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

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

DEMENZA E QUALITA' DELLA VITA: INTERVENTI NON FARMACOLOGICI PER I PAZIENTI E PER I FAMILIARI

Il presente elaborato si colloca entro l’area di ricerca sull’invecchiamento patologico, con particolare riferimento al paziente con diagnosi di demenza moderata e grave e al relativo caregiver; tema centrale è la qualità della vita dei due membri della diade paziente/familiare, e la necessità di diversificare e arricchire l’attività psicologica entro i contesti di ricovero a lungo termine in favore di un miglioramento del benessere della diade stessa. A tale scopo, il lavoro si articola in due studi distinti: nel primo, si propone un intervento di stimolazione musicale individualizzata diretta al paziente con diagnosi di demenza moderata o grave, nel secondo un intervento di reminiscenza che ha come target il familiare. La tesi si articola in tre sezioni: la prima è una cornice teorica di riferimento, la seconda e la terza espongono rispettivamente il primo e il secondo studio sperimentale. Il primo capitolo ha lo scopo di fornire un quadro teorico e empirico aggiornato in merito al tema dell’invecchiamento. Inizialmente viene trattata la questione della “Ageing Society” da un punto di vista globale, delineando nel corso del capitolo le caratteristiche e le criticità legate all’invecchiamento patologico e alla sua gestione entro il Sistema Sanitario Nazionale, con particolare interesse verso la realtà delle Residenze Sanitario-Assistenziali (RSA), contesto entro il quale si sono svolti i due lavori di ricerca proposti. Si tocca infine il tema dell’intervento non farmacologico diretto al paziente. In una seconda parte è descritta la prospettiva del familiare, il concetto di burden e il ruolo della relazione pregressa tra paziente e caregiver da un punto di vista teorico; segue la descrizione degli interventi non farmacologici diretti al caregiver finora proposti in letteratura, ideati allo scopo di alleviare stress legato al ruolo di cura e alle sue implicazioni. Il secondo capitolo ha lo scopo di esporre il primo studio della tesi, che si è occupato di verificare l’efficacia di un intervento di ascolto musicale individualizzato sulla qualità della vita di pazienti con diagnosi di demenza moderata o grave. Per questo motivo, si sono prima di tutto descritti i sintomi comportamentali della demenza, con particolare riferimento alla agitazione psicomotoria e al suo ruolo di indice dello stato psicologico del paziente con deficit cognitivi avanzati. Nella sezione empirica del capitolo viene descritta nei dettagli la modalità di intervento selezionata, gli obiettivi dello studio e i risultati ottenuti in base alla misurazione pre-post delle variabili di outcome selezionate e al confronto tra gruppo sperimentale e gruppo di controllo. Il terzo capitolo tratta il secondo studio del lavoro di tesi, che ha indagato l’efficacia di un intervento di reminiscenza sulla qualità della vita percepita dai familiari di pazienti con diagnosi di demenza afferenti alla RSA Monsignor Bicchierai – Istituto Auxologico Italiano di Milano. Allo scopo di motivare le ragioni della scelta di questa modalità di intervento, si sono descritte le premesse teoriche della teoria della reminiscenza e le sue potenzialità come forma di approccio al paziente anziano; l’idea dello studio è stata quella di applicare tale modalità di intervento sul caregiver, allo scopo di alleviare il burden percepito conseguente al carico pratico e emotivo che la cura della persona cara comporta. Analogamente al secondo capitolo, segue la sezione empirica dello studio, con un esteso approfondimento metodologico e la descrizione e discussione dei risultati ottenuti. Una sezione finale avrà lo scopo di proporre riflessioni e spunti clinici emersi da entrambi gli studi, entro una visione globale della presa in carico della diade paziente/caregiver.This research thesis refers to pathological aging, with a particular focus on the patient with a diagnosis of dementia and his/her caregiver. The intended central theme is the patient and the caregiver’s quality of life, assuming them as a dyad; the work also concentrated on the need to diversify and enrich the psychological offer within the context of long-term hospitalization. To this end, it is divided into two separate studies. In the first one, we propose an individualized musical intervention directed to the patient with a diagnosis of moderate or severe dementia; in the second the effcacy of a reminiscence intervention that targets the family member is tested. The thesis consists of three separate sections: the first is a theoretical frame, the second and the third expose the first and the second experimental study respectively. The first chapter aims at providing an updated theoretical and empirical framework on the subject of aging. The problem of the "Aging Society" is firstly discussed; among the chapter the characteristics and the critical issues related to pathological aging and its management are debated. This topic requested a deepening into the features of the italian National Health System, with a particular focus on the reality of Nursing Homes (RSA), within which the two proposed research works were carried out. Finally, the topic of non-pharmacological intervention directed to the patient is treated. The second part describes the caregivers’ perspective, the concept of burden and the role of the prior relationship between patient and caregiver: in order to act on the stress related to the role of care and its implications, non-pharmacological interventions directed to the caregiver according to scientific literature are described. The second chapter objective is to display the first study, which aimed at testing the effectiveness of an individualized music listening intervention on the quality of life of patients diagnosed with moderate or severe dementia. For this reason, the behavioral symptoms of dementia (BPSD) were first described, with particular reference to agitation and its role as an index of the psychological state of the patient with advanced cognitive impairment. In the empirical section of the chapter the intervention is carefully described, together with the objectives of the study and the results obtained based on the pre-post measurement of the selected outcome variables and the comparison between the experimental group and the control group. The third chapter deals with the second study of the thesis work, which investigated the effectiveness of a reminiscence intervention on the caregivers’ perceived quality of life; they belonged to the RSA Monsignor Bicchierai - Italian Auxologic Institute of Milan. In order to support the choice of this modality of intervention, the theoretical premises and its potential use as a form of treatment for dementia patients have been described; the seminal idea of the study was to apply this kind of intervention on the caregiver, in order to relieve the burden resulting from the practical and emotional load requested. Similarly to the second chapter, the empirical section of the study follows, with an extensive methodological study together with a description of the obtained results. A final section had the purpose to think over the clinical ideas emerged from both studies, viewing the dyad patient-caregiver as a single care recipient

Could cognitive estimation ability be a measure of cognitive reserve?

Could cognitive estimation ability be a measure of cognitive reserve