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

BACKGROUND: 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. OBJECTIVES: To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases. METHODS: A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions. RESULTS: The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive-Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post-Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache. CONCLUSIONS: Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the pape

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

Evaluation of strength muscle recovery with isokinetic, squat jump and stiffness tests in athletes with ACL reconstruction: A case control study

Background: The anterior cruciate ligament (ACL) rupture accounting for about 50% of all knee ligament injuries. The rehabilitation program requires a long time to rebuild muscle strength and to reestablish joint mobility and neuromuscular control. The purpose of the study is to evaluate the muscle strength recovery in athletes with ACL reconstruction. Methods: We enrolled soccer atlethes, with isolated anterior cruciate ligament rupture treated with bone-patellar tendon-bone autograft artroscopic reconstruction. Each patients were evaluated comparing operated and controlateral limb by isokinetic test and triaxial accelerometer test. Isokinetic movements tested were knee flexion–extension with concentric-concentric contraction. Accelerometer test were Squat Jump Test (SJT) and Stiffness Test (ST). Results: 17 subjects were selected, there was no significant difference in isokinetic quadriceps and hamstrings results in strength and endurance values. Parameters of ST were comparable between the operated and unoperated side. In SJT a significant statistical difference was in height of jump (p=0,02) no statistical difference was evidenced in the other measures. Conclusion: Currently complete recovery of symmetric explosive strength seems to be an important parameter for evaluating the performance after ACL reconstruction and the symmetry in test results jump could be associated with an adequate return to sports. In our study the explosive strenght is lower in the limb operated than the healthy one. Explosive strength recovery with pliometric training should be included in the post-surgical rehabilitation protocol and its measurement should be performed to assess the full recovery before the restart of sport activities

Neuromuscular recovery in ACL reconstruction with bone-tendon-patellar-bone and semitendinosus-gracilis autograft

Objective: Several different types of grafts have been used in ACL rupture. The purpose of the study was to compare the recovery of lower limbs muscle strength and proprioception in athletes, who underwent ACL reconstruction with Bone-Patellar-Tendon-Bone (BPTB) versus semitendinosus and gracilis (HS) autografts. Methods: We enrolled 30 male amateur athletes. Each patient was evaluated by isokinetic test, triaxial accelerometer test and balance test with stabilometric platform. Isokinetic test evaluated quadriceps and hamstrings Peak Torque. Accelerometer test evaluated squat jump test (SJT) and stiffness test (ST). The recording on the balance platform was performed with open and closed eyes and evaluated medio-lateral and anteriorposterior pathways. Results: 30 patients were selected (15 in group BPTB and 15 in group HS). In SJT we noticed a statistically significant difference in height of jump in the involved side in favour of Group BPTB (p=0.037) and not significant difference in the other parameters. In the ST, we did not observe significant statistical differences in the parameters of the test. The stabilometric platform data and isokinetic peak torque parameters did not show a significant difference. Discussion: Little high quality researches are available to help determine when patients can safely return to full activity and sport. Included evaluation criteria were a combination of factors regarding knee motion, muscles strength and neuromuscular function. Conclusion: In our study, despite a not full recovery of explosive strength in HS group, the balance and the other parameters after one year are comparable between the two graft. In our findings there isnâ\u80\u99t clinical difference between the two grafts. We suggest that the evaluation of explosive strength and proprioception are the priority parameters in neuromuscular recovery after ACL reconstruction. (www.actabiomedica.it

Validity of the Microsoft Kinect™ in assessing spatiotemporal and lower extremity kinematics during stair ascent and descent in healthy young individuals

•The Kinect™ provides valid and reliable hip and knee kinematics in stair negotiation.•The Kinect™ also provides valid and reliable hip and knee spatiotemporal data.•Ease of testing, cost and space requisites make the Kinect™ feasible for clinical use.•Further research is required to improve assessment for the ankle. Stair negotiation is one of the most challenging, yet frequently encountered, locomotor tasks in daily life. This study is the first attempt to investigate the capacity of the Kinect™ sensor to assess stair negotiation spatiotemporal and sagittal plane kinematic variables. The goal of this study was to examine the validity of the Kinect™ v2 sensor in assessing lower extremity kinematics and spatiotemporal parameters in healthy young individuals; and to demonstrate its potential as a low-cost stair gait analysis tool. Twelve healthy participants ascended and descended a 3-step custom-built staircase at their preferred speed, as spatiotemporal parameters and kinematics were extracted simultaneously using the Kinect™ and a three-dimensional motion analysis. Spatiotemporal measures included gait speed, swing phase time, and double stance time. Kinematic outcomes included hip, knee, and ankle joint angles in the sagittal plane. Consistency (ICC2,1) and absolute agreement (ICC3,1) between the two systems were assessed using separate interclass correlations coefficients. In addition, ensemble curves and associated 90% confidence intervals (CI90) were generated for the hip, knee, and ankle kinematics to enable between system comparisons throughout the gait cycle. Results showed that the Kinect™ has the potential to be an effective clinical assessment device for sagittal plane hip and knee joint kinematics and for some spatiotemporal parameters during the stair gait negotiation

