Placebo effects: clinical aspects and neurobiology

From injury to rehabilitation: How kinesiology taping helps patients with first metatarsophalangeal joint sprain (turf toe) in pain reduction, gait parameters and functional ability improvement. A randomized clinical trial

Objective

Turf toe is a common sports injury that may affect mobility and functional ability. For complete recovery, rehabilitation modalities are required to overcome these issues. This study investigated whether kinesio taping (KT) would reduce pain, improve gait performance, and enhance the functional capacity of turf toe patients undergoing physical therapy.

Methods

sixty patients with grade II turf toe (age; 25-30 years) assigned randomly into three treatment groups; KT applied alongside an exercise program conducted three times/week for 12 successive weeks. (KT group; n = 20), placebo taping plus exercise (Placebo group; n = 20), or exercise only (Control group; n = 20). Pain, gait parameters, and functional ability assessed using VAS, 3D gait analysis, and 6MWT respectively pre- and post-treatment.

Results

There was a significant post-treatment decrease in VAS score in the KT group lower than the control or placebo group and a significant increase in 6MWT distance in the KT group higher than the control or placebo group (p < 0.001). Additionally, there was a significant post-treatment increase in step length, stride length, cadence and velocity of KT group higher than control and placebo group (p < 0.05). There was no significant difference in gait parameters between control and placebo groups post treatment (p > 0.05).

Conclusions

The findings of the study demonstrated that KT is a useful complementary modality to exercise in patients with turf toe, as it may result in more favorable improvements to pain, gait characteristics, and functional abilities. Further studies should be conducted to assess the long-term effects, different KT application methods, and tailored treatment protocols on turf toe.

Stretching is not essential for managing MS spasticity: A randomized controlled trial

BACKGROUND

Clinical practice, expert opinion, and evidence-based guidelines recommend daily stretching as first-line treatment for multiple sclerosis (MS) spasticity, but this has not been evaluated by fully powered clinical trials.

OBJECTIVE

To determine whether MS Spasticity: Take Control (STC), a guideline-based program of spasticity education and stretching exercises has different effects on the impact of spasticity than a control program of different spasticity education and range of motion (ROM) exercises.

METHODS

Ambulatory people with self-reported MS spasticity were randomly assigned to STC or ROM, delivered in same duration, facilitator-led, group classes, face-to-face (F2F) initially and later virtually, due to coronavirus disease 2019 (COVID-19). Multiple Sclerosis Spasticity Scale (MSSS) scores were compared between groups at 1 (primary outcome) and 6 months after interventions.

RESULTS

A total of 231 people enrolled. There was no significant difference in MSSS scores between STC and ROM at 1 month (mean difference = 0.28, 95% (confidence interval (CI)) = [-9.45 to 10.01], p = 0.955). There were significant group mean improvements in MSSS scores and most other outcomes at 1 and 6 months.

CONCLUSION

Education with stretching exercises, the first-line recommended treatment for MS spasticity, and education with ROM exercises may both improve MS spasticity to a similar degree. This study debunks the belief that stretching is essential to managing MS spasticity.

Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis: An updated systematic review

BACKGROUND

Evidence-based recommendations for treatment of Lyme neuroborreliosis (LNB) should rely on the available literature. As new data emerges, close review and evaluation of the recent literature is needed to build evidence-based recommendations to inform clinical practice and management of LNB. We performed an update of a previous systematic review on treatment of LNB.

METHODS

A systematic literature search of Medline and CENTRAL was performed for published studies from 2015 to 2023 to update a previous systematic review. Randomized controlled trials (RCTs) and non-randomized studies (NRS) were evaluated. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs; NRS were assessed using the ROBINS-I-tool. Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data were integrated into an existing meta-analysis of the available literature.

RESULTS

After screening 1530 records, two RCTs and five NRS with new and relevant data were additionally identified. Meta-analysis showed no statistically significant difference between doxycycline and beta-lactam antibiotics regarding residual neurological symptoms after 12 months. Meta-analysis showed no benefit of extended antibiotic treatment of LNB. Three NRS show no benefit for additional steroid use in LNB with facial palsy.

DISCUSSION

Additional incorporated recent research corroborates existing guideline recommendations for treatment of LNB. New RCTs add to the certainty of previous analysis showing similar efficacy for doxycycline and beta-lactam antibiotics in LNB. Available evidence shows no benefit for extended antibiotic treatment in LNB. NRS do not suggest a role for steroids in facial palsy due to LNB.

The Effect of Aromatherapy with Lavender on Pain of Needle Insertion and Severity of Restless Legs Syndrome in Hemodialysis Patients; a Systematic Review and Meta-analysis

Introduction

Pain experienced during the insertion of a catheter into the arteriovenous fistula (AVF) and restless legs syndrome (RLS) are prevalent issues among Hemodialysis (HD) patients. The primary objective of this systematic review and meta-analysis was to consolidate the findings from randomized clinical trial (RCT) studies examining the impact of aromatherapy with lavender on the pain associated with AVF catheter insertion and RLS in HD patients.

