Archive for the ‘Medical Info’ Category
Neuroscience and chemobrain
Posted on: March 17, 2012
The after-effects of chemo on brain function can be permanent. I just read a study on people ten years after chemotherapy comparing them to random population controls on neuropsychological tests. The effects seems to mirror the condition of patients just finishing chemo.
What can be done?
Assessment by a neuropsychologist looks at things such as attention, new learning, organization and memory. The treatments are called cognitive remediation or cognitive rehabilitation. That is, I’m guessing, working with techniques to help work with the ongoing condition. Some symptoms can be helped with medications.
The problem is a dysfunction of frontal-subcortical networks which can interfere with reasoning, decision-making, resource allocation, processing speed, inhibition, and goal-oriented behaviors. Some people have memory problems.
For me the memory is fine, as are all the other functions, it just is harder to concentrate.
Sources
Neuropsychological Performance in Survivors of Breast Cancer More Than 20 Years After Adjuvant Chemotherapy, Vincent Koppelmans et al., Journal of Clinical Oncology, Feb 27, 2012
Neuropsychological Consequences of Cancer and Cancer Treatment, Jacob Keane, Dona Locke, Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders December 2008 vol. 18 no. 4 144-151
Behind the fatigue
Posted on: February 17, 2012
- In: Medical Info | Nutrition
- 2 Comments
A documentary on the teenage brain discussed dopamine, explaining that this neurotransmitter is at the root of our motivation and stimulates feeling good with accomplishment and bad feelings when you fail.
I realized that this system may be messed up for me right now, even more so than it was after my first round of cancer treatments in 2001. So many people seem to get back to feeling OK within weeks or months of treatments ending. Both times, for me, it continued to a debilitating extent for over a year.
I have two problems right now: I need to nap twice a day for a total of about 2 hours. In between the naps, most days I’ve been unable to concentrate with that “I just woke up” feeling that won’t go away for any reason. I generally am very energetic and curious and always busy and find it reasonably easy to do whatever I set my mind to. None of that is working right now. In the past six weeks especially I’ve not felt like doing much of anything. Talk about boring. It is hard to say when this started. I’ve had problems since the first radiation two years ago. It seems worse now, since I am now free of the debilitating pain and done with all harsh treatments. Recovery should be mostly done, yet I’m feeling as if I am home sick without any symptoms other than being wiped out.
I did some research. There is next to nothing in research specifically related to dopamine and effects of cancer treatments. There are some links with dopamine levels and chronic pain.
Dopamine levels can be reduced after stress. Four big surgeries, two rounds of radiation and 12 weeks of chemotherapy count as stressors, yet there is very little information I can find on any research about dopamine levels post-cancer treatment.
Symptoms of low dopamine include:
- feeling depressed, flat, bored, apathetic
- lowered physical or mental energy.
- drive, enthusiasm and motivation decreased.
- difficulty concentrating, poor attention and focus.
- low feelings of of satisfaction
- low sex drive
Diet and exercise can increase levels of dopamine. Vigorous exercise for at least 30 minutes a day can help, provided one can motivate oneself to do it. I was surprised when I saw the list of food for increasing dopamine levels – I’ve been focused on cooking some new recipes – most of which contain ingredients that are high in amino acids, Tyrosine, Tryptophan and Phenylalanine. I don’t usually go for things like foods cooked with chickpea flour or avocados.
Foods to increase dopamine levels:
- High protein foods: meats, poultry of all kinds,eggs
- Milk foods: Cottage cheese, milk, cheese
- Beans: edamame, black beans, chick peas, lima beans, lentils, Soybeans
- Nuts and seeds
- Fruits: Apples, avocado, bananas, watermelon
- Whole Grains
In my own experiments, I found that taking 50 mg of 5HTP twice a day made me feel a bit better. 100mg twice a day and I felt a significant improvement in motivation and mood. Last night, Philippe pointed out I was talking energetically about all sorts of things, something I’ve not done in weeks. I’ve only done this for three days and this is a major improvement. That said, I’m still nowhere’s near what is normal for me, but at least I feel like doing things between naps rather than just reading.
I also have tried to shift my diet to much more protein. In 2001, I had to start eating meat again for energy levels, after years of vegetarian eating which I prefer.
5-HTP, related to the amino acid tryptophan, is not a precursor of dopamine, yet influences the release of dopamine and norepinesphrine. Tryptophan is a precursor to amino acid serotonin. Seratonin is related to mood and sleep.
