What is the role of the placebo effect for pain relief in neurorehabilitation? Clinical implications from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods: A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results: 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications: These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy

Psychological considerations in the assessment and treatment of pain in neurorehabilitation and psychological factors predictive of therapeutic response: Evidence and recommendations from the Italian consensus conference on pain in neurorehabilitation

In order to provide effective care to patients suffering from chronic pain secondary to neurological diseases, health professionals must appraise the role of the psychosocial factors in the genesis and maintenance of this condition whilst considering how emotions and cognitions influence the course of treatment. Furthermore, it is important not only to recognize the psychological reactions to pain that are common to the various conditions, but also to evaluate how these syndromes differ with regards to the psychological factors that may be involved. As an extensive evaluation of these factors is still lacking, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) aimed to collate the evidence available across these topics

Consensus-based management protocol (CREVICE protocol) for the treatment of severe traumatic brain injury based on imaging and clinical examination for use when intracranial pressure monitoring is not employed

Globally, intracranial pressure (ICP) monitoring use in severe traumatic brain injury (sTBI) is inconsistent and susceptible to resource limitations and clinical philosophies. For situations without monitoring, there is no published comprehensive management algorithm specific to identifying and treating suspected intracranial hypertension (SICH) outside of the one ad hoc Imaging and Clinical Examination (ICE) protocol in the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial. As part of an ongoing National Institutes of Health (NIH)-supported project, a consensus conference involving 43 experienced Latin American Intensivists and Neurosurgeons who routinely care for sTBI patients without ICP monitoring, refined, revised, and augmented the original BEST:TRIP algorithm. Based on BEST:TRIP trial data and pre-meeting polling, 11 issues were targeted for development. We used Delphi-based methodology to codify individual statements and the final algorithm, using a group agreement threshold of 80%. The resulting CREVICE (Consensus REVised ICE) algorithm defines SICH and addresses both general management and specific treatment. SICH treatment modalities are organized into tiers to guide treatment escalation and tapering. Treatment schedules were developed to facilitate targeted management of disease severity. A decision-support model, based on the group's combined practices, is provided to guide this process. This algorithm provides the first comprehensive management algorithm for treating sTBI patients when ICP monitoring is not available. It is intended to provide a framework to guide clinical care and direct future research toward sTBI management. Because of the dearth of relevant literature, it is explicitly consensus based, and is provided solely as a resource (a “consensus-based curbside consult”) to assist in treating sTBI in general intensive care units in resource-limited environments

Psychological treatments and psychotherapies in the neurorehabilitation of pain: Evidences and recommendations from the italian consensus conference on pain in neurorehabilitation

It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams

Time for a consensus conference on pain in neurorehabilitation

O uso do enxerto autólogo de gordura ou lipoenxertia (termo em inglês - “lipofilling”) na reconstrução imediata da cirurgia conservadora de mama vem sendo aplicada a fim de atingir resultado estético satisfatório na primeira cirurgia para o câncer de mama em pacientes com relação tumor/mama desfavorável ou em localização de difícil reparo. A segurança oncológica da técnica ainda é discutida devido ao pouco número de pacientes em seguimento. Objetivo: determinar se há diferença nas taxas de recidiva local e sobrevida livre de doença em relação à realização ou não de lipoenxertia imediata na cirurgia conservadora. Metodologia: Foram selecionados retrospectivamente os pacientes submetidos à cirurgia conservadora com ou sem lipoenxertia entre 2004 e 2016. Os grupos foram pareados por idade, estadiamento, grau e perfil imuno-histoquímico do tumor. Os pacientes foram acompanhados por uma média de 60 meses e as taxas de recorrência e sobrevida livre de doença foram avaliadas. Resultados: 320 pacientes acompanhadas, casos pareados com controles na proporção de 1:4. Não foram observadas diferenças significativas na recorrência loco-regional (LRR) das pacientes que foram submetidas à lipoenxertia simultaneamente à cirurgia conservadora em comparação com os controles, LRR 0,86% ao ano x 0,70% ao ano, p => 0,05, respectivamente. Não houve diferenças na sobrevida livre de doença entre os grupos. Conclusão: Após 60 meses de seguimento, não houve diferença significativa nas taxas de recorrência loco-regional entre o grupo de lipoenxertia imediata e o grupo controle. Esses achados sugerem a segurança oncológica da reconstrução imediata com a lipoenxertia, propondo a técnica como eficaz, segura e com ótimo resultado estético para o câncer de mama.Importance: Autologous fat grafting (AFG), or lipofilling, has been used for immediate reconstruction at the time of breast-conserving surgery in order to achieve a satisfactory cosmetic outcome in patients with breast cancer and an unfavorable tumor-to-breast volume ratio or unfavorable tumor location. However, the oncologic safety of this technique is still unclear. Objective: To determine whether AFG performed simultaneously with breast-conserving surgery is associated with differences in local relapse rates and disease-free survival. Design: Matched retrospective cohort study. Setting: Tertiary referral center. Participants: Patients undergoing breast-conserving surgery with or without AFG between 2004 and 2016 were retrospectively enrolled and matched for age, staging, grade, tumor histology, and tumor immunohistochemical profile. Main Outcome(s) And Measure(s): The cumulative incidence of locoregional recurrence (LRR) and disease-free survival were the primary end points, while distant recurrence and overall survival were the secondary end points. Results: A total of 320 patients were followed. Cases were matched with controls at a 1:4 ratio. There was no difference in LRR or distant recurrence of breast cancer between the two groups. The annual LRR rate was 0.86% in patients who received immediate AFG vs. 0.7% in patients undergoing breast-conserving surgery alone (P≥0.05). Number of lymph nodes was the sole independent risk factor for local recurrence (p=0.045). No significant differences in disease-free survival rates were found between the groups. Conclusions and Relevance: At a mean follow-up of 5 years, no significant differences in locoregional recurrence rates were found between patients who received immediate AFG and those who underwent breast-conserving surgery alone. These findings corroborate previous research demonstrating the oncological safety of immediate AFG reconstruction, further suggesting that this technique as a safe, effective way to achieve optimal cosmetic outcomes in primary breast cancer surgery without jeopardizing oncologic outcomes

Time for a consensus conference on pain in neurorehabilitation

Time for a Consensus Conference on pain in neurorehabilitation

Time for a Consensus Conference on pain in neurorehabilitation

Time for a Consensus Conference on pain in neurorehabilitation

Time for a Consensus Conference on pain in neurorehabilitation.

Pain represents a common problem in the setting of neurorehabilitation, in that it is a common outcome measure but may also have a negative effect on motor and cognitive outcomes. Guidelines, expert opinions or consensus statements on pain in neurorehabilitation are largely lacking. The Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) was promoted to answer some questions on this topic, and its recommendations may offer practical and useful information and represent the basis for future studies on pain in neurorehabilitation