Methods

A systematic search was conducted on PubMed, Web of Science, Scopus, Cochrane, Embase, ClinicalTrials.gov, and Google Scholar search engine from inception to August 1, 2022, using keywords extracted from Medical Subject Headings, such as "Aromatherapy", "Lavender", "Arteriovenous fistula", "Pain", "Restless legs syndrome", and "Hemodialysis".

Results

Finally, eleven articles were included in this systematic review and meta-analysis. The results showed that aromatherapy reduced the average pain of catheter insertion in AVF compared to the control group (Standard Mean Difference: -1.60, 95% Confidence Interval: -2.32 to -0.87, Z=4.32, I2:90.3%, P<0.001). Also, aromatherapy massage reduced the average severity of RLS compared to the control group, which was statistically significant (Weighted Mean Difference: -13.21, 95% Confidence Interval: -17.50 to -8.91, Z=6.03, I2:93.0%, P<0.001). Also, the subgroup analysis showed that lavender in the intervention group significantly decreased the pain intensity compared to the "no intervention" group (P<0.001), yet it was not significant compared to the placebo group (P=0.12).

Conclusion

In summary, the findings indicate a notable reduction in catheter insertion pain in AVF and relief from RLS among HD patients through the use of lavender essential oil. As a result, future research is encouraged to include a comparison of lavender's effects with those of a placebo group.

Individualized Homeopathic Medicines for Low Back Pain in Lumbar Spondylosis: Double-Blind, Randomized, Placebo-Controlled Trial

INTRODUCTION

Lumbar spondylosis (LS) is a degenerative disorder of the lumbar spine. Despite substantial research efforts, no gold-standard treatment for LS has been identified. The efficacy of individualized homeopathic medicines (IHMs) in LS has remained under-researched. In this study, the efficacy of IHMs was compared with identical-looking placebos in the treatment of low back pain associated with LS.

METHODS

A double-blind, randomized (1:1), placebo-controlled trial was conducted at the National Institute of Homoeopathy, West Bengal, India. Patients were randomized to receive IHMs or placebos, along with standardized concomitant care for both the groups. The Oswestry low back pain and disability questionnaire (ODQ) was the primary outcome; the Roland-Morris questionnaire (RMQ) and the short form of the McGill pain questionnaire (SF-MPQ) were the secondary outcomes. Each was measured at baseline and every month for 3 months. The intention-to-treat (ITT) sample was analyzed to detect any inter-group differences using two-way repeated measures analysis of variance models overall and by unpaired t-tests at different time points.

RESULTS

Enrolment was stopped prematurely because of time restrictions; 55 patients were randomized (verum: 28; control: 27); 49 were analyzed by ITT (verum: 26; control: 23). Inter-group differences in ODQ (F 1, 47 = 0.001, p = 0.977), RMQ (F 1, 47 = 0.190, p = 0.665) and SF-MPQ total score (F 1, 47 = 3.183, p = 0.081) at 3 months were not statistically significant. SF-MPQ total score after 2 months (p = 0.030) revealed inter-group statistical significance, favoring IHMs against placebos. Some of the SF-MPQ sub-scales at different time points were also statistically significant: e.g., the SF-MPQ average pain score after 2 months (p = 0.002) and 3 months (p = 0.007). Rhus toxicodendron, Sulphur and Pulsatilla nigricans were the most frequently indicated medicines.

CONCLUSION

Owing to failure in detecting a statistically significant effect for the primary outcome and in recruiting a sufficient number of participants, our trial remained inconclusive.

TRIAL REGISTRATION

CTRI/2019/11/021918.

Functional Brain Networks to Evaluate Treatment Responses in Parkinson's Disease

Network analysis of functional brain scans acquired with [18F]-fluorodeoxyglucose positron emission tomography (FDG PET, to map cerebral glucose metabolism), or resting-state functional magnetic resonance imaging (rs-fMRI, to map blood oxygen level-dependent brain activity) has increasingly been used to identify and validate reproducible circuit abnormalities associated with neurodegenerative disorders such as Parkinson's disease (PD). In addition to serving as imaging markers of the underlying disease process, these networks can be used singly or in combination as an adjunct to clinical diagnosis and as a screening tool for therapeutics trials. Disease networks can also be used to measure rates of progression in natural history studies and to assess treatment responses in individual subjects. Recent imaging studies in PD subjects scanned before and after treatment have revealed therapeutic effects beyond the modulation of established disease networks. Rather, other mechanisms of action may be at play, such as the induction of novel functional brain networks directly by treatment. To date, specific treatment-induced networks have been described in association with novel interventions for PD such as subthalamic adeno-associated virus glutamic acid decarboxylase (AAV2-GAD) gene therapy, as well as sham surgery or oral placebo under blinded conditions. Indeed, changes in the expression of these networks with treatment have been found to correlate consistently with clinical outcome. In aggregate, these attributes suggest a role for functional brain networks as biomarkers in future clinical trials.