Taking the 5-HTP, I can motivate myself to exercise more. No matter how bad I felt, I was trying to go out to walk in Montreal cold weather at least every other day. Lately, I have walked farther and done additional exercises in the house.
I was having trouble putting words to how I was feeling. The description is troublesome, since we all can use these terms to describe how we feel on a regular basis. The difference is in orders of magnitude and inability to get out of this mode. My goal now is to find how to explain all this to doctors so maybe they can help me figure this out. So far, I’ve got some clues, and need to keep looking to find real patterns.
5-HTP does not convert, but influences the release of dopamine and norepinesphrine.
A new study concludes that many cancer patients have extended side effects last for at least several years. The new discovery is that these effects are seen with patients receiving ONLY radiation as well as those who underwent chemotherapy, or a combination treatment. There seems to be no mental side effects to hormonal therapies such as Tamoxifen.
Study: “Cognitive functioning after cancer treatment: A three-year longitudinal comparison of breast cancer survivors treated with chemotherapy or radiation and non-cancer controls.” Kristin M. Phillips, Heather S. Jim, Brent J. Small, Christine Laronga, Michael A. Andrykowski, and Paul B. Jacobsen. CANCER; Published Online: December 12, 2011 (DOI: 10.1002/cncr.26432).
I’m reading yet another article about changes in routine breast cancer screening policies.
“An entire generation had been told self-examinations and mammograms were the best tools for early detection. Now, a federal review board was telling them, essentially, “Sorry, girls, it was all voodoo.”
…
“We still feel that breast-screening is the gold standard for early detection,” said Dr. Christine Wilson, medical director of the province’s Screening Mammography Program.
“I think most women can live with a little bit of anxiety but they can’t live with a little bit of cancer. “
Women have been blanketed with memos to be sure to get a baseline mammogram at age 40, then annual exams forever. There was an outcry from natural health communities about the dangers of annual radiation on healthy breasts. Now, in Canada, after reviewing research, they have determined that screening should be postponed to age 50, and then done less frequently (every 2 years I think). The rational focuses on the stress of false positives and unnecessary biopsies. This recommendation is under consideration in many other places.
This new mandate does not affect me, since I’m in a high risk group. These recommendations are only for women without a family or personal history of cancer.
This is difficult for me to deal with, since I was under 50 years by a long shot when a mammogram identified an anomaly that turned out to be malignant. My life might have been in danger if they had waited to give me that first mammogram.
The big question is how do we deal with evolving health policies?
Is this new approach really medically sound or is it a ploy by insurance companies to reduce health care costs?
After accepting and embracing the “Must have mammogram to live” mantra it is hard to accept that less screening is adequate. If cancer is there, it can do a lot of growing in the time between tests. In some cases, enough to make a difference between life and death.
Psychologically, it is hard to give up something we believe. We justify beliefs more strongly when we have gone through something difficult or uncomfortable like a mammogram.
The experts claim that there is lots of data to backup this change in policy. That this is the healthiest option for most women. Then again, six out of seven women don’t get breast cancer.
What is healthiest for the one in seven who do have cancer? They are even balking at self-exams as unnecessary. I found the second and third cancerous lumps myself before any equipment did.
At the moment, I don’t know what to think about these changes. They have cut back on pap tests from every one year to every two years with less media attention.
This is a tough one. I guess I’ll have to read more about it.
Keeping strong bones
Posted on: October 19, 2011
When we were kids were instructed to drink lots of milk to make strong bones.We all know that old people may have weak bones that break more easily and can take longer to heal after a problem. In between these years, we dont’ give much thought to our bones until we are sent for a bone density scan.
Our bones are made of minerals, mainly calcium, potassium, manganese, magnesium, with many other minerals in smaller quantities. Our bodies use the calcium both as a structural material, but also for many chemical processes, including every time we move a muscles. When our blood is lower in calcium, it will pull what it needs from the bones. When you eat a lot of calcium or levels are higher in the blood, calcium and other minerals are stored in the bones. Over time, if we borrow too much calcium and minerals from our bones, which is almost always the case, our bones begin to weaken. This is called osteoporosis.
When osteoporosis is bad, our bones can get tiny fractures, so tiny that we don’t even feel it happening. This is often what causes the stooped posture more common in older people. The inability to use bones to support your weight leads to all sorts of pains and difficulty moving around.
