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

'Broken Pillars': The Counter-Monumental Texture of Ulysses

... Using an interdisciplinary theoretical-literary approach, this essay offers a fresh perspective on Joyce’s representations of monuments: what I refer to as Joyce against monuments. My aim is to explore the ways in which Joyce’s texts expand, qualify, and supplement the historical, cultural geographical, and theoretical material in relation to this counter-monumental dynamic. This essay is one example of this approach, though here I am limiting the study to only certain monuments, in particular Nelson’s Pillar, as it is represented in Ulysses In complementary ways this essay is both a revisioning of Henri Lefebvre’s thoughts on monuments through Ulysses and a reconsideration of monumental space in Ulysses along and against Lefebvre. Furthermore, it engages with a theoretical and critical matrix comprising the ideas and perspectives of Maurice Blanchot, Michel de Certeau, Michel Foucault, Jean- Luc Nancy, Pierre Nora, W.J.T. Mitchell, James E. Young, and historical and cultural geographers.3 The starting point has to be a rather long, but extremely useful quotation from Lefebvre’s The Production of Space..

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

Background: 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. Objectives: To determine the psychological factors which are associated with or predictive of pain secondary to neurological conditions and to assess the influence of these aspects on the outcome of neurorehabilitation. Methods: Two reviews were performed. In the first, a PUBMED search of the studies assessing the association between psychological factors and pain or the predictive value of these aspects with respect to chronic pain was conducted. The included papers were then rated with regards to their methodological quality and recommendations were made accordingly. In the second study, the same methodology was used to collect the available evidence on the predictive role of psychological factors on the therapeutic response to pain treatments in the setting of neurorehabilitation. Results: The first literature search identified 1170 results and the final database included 189 articles. Factors such as depression, anxiety, pain catastrophizing, coping strategies, and cognitive functions were found to be associated with pain across the various conditions. However, there are differences between chronic musculoskeletal pain, migraine, neuropathy, and conditions associated with complex disability with regards to the psychological aspects that are involved. The second PUBMED search yielded 252 studies, which were all evaluated. Anxiety, depression, pain catastrophizing, coping strategies, and pain beliefs were found to be associated to different degrees with the outcomes of multidisciplinary programs, surgery, physical therapies, and psychological interventions. Finally, sense of presence was found to be related to the effectiveness of virtual reality as a distraction tool. Conclusions: Several psychological factors are associated with pain secondary to neurological conditions and should be acknowledged and addressed in order to effectively treat this condition. These factors also predict the therapeutic response to the neurorehabilitative interventions

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

BackgroundIt 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.MethodsA 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.Results11 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 implicationsThese 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

STUDIO OSSERVAZIONALE SULL’INTEGRAZIONE CON LICOPENE BIOLOGICO NELLA DEGENERAZIONE MACULARE LEGATA ALL’ETÀ (DMLE): CARATTERISTICHE IN CONDIZIONI BASALI DEI PAZIENTI.