Transcranial Magnetic Stimulation for the Treatment of Chemo Brain

This pilot feasibility study aimed to evaluate the effects of transcranial magnetic stimulation (TMS) on chemotherapy-related cognitive impairment (CRCI), and we report here on the first patient.

BACKGROUND

Deleterious cognitive changes due to chemotherapy or CRCI are commonly referred to as "chemo brain". With the increasing survival of cancer patients, this poorly understood and inadequately treated condition will likewise have an increasing toll on individuals and society. Since there is no approved treatment for chemo brain, we have initiated a therapeutic trial using transcranial magnetic stimulation (TMS), a non-invasive brain stimulation technique approved in many countries for the treatment of neurologic and psychiatric conditions like migraine and depression.

CASE PRESENTATION

A 58-year-old woman, diagnosed 7 years prior with left breast cancer, underwent partial mastectomy with sentinel lymph node biopsy. She then received four cycles of adjuvant chemotherapy followed by radiation therapy. Afterwards, she was on tamoxifen for 4 years and then switched to aromatase inhibitors. The patient's CRCI started during chemotherapy and severely impaired her quality of life for an additional two years. In the third year after chemotherapy, the CRCI partially cleared to stabilize to the level at the time of presentation for this trial. The patient continues to have memory difficulties and decreased concentration, which makes multi-tasking very difficult to impossible. She is reliant on memory aids at work and at home. The participant underwent 10 consecutive sessions of TMS during weekdays for 2 weeks. Stimulation was directed to the left dorsolateral prefrontal cortex. After TMS, the participant significantly improved in memory function on neuropsychological testing. While she reported no subjective differences in concentration or memory, she did report an improvement in her sleep. Functional magnetic resonance imaging of the brain before and after TMS showed increased resting-state functional connectivity between the stimulation site and several brain regions. Remarkably, after 6 years of chemo brain and remaining in the same position at work due to her inability to concentrate and multi-task, she applied for and received a promotion 5-6 months after her TMS treatments.

CONCLUSIONS

This first patient in the phase 1 clinical trial testing of TMS for the treatment of "chemo brain" provided important lessons for feasibility and insights into mechanisms of potential benefit.

Safety and efficacy of zilucoplan in patients with generalised myasthenia gravis (RAISE): a randomised, double-blind, placebo-controlled, phase 3 study

BACKGROUND

Generalised myasthenia gravis is a chronic, unpredictable, and debilitating rare disease, often accompanied by high treatment burden and with an unmet need for more efficacious and well tolerated treatments. Zilucoplan is a subcutaneous, self-administered macrocyclic peptide complement C5 inhibitor. We aimed to assess safety, efficacy, and tolerability of zilucoplan in patients with acetylcholine receptor autoantibody (AChR)-positive generalised myasthenia gravis.

METHODS

RAISE was a randomised, double-blind, placebo-controlled, phase 3 trial that was done at 75 sites in Europe, Japan, and North America. We enrolled patients (aged 18-74 years) with AChR-positive generalised myasthenia gravis (Myasthenia Gravis Foundation of America disease class II-IV), a myasthenia gravis activities of daily living (MG-ADL) score of least 6, and a quantitative myasthenia gravis score of at least 12. Participants were randomly assigned (1:1) to receive subcutaneous zilucoplan 0·3 mg/kg once daily by self-injection, or matched placebo, for 12 weeks. The primary efficacy endpoint was change from baseline to week 12 in MG-ADL score in the modified intention-to-treat population (all randomly assigned patients who received at least one dose of study drug and had at least one post-dosing MG-ADL score). Safety was mainly assessed by the incidence of treatment-emergent adverse events (TEAEs) in all patients who had received at least one dose of zilucoplan or placebo. This trial is registered at ClinicalTrials.gov, NCT04115293. An open-label extension study is ongoing (NCT04225871).

FINDINGS

Between Sept 17, 2019, and Sept 10, 2021, 239 patients were screened for the study, of whom 174 (73%) were eligible. 86 (49%) patients were randomly assigned to zilucoplan 0·3 mg/kg and 88 (51%) were assigned to placebo. Patients assigned to zilucoplan showed a greater reduction in MG-ADL score from baseline to week 12, compared with those assigned to placebo (least squares mean change -4·39 [95% CI -5·28 to -3·50] vs -2·30 [-3·17 to -1·43]; least squares mean difference -2·09 [-3·24 to -0·95]; p=0·0004). TEAEs occurred in 66 (77%) patients in the zilucoplan group and in 62 (70%) patients in the placebo group. The most common TEAE was injection-site bruising (n=14 [16%] in the zilucoplan group and n=8 [9%] in the placebo group). Incidences of serious TEAEs and serious infections were similar in both groups. One patient died in each group; neither death (COVID-19 [zilucoplan] and cerebral haemorrhage [placebo]) was considered related to the study drug.