There are things we all can do to help improve the strength of our bones. First is to eat more calcium/mineral rich foods such as milk, cheese, and dark green vegetables. Make sure to take Vitamin D along with the calcium to make sure it is absorbed properly. Many doctors now recommend a calcium supplement for all women over forty or so, since we can rarely get enough calcium in modern diets. Exercise is another important thing for strong bones. “Use it or lose it” applies here. Walking is an ideal exercise for keeping bones strong, reminding the body that you are using the bones so they need to stay strong.
When these lifestyle changes are not enough, doctors can prescribe a variety of medicines that can help keep calcium in the bones. For women who have been treated with breast cancer, doctors will tend to be ever vigilante with bone density monitoring. Tamoxifen can help increase bone density, while aromatase inhibitors tend to leach calcium from the bones.
There are specific medicines such as Evista, which are given to patients to increase bone density. This can also help lower risks of developing breast cancer in high risk patients. For some patients, doctors recommend an annual shot called a Reclast injection that can help improve bone density. It seems odd a single shot can make that big effect for an entire year, but that is what happens. Many doctors like the idea of an annual shot, since apparently many patients stop taking pills or take them erratically.
How important is all this? I heard recently some very scary statistics show how quickly many older people die after a fall that results in hip fractures. We all need to take appropriate measures to help keep our bones healthy. Even for people taking bone strengthening medicines, we all need to be concentrating on eating good nutritious foods and getting out to walk every day.
My oncologist wants to see me every three months. For many, it is not long before the three month visits extend to six months. I was seeing Dr. Langleben every six months for several years, prior to the discovery of tumor of 2010. The frequent check-ups are a reminder to me that I am still at a risk for recurrence. I can never let up on the vigilance to find anything nasty “thing” as early as possible. That is the best path to long term survival.
My eReader is awesome, a part of the routine so that I don’t mind the long waits to see the doctor. I find myself watching everyone’s hair. I used to think that most people in the waiting area all looked so healthy. Now I can better pick out tell-tale signs of wigs, and the reality that most of the shortest haircuts came free with the chemotherapy. This time, there was not the anxious looking couple, obviously awaiting results, nor a person walking in the dazed stupor of the “just diagnosed”.
At one point a couple came with a baby in a stroller and sat together on the far side of the waiting room. My reading was disturbed by a loud, very identifiable sound, the kind that would have caused an uproar in any elementary school classroom. As all eyes went into the direction of the sound, the mortified woman exclaimed loudly “It was not US! It was the baby! Really, it was the baby!” I was amused how certain body functions can cause such embarrassment, and the need for a thirty-something woman to exonerate her self, even in a cancer waiting room.
My term finally came to see the doctor. Like the surgeon, he commented that I looked far better than I had three months ago, when both hips were so bad. That last visit, I could barely walk with the pain. His interest in the details of the surgery and recovery process surprised me. We so often think of doctors as all-knowing, yet the reality is that they only have time to keep up on the advances in their own specialty.
When I mentioned the ceramic-ceramic hip prosthesis, he remembered a recent seminar referencing this device. I remarked that ceramic-ceramic was a device appropriate for younger, more active patients. He responded “So they expect you to live a long healthy life!”
He was right, and yet, this reminded me that my future is still in question. Cancer can occur or recur at any point in our lives, but this first few years after treatment are the highest risk.
So all is well. His concern, as before, is with balancing the risk of blood clots from joint replacement surgery against the increased risk of cancer growth from two months without Tamoxifen. Normally, patients stop Tamoxifen four weeks before and after surgery. For me, the risk of recurrence is higher, so I will stop Tamoxifen 7 days before and 10 days after surgery.
Because of the crutches, the oncologist walked me to the secretaries desk to carry my chart.
As he headed back, past the waiting area, he called out “Make sure to uphold the reputation of the Oncology team [while you are over in orthopedics]!”
I responded “I always feel like I’m cheating on you guys, with me seeing other doctors!”
Do I have to pick like a Twilight fan? Am I “Team Oncology” or “Team Orthopedics”?
- In: Medical Info | Recovery
- 3 Comments
When we get diagnosed with cancer, our long term vision is to stay alive. Most information available helps with getting through treatments, but there is little discussion of life after the treatments end.
The capsule on a normal shoulder is smooth and nice.
For many, things do return pretty much to life as it was. For others, like me, there are some residual issues that need to be addressed if I don’t want them to be permanent. I’m still battling fatigue, shoulder pain and very curly hair (it used to be much straighter.)
