more common in palliative care than diarrhoea and results not just from the use of opioids but also from the multifactorial effects of debility secondary to disease. Most palliative care patients will require regular administration of an oral laxative in a dose titrated against response, with the aim of avoiding the use of suppositories or enemas if possible as these are less liked. The lack of clear differences in laxative efficacy means that cost and patient choice are key factors in guiding treatment. Diarrhoea in palliative care most often results from excess laxative or from common infections that can be simply managed. Bowel shortening or diversion causes more resistant diarrhoea. Cytotoxic chemotherapy can lead to diarrhoea either as an adverse effect of treatment or from potentially life-threatening neutropenic colitis.
Stoma therapy in palliative care
Authors: Barr Jane Ellen
Published: April 2015

Patients with ostomies, wounds, or incontinence in the setting of a serious or life-threatening illness experience numerous challenges, including distress related to pain and other symptoms, psychological disturbances, and family concerns. Expert management of these conditions and their many complications is an essential part of a comprehensive palliative plan of care. In many countries, nurse specialists with advanced training in the management of ostomies, wounds, or incontinence are available as consultants or as members of a specialist palliative care team. These professionals can improve health care and quality of life for selected patients across venues of care that include hospital, home, long-term care, hospice, and specialized settings. If a stoma nurse specialist is available, he or she may have a key role in directing decision-making and care management related to these problems, evaluating and controlling symptoms that cause patients and families suffering, and providing psychosocial and spiritual support.
Burnout, compassion fatigue, and moral distress in palliative care
Authors: Cherny Nathan I. , Werman Batsheva , Kearney Michael
Published: April 2015

Clinicians involved in the provision of palliative care constantly confront professional, emotional, and organizational challenges. These challenges can make clinicians vulnerable to experiencing one or more of three well-described interrelated syndromes-burnout, compassion fatigue, and moral distress-each of which can lower the threshold for the development of the others. Burnout results from stresses that arise from the clinician’s interaction with the work environment, compassion fatigue evolves specifically from the relationship between the clinician and the patient, and moral distress is related to situation in which clinicians are asked to carry our acts that run contrary to their moral compass. Clinicians who care for dying patients are at risk of all of these and it is vital that palliative care clinicians are aware of these potential problems and with strategies to mitigate risks and to manage them when they present either in their own individual lives or in the work environment.
Rehabilitation medicine approaches to pain management
Authors: Cheville Andrea L. , Basford Jeffrey R.
Published: April 2015

Pain is a frequent but poorly controlled aspect of cancer and other medical conditions which may, in part, stem from the clinician’s lack of understanding of its severity or impact. However, even with the best of care, current approaches are associated with poorly tolerated side effects and frequently fall far short of complete control. Rehabilitation medicine has developed strategies that may reduce pain in general, but are particularly targeted to movement-related pain. These approaches can be grouped into four general categories: (1) modulating nociception, (2) stabilizing and unloading painful musculoskeletal structures, (3) influencing pain perception, and (4) alleviating musculotendinous pain. This chapter reviews each of these categories in detail and offers examples to illustrate their clinical application. It will be noted that the majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.
An interdisciplinary approach to neurological rehabilitation
Authors: Wade Derick
Published: April 2015

People with neurological disability present healthcare systems with a large range of complex problems covering many different domains and often lasting a long-time. Consequently, they need a large range of different professional staff, often from different organizations. These people will be considering different, small parts of the overall set of difficulties. In order to ensure both that all problems are considered and that all those involved work in an efficient and effective way one should have a system of cooperation and collaboration. The key features are that the group should work within an agreed model of illness, the biopsychosocial model of illness, using a patient-centred goal-setting process. For this to work effectively people need to work with a consistent set of colleagues, and within a single managerial and budgetary organization based in a single geographical place. This chapter describes an interdisciplinary team approach to neurological rehabilitation.
Spinal neuronal dysfunction after deprivation of supraspinal input
Authors: Hubli Michèle , Dietz Volker
Published: April 2015

The comprehension of basic spinal neuronal alterations after central nervous system lesions, such as spinal cord injury (SCI) or stroke, enables us to optimize rehabilitative approaches for affected subjects. Adverse changes in spinal neuronal function are best investigated by recordings of spinal reflexes (SR) and locomotor electromyography (EMG). In the first few weeks after an SCI, neither locomotor nor SR activity can be evoked. Once spinal shock has resolved, an early SR component can be re-evoked and locomotor EMG activity reappears in response to appropriate peripheral input. In a more chronic stage of SCI, however, alterations in SR components are accompanied by a decline of EMG amplitude in the leg muscles during assisted locomotion. It is assumed that not only the deprivation of supraspinal input but also of the lack of meaningful proprioceptive input to spinal neuronal networks account for such alterations in chronic immobilized individuals with SCI..A critical combination of sensory cues through appropriate training strategies seems to prevent the development of spinal neuronal dysfunction and to improve locomotor ability.
Animal models of damage, repair, and plasticity in the brain
Authors: Luft Andreas
Published: April 2015