INTERPRETATION

Zilucoplan treatment showed rapid and clinically meaningful improvements in myasthenia gravis-specific efficacy outcomes, had a favourable safety profile, and was well tolerated, with no major safety findings. Zilucoplan is a new potential treatment option for a broad population of patients with AChR-positive generalised myasthenia gravis. The long-term safety and efficacy of zilucoplan is being assessed in an ongoing open-label extension study.

FUNDING

UCB Pharma.

Usefulness of the placebo lead-in design for clinical trials with binary outcomes

BACKGROUND

In placebo-controlled clinical trials to develop new drugs for the treatment of psychiatric or neurological disorders, a high and sometimes greater-than-expected placebo response makes it difficult to show the superiority of an investigational drug over a corresponding placebo. To avoid such difficulty, a placebo lead-in design has been presented, but its usefulness has been open to discussion. Although the statistical properties of the placebo lead-in design are investigated in the context of continuous outcomes, whether these properties can be generalized for binary or ordinal cases remains unclear.

METHODS

We investigate whether the placebo lead-in design is useful in clinical trials with binary outcomes through mathematical formulae and a numerical investigation. Specifically, we compare the proportion of placebo responders, the drug-placebo difference, and the effect size between two populations: one enriched for placebo nonresponders and the other comprising the all-comers.

RESULTS

Under positive correlation of the data between the lead-in stage and the randomized stage for both treatment groups, we mathematically show that the proportion of responders in the population enriched for placebo nonresponders is less than that in the all-comers population, and whether the placebo lead-in design increases the drug-placebo difference depends on the variances of outcomes in both treatment groups as well as the correlations of the outcomes between two stages. Further, through a numerical investigation, we show that whether the placebo lead-in design increases the effect size strongly depends on the magnitude of the correlations and their difference.

CONCLUSION

If the correlation of the placebo-placebo group is much higher than that of the placebo-drug group, the placebo lead-in design is advantageous in most cases but has an impact on an estimand in placebo nonresponders. Therefore, we do not recommend using the placebo lead-in design for clinical trials with binary outcomes.

Adjunctive neuronavigated accelerated continuous theta-burst stimulation in obsessive-compulsive disorder: a randomized sham-controlled study

BACKGROUND

Approximately 40% of patients treated for obsessive-compulsive disorder (OCD) do not respond to standard and second-line augmentation treatments leading to the exploration of alternate biological treatments. Continuous theta burst stimulation (cTBS) is a form of repetitive transcranial magnetic stimulation inducing more rapid and longer-lasting effects on synaptic plasticity than the latter. To the best of our knowledge, only one recent study and a case report investigated the effect of cTBS at the supplementary motor area (SMA) in OCD.

OBJECTIVE

This study aimed to examine the effect of accelerated robotized neuronavigated cTBS over SMA in patients with OCD.

METHODS

A total of 32 patients with OCD were enrolled and randomized into active and sham cTBS groups. For active cTBS stimulation, an accelerated protocol was used. Bursts of three stimuli at 50 Hz, at 80% of MT, repeated at 5 Hz were used. Daily 2 sessions of 900 pulses each, for a total of 30 sessions over 3 wk (weekly 10 sessions), were given. Yale-Brown Obsessive-Compulsive Rating Scale (YBOCS), Clinical Global Impressions scale (CGI), Hamilton Depression Rating Scale (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A) were administered at baseline and at end of weeks 3 and 8.

RESULTS

A total of 26 patients completed the study. Active cTBS group showed significant group × time effect in YBOCS obsession (P < .001, η2 = 0.288), compulsion (P = .004, η2 = 0.207), YBOCS total (P < .001, η2 = 0.288), CGI-S (P = .010, η2 = 0.248), CGI-C (P = .010, η2 = 0.248), HAM-D (P = .014, η2 = 0.224) than sham cTBS group.

CONCLUSIONS

Findings from our study suggest that adjunctive accelerated cTBS significantly improves psychopathology, severity of illness, and depression among patients with OCD. Future studies with larger sample sizes will add to our knowledge.

Acupuncture for menstruation-related migraine prophylaxis: A multicenter randomized controlled trial

Objective

The aim of this study was to evaluate the efficacy of acupuncture, an alternative medicine therapy, as a preventive treatment for menstruation-related migraine (MRM).

Patients and methods

This was a prospective, multicenter, double-dummy, participant-blinded, randomized controlled clinical trial conducted in China between 1 April 2013, and 30 April 2014. The participants were enrolled from four study centers and randomized to into either the acupuncture group, which received 24 sessions of acupuncture at traditional acupoints plus placebo, or the medication group, which received sham acupuncture plus naproxen. The primary endpoint was change from the baseline average number of migraine days per perimenstrual period over cycles 1−3. The secondary endpoints included changes from the baseline average number of migraine days outside the perimenstrual period, mean number of migraine hours during and outside the perimenstrual period, mean visual analog scale score during and outside the perimenstrual period, ≥50% migraine responder rate, and the proportion of participants who used acute pain medication over cycles 1−3 and 4−6.