After 3 surgeries and 3 rounds of radiation, I’ve got stiffness in my left shoulder which is literally a pain each time I get dressed or use the arm for any sort of reaching action. When a shoulder stays stiff for a long time, this is referred to as “frozen shoulder” or Adhesive Capsulitis. My physiotherapist says that frozen shoulders are common in women who have had breast cancer. Some seem to have problems even before any diagnosis or treatment, in his experience.
What is it?
The problem comes from the joint capsule ( a lining in the shoulder joint) gets sticky and messes up how the muscles work. The condition usually starts with some sort of simple trauma, like reaching for something causing a bit of pain. The pain does not go away and actually begins to increase with time, getting more and more stiff.
The capsule on a frozen shoulder.
The Mayo Clinic describes it as “The bones, ligaments and tendons that make up your shoulder joint are encased in a capsule of connective tissue. Frozen shoulder occurs when this capsule thickens and tightens around the shoulder joint, restricting its movement.” Wikipedia adds that the amount of synovial fluid is also reduced in the joint. Scar tissue forms inside the capsule. All this reduces the amount of room for the shoulder to move.
The shoulder has three kinds of muscles, one set to hold the joint still, then one to do the work of moving the arm and another set of muscle that counterbalance the movement. When the shoulder is frozen, the muscles quit using the normal choreography and instead, the wrong muscles are recruited to do the work. If I look in the mirror as I move my arms, they two sides do not move the same.
The shoulder tends to keep getting worse for a year or more, then will begin to release (thaw) over the next 1 to 3 years. Movement may be permanently restricted if you don’t intervene. Physical therapy or special types of medical massage (body work or cranial sacral therapies) can help.
My physical therapist is carefully pushing my arm to extend the range of motion, three times a week. This is very painful, but does increase the range of motion with time. I have to keep stretching it multiple times a day to help speed the process along. My arm tends to get stiffer with bad weather. Weird, but true.
Most recommendation say to get physical therapy immediately when the arm begins to hurt so that you may be able to bypass the long term problem. For me, I got physical therapy on the arm for many months in 2001/2002. It never got really bad, but movement was restricted. After the 2010/11 cancer treatments, I was working with an osteopath (focused more on other body parts) and doing QiGong which helped, but did not cure the problem.
The physical therapist says he has cured many people, and I hope he’s right. Getting myself to do the stretches is not easy sometimes, since it hurts. The alternative is worse, so I do the stretches.
Some of these things linger for too long, but that is not reason to give up and accept permanent disability of a joint. This goes for other aches and pains that don’t seem to concern an oncologist or surgeon. There are specialists with a variety of hands-on techniques that can help. You may need to try a few to get the right person to help you and in the end, so much of the recovery is about how much you are willing to keep at it until the pain goes away.
Checking in with the Oncologist
Posted on: June 22, 2011
Dr. Langleben, my oncologist, asked that I see him for a final check up prior to the impending hip surgery. This turned out to be quite and easy visit – the rare time when I was in the examination room before it was even time for my appointment.
The patient before me was finishing up her conversation with Dr. Langleben as I was entering the exam room. She was a lovely woman I’d guess was in her 60’s or early 70’s, dressed impeccably in a casual looking longish flowing skirt and stylish summer weight sweater. Looking carefully, I thought she might have on a wig. If she did, it was nice one. She also had the determinated optimism I’ve seen in many people as they are in the midst of chemotherapy. I complemented her outfit and she responded “We must find beauty where ever we can.” Cancer treatment is so different from other medical procedures. I’d never expect to hear that short of comment in orthopedics.
The doctor did a quick exam, checked that all was in order, no lumps or bumps. He told me to stop taking Tamoxifen one week before the surgery (starting in two days) and stay off of it for two weeks after the surgery, making a total of three weeks where cancer cells could grow more easily. He said not to worry. This was not a long time and I would be fine. Blood clots are higher risk after joint replacement surgeries, and drugs like Tamoxifen can also increase the same risk. After surgery, a patient is put on blood thinners to prevent the clots.
I’m suddenly now weirded out by stopping the Tamoxifen. I was so afraid of taking it at the beginning, and now it is the one thing I do each day to prevent a recurrence. How perspective changes.
Dr. Langleben wished me a very genuine “good luck” with the surgery, mentioning I should be sure the smile at the surgeon, they like that. That was the moment my surgeon, Dr. Derossis stepped out of an exam room and was updated on my upcoming surgery. She also wished me well.