Recovery after a stroke is a multidimensional process depending on the individual deficit. Within each functional domain, spontaneous recovery occurs to a variable degree and can be improved by specific neurorehabilitative interventions. The knowledge about the neurophysiology of the processes that lead to recovery and render neurorehabilitative interventions effective is scarce. Such knowledge, however, would be necessary to find new treatments that can fully exploit the brain’s capacity for recovery. Animal models can be an experimental platform to investigate these mechanisms. But it has to be realized that they oversimplify the human condition. The complexity of motor, cognitive, social, emotional, and other factors contributing to recovery in humans cannot be modelled in animals. The opportunities and caveats of animal models are discussed.
The role of neuroimaging in understanding the impact of neuroplasticity after CNS damage
Authors: Ward Nick
Published: April 2015

After stroke, there is little restitution of neural tissue, but reorganization of surviving neural networks appears to be important for recovery of function. Non-invasive techniques such as functional magnetic resonance imaging and magnetoencephalography allow some aspects of this brain reorganization to be studied. For example, early after stroke there appears to be an upregulation in task-related activity, which diminishes with time and recovery. Those with the most complete recovery tend to have the most ‘normal’ activation pattern, and those with less complete recovery tend to rely on additional brain regions. This reorganization is functionally relevant. Advances in functional neuroimaging allow the study of alterations in connections between brain regions. Understanding how brain organization is related to anatomical damage, as well as impairment and recovery that can take place over weeks and months following stroke opens the way for functional brain imaging to become a clinically useful tool in rehabilitation.
Rehabilitation of gait and balance after CNS damage
Authors: Duysens Jacques , Verheyden Geert , Massaad Firas , Meyns Pieter , Smits-Engelsman Bouwien , Jonkers Ilse
Published: April 2015

This chapter discusses the importance of basic and clinical science for the rehabilitation of patients with stroke or SCI (spinal cord injury). Examples are given from novel approaches in rehabilitation. Insights can be obtained by investigating normal locomotor or postural activity but it is argued that the use of more challenging locomotor tasks can provide much needed additional information. To update rehabilitation tools it is also essential to keep track of new technological developments and new assessment tools. Careful assessments, based on advanced 3-D recordings of posture and gait, can assist in making proper decisions about planned interventions, aimed at alleviating some clinical symptoms such as spasticity. With respect to training, the focus here is on general principles of sensorimotor rehabilitation of gait and posture. Learning is context dependent. The consequence is that current rehabilitation approaches need to emphasize that training should be ‘task-oriented training’, and should involve the whole body.
Neurorehabilitation approaches for disorders of the peripheral nervous system
Authors: Huynh William , Lee Michael , Kiernan Matthew
Published: April 2015

Disorders of the peripheral nervous system comprise both traumatic and non-traumatic aetiologies that may involve different levels in the spinal cord, emerging spinal nerve roots, brachial or lumbosacral plexus, to the peripheral nerves. Lesions can be focal, as in most cases of traumatic aetiology, or multifocal or generalized as commonly seen in non-traumatic causes. Current rehabilitative strategies aim at reversing the underlying cause of the nerve lesion, whilst at the same time, treating the symptoms, and preventing complications. More specifically, the emphasis of rehabilitation is to maximize functional independence, locomotion, prevent physical deformity, facilitate integration into society, and overall, improve quality of life. This chapter provides a basic understanding of the pathophysiology of neurological deficits associated with lesions of the peripheral nervous system, followed by a systematic discussion of the general principles. The aim is to provide the healthcare professional with a template and practical approach to the delivery of such therapy.
Neuropsychological rehabilitation of higher cortical functions after brain damage
Authors: Ptak Radek , Schnider Armin
Published: April 2015

Neuropsychological interventions for impairments of higher cognitive functions can be divided into four approaches:�restoration of function, compensation, physiological stimulations, and metacognitive strategies. Training that aims to restore an impaired function or to increase processing speed or capacity is repetitive and highly stereotyped. For some cognitive domains (such as memory), restoration of function is mostly impossible; consequently, training mainly relies on compensatory strategies. A�third type of approach is applied in neglect rehabilitation and uses physiological stimulations to bias attention and sensory representations or decrease interhemispheric inhibition. Finally, the fourth approach is to structure behaviour and to enhance metacognitive abilities, and is applied in the rehabilitation of complex problem-solving skills and impaired emotional regulation. Although it is difficult to control experimental biases in intervention studies targeting cognitive and behavioural disturbances, an increasing number of controlled clinical trials provide evidence for the efficacy of each of the four therapeutic approaches.
The impact of fatigue on neurorehabilitation
Authors: Welch Killian , Mead Gillian
Published: April 2015