Results

A total of 172 women with MRM were enrolled; 170 in the intention-to-treat analyses. Our primary outcome reported a significant between-group difference that favored the acupuncture group (95% CI, 0.17–0.50; P < 0.001), with the average reduction of migraine days per perimenstrual period from the baseline was 0.94 (95% CI, 0.82–1.07) in the acupuncture group and 0.61 (95% CI, 0.50–0.71) in the medication group over cycles 1−3.

Conclusion

This study showed that compared to medication, acupuncture reduces the number of migraine days experienced by patients with MRM. For patients who received the acupuncture treatment over three cycles, the preventive effect of the therapy was sustained for six cycles.

Clinical trial registration

[https://www.isrctn.com/ISRCTN57133712], identifier [ISRCTN15663606].

Methodology and preliminary data on feasibility of a neurofeedback protocol to improve visual attention to letters in mild Alzheimer's disease

Background

Brain-computer interface (BCI) systems are controlled by users through neurophysiological input for a variety of applications, including communication, environmental control, and motor rehabilitation. Although individuals with severe speech and physical impairment are the primary users of this technology, BCIs have emerged as a potential tool for broader populations, including delivering cognitive training/interventions with neurofeedback (NFB).

Methods

This paper describes the development and preliminary testing of a protocol for use of a BCI system with NFB as an intervention for people with mild Alzheimer's disease (AD). The intervention focused on training visual attention and language skills, as AD is often associated with functional impairments in both. This funded pilot study called for enrolling five participants with mild AD in a six-week BCI EEG-based NFB intervention that followed a four-to-seven-week baseline phase. While two participants completed the study, the remaining three participants could not complete the intervention phase because of COVID-19 restrictions.

Results

Preliminary pilot results suggested: (1) participants with mild AD were able to participate in a study with multiple assessments per week and complete all outcome measures, (2) most outcome measures were reliable during the baseline phase, and (3) all participants with mild AD learned to operate a BCI spelling system with training.

Conclusions

Although preliminary results demonstrate practical feasibility to deliver NFB intervention using a BCI to adults with AD, completion of the protocol in its entirety with more participants is needed to further assess whether implementing NFB-based cognitive intervention is justified by functional treatment outcomes.

Trial registration

This study was registered with ClinicalTrials.gov (NCT03790774).

Association of Long-Term Speech Therapy and Neuromodulation in Primary Progressive Aphasia: Lessons from a Case Report

Primary progressive aphasia (PPA) is a neurodegenerative disorder with a progressive loss of language. Long-term support requires speech therapy but also individually set training programs. Here we propose an 8-month individualized speech-training program which alternates 3-week periods of transcranial direct current stimulation (tDCS) treatment with intensive daily language exercises and a 3-week period without tDCS treatment and a less intensive language exercise from home in a patient with non-fluent variant PPA (nfvPPA). The endpoints were the following: adherence to this program, language data after 8 months, questionnaires related to emotional valence, and brain volume changes. The results showed a persistent adherence after 8 months and a positive compliance reported by both the patient and the partner. The language evaluation showed a clinical stabilization. Moreover, a significant and positive influence of tDCS on mood was observed. This is, to our knowledge, the first ever published report of a combined neuromodulation and language training during the course of 8 months. Our finding suggests the feasibility of programs integrating hospital speech therapy, home training, and tDCS modulation in PPA. Further studies should be conducted in order to disentangle the contextual influences on language performance from the tDCS intervention effects and to address the observation of an initial improvement and a subsequent stabilization effect of language performances.

HPA axis activity across the menstrual cycle - a systematic review and meta-analysis of longitudinal studies

Differential HPA axis function has been proposed to underlie sex-differences in mental disorders; however, the impact of fluctuating sex hormones across the menstrual cycle on HPA axis activity is still unclear. This meta-analysis investigated basal cortisol concentrations as a marker for HPA axis activity across the menstrual cycle. Through a systematic literature search of five databases, 121 longitudinal studies were included, summarizing data of 2641 healthy, cycling participants between the ages of 18 and 45. The meta-analysis showed higher cortisol concentrations in the follicular vs. luteal phase (d_SMC = 0.12, p =.004, [0.04 - 0.20]). Comparisons between more precise cycle phases were mostly insignificant, aside from higher concentrations in the menstrual vs. premenstrual phase (d_SMC = 0.17, [0.02 - 0.33], p =.03). In all included studies, nine samples used established cortisol parameters to indicate HPA axis function, specifically diurnal profiles (k = 4) and the cortisol awakening response (CAR) (k = 5). Therefore, the meta-analysis highlights the need for more rigorous investigation of HPA axis activity and menstrual cycle phase.