As I was waiting to check out, Dr. Derossis walked past me again, leaned over and gave me a little encouraging pat on my arm as she said “Karen, I hope this all goes very well for you!” With all her patients, she knows me by name. I really feel I am a member of a team effort.
I’ll see them both again at the end of the summer, when one hip will be fully fixed.
Flattest breasts ever!
Posted on: May 31, 2011
- In: Biopsy | Cancer | Medical Info | Radiation
- 1 Comment
Another sign of normal life returning… I had my first post-cancer mammogram! We are once again looking in general rather than treating a nasty. YEAH!
Mammograms are essential for females starting around age 40 unless there is a strong family history when they start looking around age 35. The mammogram is consists of two x-rays for each breast. One view is horizontal the floor, the other is horizontal to the walls (more or less). The point is to get a look at the breast tissue from two angles.
I was unable to locate an image of the true contorted position required for a mammogram with one jaw pushing up tightly against the top of the machine, one arm hanging on for dear life across the top of the machine as the two plates lock down to flatten the breast for a picture. This image just shows the starting position. The final position has the breast flattened to well below an inch diameter.
If you have had a mammogram before, it is important to bring your last one with you, so if they see an anomaly, they can see how much it has changed. Most breast cancers will be visibly different if left in place for a year or more.
When setting up the appointment for a mammogram, you need to realize there are two types of mammograms, one is called a “screening mammogram” the other is a “diagnostic mammogram”. If you’ve never had problems, you get the screening mammogram. After cancer treatments, or if you are being watched more carefully, they give the diagnostic mammogram, which more than anything means that they need a radiologist around to decide on the spot if additional images or magnified views are needed.
The day of the mammogram they ask that you use no deodorant or creams on your chest and armpits. Most deodorants contain a metal like aluminum that may be problematic for the images. The creams and deodorants can also leave a gooey residue on the equipment.
They handed me the standard hospital gown and request I remove all clothing above the waist. I can keep wearing like rings and my watch, necklaces should be removed.
Each screening room is unigue, but in general they have a big machine in the middle of the room, and a shielded area for the technician to hide during the x-ray.
Most of the time is spent posing the breasts for the photo. The point is to get as much of the breast tissue between the two plates as possible. The flatter they can squish the breasts, the better. “Put your face here up against the machine. Now reach and hang onto the back of the machine for balance.” then she cranks down the breast flattener. We repeat this three or four times, each time getting the breast flatter and flatter.
The area where I had the most surgery and radiation began to pull and feel uncomfortable. As the technician sweetly asked about the my gasping for air and grimace, she cranked it down one more time. This was the most effect breast flattening I’ve ever had (and I’ve had many so far in my life.)
Luckily, I only spent maybe 15 seconds in this tightest pose as I held my breath for the picture. She released the pressure immediately. A sigh of relief. Then onto the next view.
For these images, the flatter they can get the breast tissue, the more detail they can see, which is important. The other breast was easy by comparison, since there were no surgical scarring inside. The entire thing took only about five minutes for the four images.
They always have patients wait, to check the pictures before having you get dressed, just in case there is a need for another view.
As I got dressed, I was informed the pictures looked good, nothing suspicious, yet this is initial results. No reason to think the radiologist will see more problems.
This time, as I underwent the big squeeze, I realized the short comings of the test. A mammogram examines the tissue that falls onto the plate, but nothing more. This is how we missed the lump, below my breast down in the ribs. This tissue does not make it into the machine, nor the armpit tissue or areas around the edges by the chest wall up to the collar bone. This is why we have to do the regular self-exams on a monthly basis focusing especially on these areas, feeling for anything hard or irregularly shaped. We want to find anything as early as possible, when it is still the size of a pimple to make sure it does not have time to spread.
The radiologist is looking mainly for lumps, which show up as whiter areas, or for calcifications. Calcifications are a small ring of white dots that appear in specific “suspicious” patterns. My first cancer had no lump, just a pin point group of calcifications that indicated something was growing abnormally.
It is important to know that most suspicious things in a mammogram turn out to be normal anomalies. The test is 85-90% accurate, which means 10 or 15 women in 100 will be invited for further investigation when there is not a real problem. Don’t expect the worst until after seeing the results of a biopsy. Up to that point, in statistics are in your favor that you don’t have cancer. I’m grateful that most mammogram offices now have ultrasound machines onsite, so they can go ahead and get more information quickly when there is a question. The waiting for tests and results is tough.