Microsoft Kinect can distinguish differences in over-ground gait between older persons with and without Parkinson's disease

•Kinect v2 provides comparable data to 3D motion analysis system for PD gait.•Kinect v2 can quantify kinematic and temporal special PD gait parameters.•Kinect v2 is a feasible diagnostic tool for use in clinics and patients' homes.•Kinect v2 can distinguish compromised from healthy gait.•Kinect v2 may also serve as a training tool for PD and other populations. Gait patterns differ between healthy elders and those with Parkinson's disease (PD). A simple, low-cost clinical tool that can evaluate kinematic differences between these populations would be invaluable diagnostically; since gait analysis in a clinical setting is impractical due to cost and technical expertise. This study investigated the between group differences between the Kinect and a 3D movement analysis system (BTS) and reported validity and reliability of the Kinect v2 sensor for gait analysis. Nineteen subjects participated, eleven without (C) and eight with PD (PD). Outcome measures included spatiotemporal parameters and kinematics. Ankle range of motion for C was significantly less during ankle swing compared to PD (p=0.04) for the Kinect. Both systems showed significant differences for stride length (BTS (C 1.24±0.16, PD=1.01±0.17, p=0.009), Kinect (C=1.24±0.17, PD=1.00±0.18, p=0.009)), gait velocity (BTS (C=1.06±0.14, PD=0.83±0.15, p=0.01), Kinect (C=1.06±0.15, PD=0.83±0.16, p=0.01)), and swing velocity (BTS (C=2.50±0.27, PD=2.12±0.36, p=0.02), Kinect (C=2.32±0.25, PD=1.95±0.31, p=0.01)) between groups. Agreement (RangeICC =0.93–0.99) and consistency (RangeICC =0.94–0.99) were excellent between systems for stride length, stance duration, swing duration, gait velocity, and swing velocity. The Kinect v2 can was sensitive enough to detect between group differences and consistently produced results similar to the BTS system

Combinational spectral band activation complexity: Uncovering hidden neuromuscular firing dynamics in EMG

A new approach, Combinational Spectral Band Activation Complexity (CSB-AC), that extracts the neuromuscular firing dynamics of surface electromyography (sEMG) signals by applying entropic methods in a multi-dimensional fashion by analyzing the signals temporally, spectrally, and intensity dynamics simultaneously is presented. The CSB-AC signal processing approach introduces a methodology that highlights that a small amount of key fiducial points embedded within the sEMG, 1000x reduction in EMG data, are only needed to show statistically significant changes of the neuromuscular firing dynamics. CSB-AC was compared to the more generalized sample entropy method to demonstrate physiological differences between cohorts and baseline mapping between the two measurements. Results indicated significant differences between CSB-AC and sample entropy regardless of age groups for tibialis anterior and plantar flexion muscles (gastrocnemius medialis, gastrocnemius lateralis, and soleus). Significant differences were found between older and younger subject groups for the gastrocnemius medialis and soleus with the older adults having higher complexity values. CSB-AC produces greater complexity than sample entropy, where this sparser set of data holds paramount information for describing neuromuscular firing and should not be ignored. CSB-AC, accomplishes this by simultaneously assessing the complexity of sEMG’s time, intensity, and spectral content, where latent properties of neuromuscular dynamics within this unique set of sparse sEMG data points are critical to characterizing neuromuscular firing

Efficacia di un trattamento di elettroagopuntura e del trattamento fisiochinesiterapico in pazienti affetti da malattia di parkinson: risultati preliminari