Psycho-Neuro-Endocrine-Immunological Basis of the Placebo Effect: Potential Applications beyond Pain Therapy

The placebo effect can be defined as the improvement of symptoms in a patient after the administration of an innocuous substance in a context that induces expectations regarding its effects. During recent years, it has been discovered that the placebo response not only has neurobiological functions on analgesia, but that it is also capable of generating effects on the immune and endocrine systems. The possible integration of changes in different systems of the organism could favor the well-being of the individuals and go hand in hand with conventional treatment for multiple diseases. In this sense, classic conditioning and setting expectations stand out as psychological mechanisms implicated in the placebo effect. Recent advances in neuroimaging studies suggest a relationship between the placebo response and the opioid, cannabinoid, and monoaminergic systems. Likewise, a possible immune response conditioned by the placebo effect has been reported. There is evidence of immune suppression conditioned through the insular cortex and the amygdala, with noradrenalin as the responsible neurotransmitter. Finally, a conditioned response in the secretion of different hormones has been determined in different studies; however, the molecular mechanisms involved are not entirely known. Beyond studies about its mechanism of action, the placebo effect has proved to be useful in the clinical setting with promising results in the management of neurological, psychiatric, and immunologic disorders. However, more research is needed to better characterize its potential use. This review integrates current knowledge about the psycho-neuro-endocrine-immune basis of the placebo effect and its possible clinical applications.

Improving Breast Surgery Outcomes Through Alternative Therapy: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols are the current standard of care when it comes to improving post-surgical outcomes in breast cancer patients. Compliance with all protocol items is required in order for patients to experience significant benefits. Given that the ERAS protocols involve numerous medications which each have unique side effect profiles and medication interactions, this is often difficult to accomplish. Additionally, breast cancer patients are often left with a large psychological burden, which ERAS protocols fail to address. This review aims to determine the role that alternative therapies can play in improving both the emotional and physical strains patients experience during the post-operative stage of recovery. A PubMed search was conducted using the following search terms (“alternative medicine” or “complementary medicine” or “integrative medicine” or “holistic medicine” or “natural medicine" or “mediation” or “aromatherapy” or “music” or “art” or “reiki” or “massage”) and (“surgery”) and (“pain”). Studies selected for this review include articles published or translated in English that addressed alternative medical interventions affecting pre-, peri-, or post-operative outcomes in breast biopsies, surgeries, or breast-related procedures. Eighteen articles fit the inclusion criteria, with seven addressing music, five addressing meditation, yoga, and guided imagery, five addressing massage, one addressing myofascial release, four addressing aromatherapy, two addressing acupuncture, and three addressing hypnosis. Most forms of alternative therapies offered some benefit to patients following breast-related procedures, many resulting in improvements in post-operative outcomes including pain, fatigue, energy, stress, anxiety, mood, and depression. The reviewed studies demonstrated numerous benefits to integrating alternative medicine into standardized therapy to improve postoperative outcomes. Most studies analyzed did not include placebo controls as including proper placebos was often not feasible. Future studies with larger sample sizes are needed to better quantify the benefits patients receive from these noninvasive, low-risk complementary therapies.

Persistent Postsurgical Pain in Oral Cancer Patients Reconstructed with Anterolateral Thigh Free Flap

Background and Objectives: The anterolateral thigh (ALT) flap is widely used in head and neck reconstruction, but the postoperative thigh sensory function lacks sufficient evaluation. The present study reports the postsurgical pain and cancer-related quality of life (QoL) in different stages of oral cancer patients receiving anterolateral thigh (ALT) flap reconstruction. Materials and Methods: Patients were subgrouped into postoperative early-, mid-, and late-recovery stages (postoperative 0.5–1 years, 1–2 years, and above 2 years) according to the time point of assessment. The QoL was examined using the EORTC C-30. Postsurgical donor and receipt site pain was evaluated through subjective reports and sensory tests. Results: Ninety-four patients were included in the final analysis. The functional and global health-related QoL significantly improved with time after surgery. However, spontaneous pain was reported in 57.7%, 72.3%, and 42% of patients in early-, mid-, and late-recovery stages, mainly in donor sites rather than in receipt sites. The highest incidence of donor site pain after ALT flap reconstruction in oral cancer surgery was in the mid-recovery stage but remained high in the late-recovery stage (56.8% and 36.7%, respectively). Conclusions: The postsurgical pain in the donor site might persist to or exhibit delayed onset one to two years postoperatively but is much improved after postoperatively two years later. A longer postsurgical follow-up for over two years for pain and sensory dysfunction is indicated.