The technicians are aware of the patient’s experience of the mammogram. Most are women and have had it done themselves. I was pleasantly surprised that the technician kept a hot water bottle on the breast squishing tray to warm it. To do the test right, she needs to flatten, but at least she saved me from the shock of cold plastic at the beginning. Even these little things help.
So I think this all went well. They assured me I was fine, yet we still wait for a final report. The next mammogram is in a year and I’ve “graduated” so that I can go back to getting a diagnostic mammogram in another building. The Breast Center is only for patients who needs something suspicious investigated. I have nothing suspicious any more!
PS: Please note as I describe the horrors of the mammogram in detail because it is a totally OK test that is momentarily inconvenient, so I don’t feel guilty describing every little thing as difficult. The test is quick and essential so it is fun to share the experience in its fullest detail. We all get the tests, at least the women do, and know how good it feels to get the “all clear” for another year.
Questions for doctors
Posted on: May 31, 2011
I’m going to share a conversation I just had, since I think it may be helpful to others.
“I spent all day every day managing hot flashes from Evista ( a bone density/ant-cancer drug). All day I need the air conditioner on, then off, then on again at higher level. I can only STAND a light weight cotton shirt of a certain feel. My husband despises this shirt since it is in tatters now. He is right, but it is the only thing I can bear to wear so I keep decent shirt near door to throw on when I’m around him. This is my pattern for the foreseeable future: Get clean clothes, take serious serious shower, very very clean, then in 5 min. I am breaking out into complete sweat.”
She is thinking about telephoning the doctor to see if anything can be done with the hot flashes.
Doctors are notorious for seeming to ignore our complaints, telling us to bear with it, until they identify a concrete signal that this is seriously impacting the quality of life. As patients, we don’t know what to say or how to describe the problem. It is harder, since most of us do attempt to ignore the side effects as much as we can. Dwelling on them, analyzing, only makes it worse.
For effective communication to take place, you need to find a way of transforming words like “bad”, “hurts”, “uncomfortable” into concrete, measurable terms.
This goes back to the old “Who, What, When, Where and How” we learned in school.
Before placing the phone call, spend at least a few days, preferably a week, keeping a diary of your experience on an hour to hour basis, or at least doing it four times a day – morning, afternoon, evening, night.
WHO: is obviously you, but you can keep a diary on someone else if you are the caregiver.
WHAT: define the symptoms that occur
WHEN: When did it start? About how long did it last
WHERE: The actual location should not matter, the important thing here is what were you doing when it started. This can give clues to work with – “it always happens when I’m walking, but never when I’m reading.”
HOW: This you need something concrete that you can discuss with the doctor documenting the magnitude of the problem. I’ve discussed pain scales recently, as an example of quantifying pain. The same adjectives can work with any side effect. Focus on how much it impacts your daily life and whether it forces you to change behaviors dramatically.
It is not easy to keep a good diary like this. I have been making attempts with a pain diary this week, and have many half days of data where I never got back to the paper. This means I was OK, or that I was in so much pain I did not care. Attempt to fill in the missing parts as soon as you can. After 24 hours, you will not be able to remember details very well.
This diary will help you as much as the doctor. You can begin to see patterns in both triggers of problems and things that ease the discomfort.
When you talk to the doctor about side effects, you can then say “Every day I have 4-6 hot flashes. Most are OK, but the ones at night wake me up and it is impossible to get back to sleep.” This is something the doctor can work with.
Communication is not always easy. When we make an effort to use language that is meaningful to the listener, we have a better chance of getting the answers we seek.
Resources:
The basic examples of a pain diary :
* *Simple Pain Diary: http://www.canadianpaincoalition.ca/media/pain_diary.pdf from Canadian Pain Coalition
* http://www.healthinaging.org/public_education/pain/my_pain_diary.pdf from Health in Aging
Most detailed approach to documenting pain. Same diary pages work well with keeping track of side effects.
* Chronic Pain Notebook: http://www.painfoundation.org/learn/publications/target-notebook.html
Download a pamphlet discussing how to keep records and communicate your experiences to a doctor. Targeted at pain, but good for anything you want to discuss with a doctor. It’s an extremely useful tool when discussing levels of pain, response to treatment and improvements in functioning and side effects.
*Target Chronic Pain Notebook: http://www.painfoundation.org/learn/publications/files/TargetNotebook.pdf
Cancer 2.0: The Sequel 
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