Introduzione I sintomi motori che caratterizzano la Malattia di Parkinson (MP), sono rappresentati da bradicinesia, rigidit\ue0, tremore a riposo e instabilit\ue0 posturale (Berardelli, 2013). E\u2019 noto come la riabilitazione possa migliorare i segni e sintomi non responsivi alla terapia farmacologica (Bloem, 2015). Negli ultimi anni, inoltre, \ue8 emerso come trattamenti alternativi come l\u2019agopuntura possano essere ben tollerati ed efficaci nella gestione sia dei sintomi motori che non-motori (Posadzki, 2013) con positive ripercussioni sulla qualit\ue0 di vita. Scopo di questo studio \ue8 stato quello di valutare gli effetti immediati e a distanza di un trattamento con elettroagopuntura (EAP) e del trattamento fisiochinesiterapico sulle performance motorie, equilibrio, autonomia nelle ADL e qualit\ue0 del sonno in pazienti affetti da MP. Materiali e metodi Abbiamo arruolato pazienti di entrambi i sessi con et\ue0 massima di 79 anni. La durata di entrambi i trattamenti \ue8 stata di 4 settimane. Il gruppo elettroagopuntura (EAP) ha eseguito 8 sedute di EAP della durata di 30 minuti con frequenza bisettimanale. I punti utilizzati sono stati 6PC (Neiguan), 6 EXT (Sishencong) 1EXT (Yintang), 20GV (Baihui), 34GB (Yanglingquan), 3LR (Taichong) stimolati a 4Hz o 100Hz con un\u2019intensit\ue0 appena inferiore di quella che determinasse una contrazione muscolare nella sede di infissione dell\u2019ago. Il gruppo FKT ha eseguito 5 sedute settimanali di fisiochinesiterapia della durata di 50 minuti (totale 20 sedute). Misure di performance motorie sono state valutate attraverso l\u2019uso del Six Minute Walking Test (6MWT) e del Time Up and Go (TUG); l\u2019equilibrio attraverso il punteggio ottenuto alla Berg Balance Scale (BBS), e le ADL e la motricit\ue0 globale con il punteggio ottenuto all\u2019Unified Parkinson\u2019s Disease Rating Scale parte II e III (UDPRS II e III). Infine \ue8 stata valutata la qualit\ue0 del sonno mediante la Parkinson\u2019s Disease Sleep Scale (PDSS). Ogni outcome \ue8 stato valutato all\u2019inizio, alla fine e ad un mese dai rispettivi trattamenti. Risultati Sono stati reclutati in totale 10 pazienti (8 M e 2 F, et\ue0 media 73,40\ub14,85), 5 sono stati assegnati al gruppo EAP e 5 al gruppo FKT. Entrambi i gruppi, a fine trattamento, hanno mostrato un miglioramento statisticamente significativo in termini di distanza media percorsa in 6 minuti (gruppo EAP: 400,00\ub131,81 vs 439,00\ub152,72; p value=0,043. Gruppo FKT: 352,60\ub152,71 vs 406,20\ub128,05; p value= 0,043), e alla BBS (gruppo EAP 50,20\ub13,34 vs 52,80\ub12,58; p value=0.042. Gruppo FKT: 45,80\ub14,26 vs 49,80\ub13,11; p value= 0,042). Entrambi i gruppi, inoltre, hanno evidenziato una tendenza al miglioramento ma non statisticamente significativo all\u2019UPDRS III (gruppo EAP: 16,00\ub16,12 vs 14,00\ub16,81; p value= 0,06. Gruppo FKT 17,20\ub13,11 vs 14,80\ub12,28; p value=0,066) e al TUG (gruppo EAP 8,74\ub10,93 vs 7,92\ub11,08; p value= 0,066. Gruppo FKT 9,00\ub10,82 vs 7,86\ub11,47; p value= 0,08). Infine, per quanto riguarda la qualit\ue0 del sonno, entrambi i gruppi presentano un miglioramento statisticamente significativo al PDSS (gruppo EAP: 118,20\ub111,88 vs 122,80\ub111,25; p value= 0,026. Gruppo FKT: 112,80\ub19,41 vs 121,40\ub113,16; p value= 0,042). Tutti i risultati sopra riportati si sono mantenuti nel follow up ad un mese senza differenze significative rispetto ai valori registrati all\u2019inizio di entrambi i trattamenti. Conclusioni I presenti dati preliminari del nostro studio mostrano che l\u2019esercizio fisico e il training motorio migliorano le performance correlate all\u2019equilibrio, alla mobilit\ue0 e alla qualit\ue0 del sonno. Appare, inoltre, come l\u2019EAP possa rappresentare un valido trattamento comple- mentare all\u2019ormai consolidato trattamento fisiochinesiterapico. Ci\uf2 \ue8 concorde con la letteratura che presenta l\u2019agopuntura come un trattamento complementare non invasivo utile nel migliorare le performance motorie nei soggetti con MP. La ragione potrebbe essere ricercata nell\u2019effetto neuroprotettivo sui neuroni dopaminergici determinato dall\u2019EAP e dal conseguente incremento di dopamina nelle vie nigro-striatali. Sicuramente un campione pi\uf9 ampio e una valutazione a distanza saranno dirimenti per dimostrare ulteriormente gli effetti motori e sulle ADL dell\u2019EAP su pazienti parkinsoniani

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