Placebo-Related Adverse Events in Rheumatoid Arthritis

Prospective, double-blind, randomized, placebo-controlled studies are considered to provide the highest quality of interventional evidence. This meta-analysis summarizes the frequencies of adverse events according to the Medical Dictionary for Regulatory Activities (MedDRA) in the placebo arms of 101 such studies in rheumatoid arthritis, including a total of 17,150 patients in the placebo arms and 37,819 patients in the verum arms. Placebo-treated patients reported more than one adverse event in a median of 55.0%, 65.5%, and 72.5% (compared to 72.3% in the verum arms), and a serious adverse event in 2.5%, 5.8%, and 8.6% (compared to 5.9% in the verum arms), with stable doses of corticosteroids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), and biological DMARDs as background therapies, respectively. Odds ratios were comparable between placebo and verum arms for nausea (1.00 with 95% confidence interval (CI) 0.86–1.17), for hepatobiliary disorders (1.08 with CI 0.85–1.36), for abnormal hepatic functions (1.09 with CI 0.83–1.44), and general disorders and administration site conditions (1.39 with CI 0.95–2.03). A publication bias has to be assumed for nausea (p = 0.018; Egger’s test), diarrhoea (p = 0.022), and serious infections and infestations (p = 0.009). In conclusion, patients should be aware that “adverse events” may occur even with placebo medication, independent from an additional verum medication added to the background therapy. Further studies are warranted to respect and overcome the psychological and other issues related to these placebo-related “adverse events”.

Theoretical effectiveness of steam inhalation against SARS-CoV-2 infection: updates on clinical trials, mechanism of actions, and traditional approaches

Steam inhalation therapy can be a contemporary approach for COVID-19 affected patients of all age groups to manage respiratory conditions, though it presently lacks the scientific backing to establish itself as a befitting practice. The age of COVID-19 has facilitated this traditional home remedy to resurface among the general mass as a helpful approach for the prevention and adjuvant treatment of the disease. In this review, the means of SARS-CoV-2 infection and impact of the parameters, namely steam inhalation and heat on such infection has been delineated via enumerating the effect of the parameters in the human body and against SARS-CoV-2. The literature search was conducted using PubMed, Web of Science, Scopus, ScienceDirect, Wiley Online Library, Google Scholar, and CNKI Scholar databases. The keywords used in the survey include 'Steam inhalation', 'SARS-CoV-2', 'COVID-19', 'Clinical study', 'Mechanism of action', 'Traditional uses', 'Phytochemistry' and 'Adverse effects'. Clinical studies concerning steam inhalation by COVID-19 patients have been comprehended to demarcate the scientific obscurity of the practice. The safety profile of the procedure has also been outlined emphasizing evading measures against COVID-19 and other related disease states. To recapitulate, application of the steam inhalation with herbal concoctions and phytochemicals having folkloric prevalence as an inhalable remedy against respiratory illnesses has been explored in this review work to focus on a new aspect in the COVID-19 treatment paradigm using steam and progress of further research hither.

Psychedelics, Sociality, and Human Evolution

Our hominin ancestors inevitably encountered and likely ingested psychedelic mushrooms throughout their evolutionary history. This assertion is supported by current understanding of: early hominins' paleodiet and paleoecology; primate phylogeny of mycophagical and self-medicative behaviors; and the biogeography of psilocybin-containing fungi. These lines of evidence indicate mushrooms (including bioactive species) have been a relevant resource since the Pliocene, when hominins intensified exploitation of forest floor foods. Psilocybin and similar psychedelics that primarily target the serotonin 2A receptor subtype stimulate an active coping strategy response that may provide an enhanced capacity for adaptive changes through a flexible and associative mode of cognition. Such psychedelics also alter emotional processing, self-regulation, and social behavior, often having enduring effects on individual and group well-being and sociality. A homeostatic and drug instrumentalization perspective suggests that incidental inclusion of psychedelics in the diet of hominins, and their eventual addition to rituals and institutions of early humans could have conferred selective advantages. Hominin evolution occurred in an ever-changing, and at times quickly changing, environmental landscape and entailed advancement into a socio-cognitive niche, i.e., the development of a socially interdependent lifeway based on reasoning, cooperative communication, and social learning. In this context, psychedelics' effects in enhancing sociality, imagination, eloquence, and suggestibility may have increased adaptability and fitness. We present interdisciplinary evidence for a model of psychedelic instrumentalization focused on four interrelated instrumentalization goals: management of psychological distress and treatment of health problems; enhanced social interaction and interpersonal relations; facilitation of collective ritual and religious activities; and enhanced group decision-making. The socio-cognitive niche was simultaneously a selection pressure and an adaptive response, and was partially constructed by hominins through their activities and their choices. Therefore, the evolutionary scenario put forward suggests that integration of psilocybin into ancient diet, communal practice, and proto-religious activity may have enhanced hominin response to the socio-cognitive niche, while also aiding in its creation. In particular, the interpersonal and prosocial effects of psilocybin may have mediated the expansion of social bonding mechanisms such as laughter, music, storytelling, and religion, imposing a systematic bias on the selective environment that favored selection for prosociality in our lineage.

Immunomodulation-A Molecular Solution to Treating Patients with Severe Bladder Pain Syndrome?

Background

Patients with bladder pain syndrome experience debilitating pain and extreme frequency of urination. Numerous therapeutic approaches have been tested, but as the molecular basis of disease has remained unclear, specific therapies are not available.

