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BACKGROUND Pain is one of the most feared consequences of cancer and is experienced by up to 80% of patients with head and neck carcinoma (HNC). Pain in terminal HNC patients is common and often defined as severe. This study evaluated the effectiveness of the World Health Organization (WHO) analgesic ladder in the treatment of a cohort of terminal HNC patients. METHODS The authors prospectively evaluated 62 consecutive terminal HNC patients admitted to the Chaim Sheba Medical Center Tel Hashomer Hospice or the general hospital. Data pertaining to tumor origin, spread, treatment, and results were defined. Pain was assessed with the McGill Pain Questionnaire, using a 10-point visual analogue scale (VAS) and a body map. Pain was diagnosed according to cause and type. Treatment was selected according to the guidelines provided in the WHO analgesic ladder. RESULTS Only 10 patients suffered from pain that was not locoregional. The results of the VAS score were available in the first reading in all patients with pain (n = 48), with a mean of 4.7 (standard deviation [SD] ±2.0). A mean second VAS score obtained 72 hours after the first was 1.9 (SD ± 1.1). The difference between the two scores was statistically significant (P < 0.001). A third score was available for only 6 patients, with a mean of 1.6. Only 2 patients did not experience improvement of pain after 72 hours of treatment; both of these patients had bony involvement with tumor. Thirty-one patients (65%) were diagnosed with pain of nociceptive origin; these patients were categorized as having actual nociceptive pain (22), nociceptive nerve pain (6), or referred pain to the ear (3). Nonnociceptive pain of neuropathic origin was noted for only 6 patients (12.5%). Pain that could not be well defined but was responsive to opioid analgesic treatment was noted for 11 patients. A different form of non-cancer-related pain was noted for only one patient. CONCLUSIONS Patients were treated for pain according to the WHO analgesic ladder. They received adequate narcotic analgesics and supportive measures that allowed significant reduction of pain in nearly all cases, with acceptable side effects. Cancer 1997; 80:1117-23. © 1997 American Cancer Society.

It is important to consider a differential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD)-'Conversion Motor Paralysis'. Recent important medical literature concerning the accepted treatment and rehabilitation management will be reviewed and discussed. The inter-disciplinary in-patient team management approach in a rehabilitation setting offers the benefits of a comprehensive assessment and treatment. The diagnosis is temporary and conditional, since there may be a long delay until the appearance of organic findings. A complete medical assessment is essential in order to rule out any possibility of an organic etiology. In as many as 25% to 50% of patients diagnosed as conversion, an organic medical diagnosis was found.

Study design: We present our cumulative experience with patients sustaining the most dramatic type of Conversion Disorder (CD) – Conversion Motor Paralysis. Setting: Rehabilitation departments, Reuth Medical Center, Tel-Aviv and Sheba Medical Center, Tel-Hashomer, Israel. Methods: During the period 1973–2000, 34 patients with neurological symptoms without any anatomical or physiological basis were admitted to both rehabilitation departments. This number consists of less than 1% of the total acute traumatic and non-traumatic spinal cord disorders admitted annually to these centers. Results: Twenty-five of the subjects were men (mean age of 30 years) and nine were women (mean age of 31.4 years). Neurological symptoms included: paraplegia (complete or incomplete) (18), hemiplegia or hemi paresis (11), tetraplegia (complete or incomplete) (three), monoplegia (one), triplegia (one). The final diagnosis on discharge was CD in 30 of the 34 cases, the remaining four being diagnosed as malingering. Functionally, nine patients had a complete recovery, 10 a partial recovery and 15 remained unchanged. Conclusion: Disabled people who experienced traumatic events resulting in various disabilities are admitted usually to a rehabilitation center. However, some of them are later diagnosed as having Conversion Disorder or malingering. We believe that their participation in active regular and integrative rehabilitation process is beneficial to most of them. Most of these patients gain functional independence and return to the main stream of life.

The ratio of incidence to mortality is somewhat less than 3:1 for head and neck cancer, and the 5-year relative survival rate is 50%. Despite the high mortality rate, few reports have focused on patients with terminal head and neck cancer. A growing number of these patients end their lives in a hospice facility. A retrospective analysis was undertaken of 67 patients with terminal head and neck cancer who were admitted to the Tel Hashomer Hospice between 1988 and 1992. Patient data were reviewed and analyzed, and the particular characteristics of this population were defined. This study found that terminal head and neck cancer patients seem to receive better support in a hospice than in a general hospital or some family settings.