Nel mondo la degenerazione maculare legata all’età (DMLE) è la principale causa di grave riduzione della vista (1). Negli USA questa malattia è responsabile di più del 54% dei casi di perdita della vista nella popolazione bianca (2). Studi epidemiologici indicano che più di 1 milione di Americani è affetto dalla forma neovascolare (vedi oltre) e 970 mila sono colpiti dalla forma atrofica (vedi oltre). Una recente revisione della letteratura ha mostrato che in Europa globalmente la prevalenza della DMLE nei soggetti di età compresa tra 65-75 anni varia dal 9 al 25%. Francia e Germania sono i paesi con più elevata prevalenza, rispettivamente 40% e 39%, mentre nel Regno Unito la prevalenza è del 3,5%. In Italia si stima che 1 milione di persone presenti segni di DMLE; ogni anno si registrano 20 mila nuovi casi della forma neovascolare che colpisce l’1% degli ultra 50enni, il 14% degli ultra 75enni e il 30% degli ultra 85enni. La cecità si manifesta in età avanzata: più dell’80% di quelli che ne sono affetti diventano ciechi dopo i 70 anni. La DMLE è due volte più frequente nelle donne rispetto agli uomini. L’esatta patogenesi di questa affezione rimane incerta; si tratta di una malattia multifattoriale legata all'interazione di fattori genetici e ambientali. Tra questi spicca il fumo di sigaretta. Quest’ultimo agirebbe attraverso lo stress ossidativo che è considerato uno dei principali meccanismi che influenzano l’insorgenza della DMLE. La DMLE può presentarsi in due forme: la secca (non essudativa o atrofica) e la umida (essudativa o neovascolare). • La forma secca è caratterizzata dalla comparsa nella macula delle drusen: si tratta di escrescenze di materiale colloide (lipidi, fosfolipidi, collagene) che si accumulano nella membrana di Bruch sottostante all’epitelio pigmentato retinico. Le drusen ostacolano l’ossigenazione e determinano la degenerazione dei fotorecettori, con atrofia e graduale riduzione dell’acuità. È stato evidenziato che più di 8 milioni di Americani hanno almeno una voluminosa drusen in un occhio e che in 3,6 milioni di questi sono presenti drusen bilaterali Di notevole rilevanza è il fatto che la forma secca può evolvere nella più grave forma umida. • La forma umida si manifesta con essudazione ed emorragie maculari, generate dalla neoangiogenesi coroidale, che determinano una rapida perdita della vista. La terapia standard della DMLE neovascolare è rappresentata dall’iniezione intravitreale di un farmaco anti-VEGF. Per prevenire e contrastare l’angiogenesi a livello oculare è necessario identificare molecole angiostatiche che siano dotate di scarsa o nulla tossicità e con via di somministrazione che sia la più semplice possibile. Studi molto recenti hanno dimostrato che il licopene, oltre a essere un potente antiossidante, possiede anche una spiccata attività antiangiogenica. Sahin et al., utilizzando cellule endoteliali umane, hanno infatti evidenziato che il licopene riduce in vitro, in modo dose-dipendente, la loro proliferazione, la loro migrazione e la formazione di neocapillari. L’inibizione dell’angiogenesi è stata confermata da altri studi in cui è stato osservato che questo effetto è la conseguenza di differenti meccanismi: • attività anti-VEGF; • azione anti TNF-α (pro-angiogenesi); • up-regolazione della IL-12 e dell’IFN-γ (citochine antiangiogenesi); • inibizione della MMP-2 (proteasi proangiogenesi) tramite l’attenuazione del VEGFR2. È stato sottolineato che il licopene esercita il suo effetto antiangiogenico a concentrazioni che possono essere raggiunte anche in vivo, ma, a causa della variabilità degli individui e del contenuto di licopene dei pomodori, non è ancora possibile indicare la quantità di questi ortaggi necessaria al raggiungimento dello scopo. È da tempo noto tuttavia che i livelli di licopene sono più bassi nei pazienti con DMLE e solo da poco è stato osservato che esiste una correlazione inversa tra livelli plasmatici di carotenoidi e presenza di questa grave malattia oculare e che ciò è particolarmente rilevante per il licopene che è risultato essere il solo carotenoide in grado di proteggere significativamente sia nei confronti della forma iniziale, sia ancor di più nei confronti della forma essudativa

Prosafe: a european endeavor to improve quality of critical care medicine in seven countries

BACKGROUND: long-lasting shared research databases are an important source of epidemiological information and can promote comparison between different healthcare services. Here we present ProsaFe, an advanced international research network in intensive care medicine, with the focus on assessing and improving the quality of care. the project involved 343 icUs in seven countries. all patients admitted to the icU were eligible for data collection. MetHoDs: the ProsaFe network collected data using the same electronic case report form translated into the corresponding languages. a complex, multidimensional validation system was implemented to ensure maximum data quality. individual and aggregate reports by country, region, and icU type were prepared annually. a web-based data-sharing system allowed participants to autonomously perform different analyses on both own data and the entire database. RESULTS: The final analysis was restricted to 262 general ICUs and 432,223 adult patients, mostly admitted to Italian units, where a research network had been active since 1991. organization of critical care medicine in the seven countries was relatively similar, in terms of staffing, case mix and procedures, suggesting a common understanding of the role of critical care medicine. conversely, icU equipment differed, and patient outcomes showed wide variations among countries. coNclUsioNs: ProsaFe is a permanent, stable, open access, multilingual database for clinical benchmarking, icU self-evaluation and research within and across countries, which offers a unique opportunity to improve the quality of critical care. its entry into routine clinical practice on a voluntary basis is testimony to the success and viability of the endeavor