Fatigue is a common problem in neurological disease and associated with substantial disability.Though there is overlapping symptomatology, it is distinguishable from sleepiness, apathy and depression.Convergent data across neurological conditions suggest dysfunction in the striatal-thalamic-frontal system is important in fatigue.This commonality provides some justification for extrapolating data on treatment efficacy from one condition to another. Treatment of fatigue should begin with consideration of all contributing factors, best achieved through a ‘formulation’ approach.Potential causes of fatigue such as medical comorbidity, medication side effects, depression/anxiety, and substance misuse must first be identified and addressed.Once done, across neurological conditions exercise has the best evidence for treatment.Sensibly planned aerobic exercise is safe and should be encouraged in all patients.Cognitive behavioural therapy has reasonable evidence, but availability is limited.Evidence for pharmacological treatments is weak, but amantadine and modafinil are commonly used.
Promises and challenges of neurorehabilitation technology
Authors: Rymer William , Jayaraman Arun
Published: April 2015

There has been a substantial increase in the number of different technologies that are being used in rehabilitation hospitals and clinics to help therapists and physicians improve recovery of upper or lower extremity function in patients who have sustained a severe neurological injury. These technologies include robotic devices, electrical stimulation systems, wearable sensors, and virtual reality training systems. Although initial enthusiasm for the role of these technologies was high, some of this enthusiasm has now abated, because the therapeutic benefits of these systems has been less dramatic than initially anticipated. This chapter examines some of the reasons for this reduction in enthusiasm, and potential reasons why technological approaches have not been more successful in the clinical application of these robotic systems. Finally, the chapter explores ways in which some of the observed performance limitations can be circumvented, leading potentially to more effective therapies in the near future.
Enhancing independent community access and participation: services, technologies, and policies
Authors: Luc Noreau , Edwards Geoffrey , Boucher Normand , Routhier Francois , Vincent Claude , Gascon Hubert , Fougeyrollas Patrick
Published: April 2015

This chapter examines three aspects of the community access issue: access to services, the value of both existing and emerging technologies, and social and economic policy-making. In addition to an efficient rehabilitation process focusing on physical and mental capabilities, enhancing community access and social participation will require the optimization of access to services. Key concepts in this regard include the notion of support both for individuals and their families. Technologies that enhance mobility, communication, and home adaptation also play an increasingly important role. While they are essential to compensate for various forms of disabilities, the current rapid evolution of technologies does not allow adequate efficacy testing, limiting the establishment of best practices or recommendations regarding these products and often overestimating their benefits. Finally, better community access and participation should not be based on a culture of disability but a culture of ‘ability’ that impacts all citizens.
Neurocytology
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

There are two major cell types that form the nervous system: the supporting cells and conducting cells. The majority of the organelles seen within these cells are similar to those seen in other tissues. The supporting cells in the peripheral nervous system consist of Schwann cells and fibroblasts. The supporting cells in the central nervous system consist of glia, lining cells of ventricles, the cells that form the meninges, the circulating blood cells, and the endothelial lining of the blood vessels. The supporting cells are constantly being replaced, while the vast majority of the conducting cells/neurons, once formed, remain with us throughout our lives.
Atlas of the Spinal Cord
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

We review the organization of the spinal cord by describing the contents of four different major levels of the spinal cord—the sacral, lumbar, thoracic, and cervical—and their functions. We discuss organization within the tracts, crossing of the tracts, the major ascending tracts (spinothalamic, medial lemniscus), and the major descending tract (corticospinal) within the spinal cord.
A Survey of Diseases of Peripheral Nerve and Nerve Root
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

This is a review of the major disease in the peripheral nerve and nerve root. It first reviews the contents of the cervical, brachial, lumbar, and sacral plexus and then discusses mononeuropathy of the lower and upper extremity and then polyneuropathies, including a discussion on the sciatic nerve and disorder of the nerve root.
Brain Stem
Authors: Marcus Elliott M. , Jacobson Stanley , Sabin Thomas D.
Published: April 2015

Disease in the brain stem is divided into extrinsic and intrinsic disease. Extrinsic disease originates from tumors in the cerebellar pontine angle, jugular foramen, in the cerebellum, or the tentorium of the meninges. Intrinsic disease can be cause by many vascular syndromes associated with the brain stem, which produce intrinsic disease, including aneurysms and ischemic-occlusive disease of the basilar-vertebral arteries. There are also intrinsic tumors and demyelinating disease which affect the brain stem.