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

Upper limb function and quality of life in breast cancer related lymphedema: A cross-sectional study

BACKGROUND: One of the most frequent impairments in breast cancer survivors is secondary lymphedema of the upper limbs. Several impairments and activity limitations frequently occur in these patients leading to participation restrictions and influencing Quality of Life. AIM: To investigate upper limb disability and perceived Health Related Quality of Life (HRQoL) in a group of women with breast cancer related lymphedema (BCRL) compared with a group without lymphedema. DESIGN: Cross-sectional survey. SETTING: Cancer outpatient's department of the National Cancer Institute of Naples Foundation "G. Pascale". POPULATION: 100 women treated with unilateral axillary lymphoadenectomy: 50 with unilateral BCRL (group A), and 50 without lymphedema (group B). METHODS: Arm function was assessed by the Disability of the Arm, Shoulder and Hand questionnaire (DASH). The perceived HRQoL was evaluated with SF-12. RESULTS: The mean DASH score was 36.59 (±18.03) in group A, and 23.68 (±21.46) in group B (P<0.002). Age less than 65 years, BMI≥30, the presence of comorbidities and radical mastectomy had an influence on the extent of the functional limitation, linked to the presence of the lymphedema. There were no statistically significant differences for SF-12 scores. CONCLUSION: In our population the presence of BCRL certainly affects upper limb functioning and related activities even though HRQoL was not perceived differently. CLINICAL REHABILITATION IMPACT: Lymphedema has to be early diagnosed and treated with an adequate rehabilitative plan to prevent activity limitations and participation restrictions.Background. One of the most frequent impairments in breast cancer survivors is secondary lymphedema of the upper limbs. Several impairments and activity limitations frequently occur in these patients leading to participation restrictions and influencing Quality of Life. Aim. To investigate upper limb disability and perceived Health Related Quality of Life (HRQoL) in a group of women with breast cancer related lymphedema (BCRL) compared with a group without lymphedema. Design. Cross-sectional survey. Setting. Cancer outpatient's department of the National Cancer Institute of Naples Foundation "G. Pascale". Population. 100 women treated with unilateral axillary lymphoadenectomy: 50 with unilateral BCRL (group A), and 50 without lymphedema (group B). Methods. Arm function was assessed by the Disability of the Arm, Shoulder and Hand questionnaire (DASH). The perceived HRQoL was evaluated with SF-12. Results. The mean DASH score was 36.59 (±18.03) in group A, and 23.68 (±21.46) in group B (P<0.002). Age less than 65 years, BMI≥30, the presence of comorbidities and radical mastectomy had an influence on the extent of the functional limitation, linked to the presence of the lymphedema. There were no statistically significant differences for SF-12 scores. Conclusion. In our population the presence of BCRL certainly affects upper limb functioning and related activities even though HRQoL was not perceived differently. Clinical Rehabilitation Impact. Lymphedema has to be early diagnosed and treated with an adequate rehabilitative plan to prevent activity limitations and participation restrictions

Comorbidity in patients with fragility fractures: analysis of “GISMOA study”

Introduction. Fragility fractures are a major cause of disability and death [1,2] among people in western countries. Italy is one of the countries with the highest life expectancy in the world. The increase in life expectancy is associated with a greater frailty of elderly people and a higher prevalence of chronic and degenerative diseases, including osteoporosis [3]. The aim of our study is to evaluate comorbidities in a population with fragility fractures. Materials and methods. We conducted a Regional Survey on behalf of GISMOA (Gruppo Interdisciplinare per lo Studio delle Malattie Osteo-Articolari) involving 11 physicians experienced in osteoporosis working in Campania Region. We asked each physician to collect data on osteoporotic patients over 50 years of age. For each patient they had to fill a form including: questions about medical history, evaluation of comorbidities through Comorbidity Illness Rating Scale, type and number of fragility fractures. Results. Of the 845 forms we excluded 159 patients because they did not meet the inclusion criteria or the data were incomplete, therefore the analysis was carried out on 687 patients with a mean age of 66.3 years. 665 (96.93%) were females. Of these patients 364 (53.06%) had a history of fragility fracture and 62 had more than one fracture. In particular 189 (51.92%) patients reported a history of vertebral fracture, 32 (8.79%) of hip fracture, 10 (2.74%) pelvis fractures; 31 (8.51%) humeral fractures, 99 (27.19%) wrist fractures, 11 (3.02%) both vertebral hip fracture. The mean Comorbidity Index (C.I) and Severity Index (S.I.) in patients with a vertebral fracture were respectively 1.04 and 1.19. The mean C.I. and S.I. in patients with multiple vertebral fractures was respectively 1.78 and 1.19. The mean C.I. and S.I. in patients with a fracture of the hip was respectively 1.73 and 1.38; the mean C.I. and S.I. in patients with a hip fracture and vertebral fractures were respectively 2.54 and 1.61. Conclusions. Our results confirmed that comorbidity is a major issue in patients with a history of multiple vertebral fractures and in the patients with fracture of the hip and vertebral fractures. Furthermore the C.I. of patients with multiple fracture was overlapped to the C.I. of the patients with a hip fracture. Therefore an appropriate management of comorbidities should be always taken into account in the comprehensive treatment of patients with fragility fractures. Bibliografia 1. The New England Journal of Medicine, Screening for Osteoporosis. Lawrence G. Raisz, M.D.. N.Engl J Med 2005; 353: 164-71. 2. Department of Health and Human Services. Bone Health and Osteoporosis: a report of the the Surgeon General. Rockville, Md.: Office of the Surgeon General, 2004. 3. National Institute for Statistics. Italian Statistics 2005. Rome: National Institute for Statistics; 2005

Bone quality and bone strength: benefits of the bone-forming approach.

The ability of bone to resist fracture depends on the intrinsic properties of the materials that comprise the bone matrix mineralization, the amount of bone (i.e. mass), and the spatial distribution of the bone mass (i.e. microarchitecture). Antiresorptive agents may prevent the decay of cancellous bone and cortical thinning, with no improvement of bone microstructure, leading to a partial correction of the principal bone quality defect in osteoporosis, the disruption of trabecular microarchitecture. Anabolic agents promote bone formation at both trabecular and endocortical surfaces, resulting in an increase of cancellous bone volume and cortical thickness. The improvement of cortical bone strength may be limited by an increase in cortical porosity. strontium ranelate improves trabecular network and cortical thickness that will contribute to anti-fracture efficacy at both vertebral and non-vertebral sites. The results of clinical and experimental studies are consistent with the mode of action of strontium involving dissociation between bone formation and resorption leading to a stimulation both trabecular and cortical bone formation without increasing cortical porosity