Objective

Recently, a systematic gene deletion strategy identified interleukin-1 (IL-1) hyperactivation as a cause of severe cystitis in a murine model. Treatment with an IL-1 receptor antagonist (IL-1RA) restored health in genetically susceptible mice, linking IL-1–dependent inflammation to pain and pathology in the bladder mucosa. The study objective was to investigate whether IL-1RA treatment might be beneficial in patients with bladder pain syndrome.

Design, setting, and participants

Patients diagnosed with bladder pain syndrome were invited to participate and subjected to daily IL-1RA injections for 1 wk, followed by a treatment break. Patients with other urological disorders accompanied by pain were included as controls.

Outcome measurements and statistical analysis

When symptoms returned, treatment was resumed and responding patients were maintained on treatment long term, with individualized dosing regimens. Symptom scores were recorded and molecular effects were quantified by neuropeptide and gene expression analysis. DNA samples were subjected to exome genotyping.

Results and limitations

IL-1RA treatment reduced bladder pain and the frequency of urination in 13/17 patients (p < 0.001). Substance P levels in urine were lowered, and responders returned to a more normal lifestyle. Neuroinflammatory-dependent and IL-1–dependent gene networks were inhibited, as well as regulators of innate immunity. Genotyping revealed disease-associated IL1R1, NLRP3, and IL1RN DNA sequence variants in the responders. Controls did not benefit from IL-1RA treatment, except for one patent with cystitis cystica.

Conclusions

In this clinical study, IL-1RA treatment is proposed to reduce chronic bladder pain, immediately and in the long term. Despite the limited number of study patients, the potent acute effect and lasting symptom relief indicate that this therapeutic approach may be worth exploring in controlled clinical trials.

Patient summary

Treatment with an interleukin-1 (IL-1) receptor antagonist is proposed for treating bladder pain syndrome, as it can result in symptom relief and increase quality of life. Reduced neuroinflammation and IL-1 signaling provided molecular evidence of the treatment effects.

Subjective cognition and mood in persistent chemotherapy-related cognitive impairment

PURPOSE

Persistent chemotherapy-related cognitive impairment (CRCI) is commonly reported following cancer treatment and negatively affects quality of life. While past research has focused on potential pathophysiological mechanisms underlying this relationship, the role of psychological factors, such as mood, stress, and anxiety, in the development of persistent CRCI has received less attention. As an additional analysis of data from a trial investigating the effects of transdermal nicotine patches on cognitive performance in patients with persistent CRCI, we examined whether change in mood was associated with changes in subjective and objective cognitive functioning.

METHODS

Participants were randomized to either placebo (n = 11) or transdermal nicotine (n = 11) for 6 weeks, followed by 2 weeks of treatment withdrawal for a total of 8 weeks. Participants were assessed using behavioral, subjective, and objective measures of cognitive functioning and mood at five visits before, during, and after treatment.

RESULTS

Although we did not detect an effect of treatment assignment on mood, over the course of the study, we observed a significant improvement on measures of mood that correlated with improvement in subjective and objective cognitive performance.

CONCLUSIONS

We observed improvement in objective and subjective cognitive performance measures. These changes were associated with improvement in subsyndromal mood symptoms, likely resulting from participation in the trial itself.

IMPLICATIONS FOR CANCER SURVIVORS

These results suggest that women with persistent CRCI may benefit from support and validation of their cognitive complaints, cognitive rehabilitation/therapies into their post-cancer care.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (trial registration: NCT02312943).

Clinical relevance of an intervention assessed by a meta-analysis of randomized clinical trials

OBJECTIVES

Many meta-analyses usually omit the number needed to treat, or perform the calculation incorrectly, despite its importance in clinical decision-making. Accordingly, we will explain in an easily understandable way how to perform this procedure to assess the clinical relevance of the intervention.

STUDY DESIGN AND SETTING

The expressions of the Cochrane Library and the concepts of clinical relevance and evidence-based medicine were applied. Simple cutoff points were also established to facilitate the task of interpreting results. The method was applied to two published meta-analyses to illustrate its application to real cases (treatment nonadherence).

RESULTS

In the first example, with a risk in the control group ranging from 0.22 to 0.70, sending mobile phone messages to remind chronic patients to take their medication is clinically relevant with a high degree of evidence. For the second example (single-pill regimen in patients suffering from hypertension and/or dyslipidemia after 6 months), the range of the assumed control risk was between 0.28 and 0.57.

CONCLUSION

The constructed algorithm could be applied to published meta-analyses or incorporated systematically in all meta-analyses with these characteristics.

The effects of an internet-based mindfulness meditation intervention on electrophysiological markers of attention

Evidence suggests that mindfulness meditation training has the potential to train aspects of attention. However, the neurophysiological mechanisms underpinning the attentional benefits from mindfulness remain unclear. This randomized controlled trial examined changes in electrophysiological markers of attention before and after completion of a 6-week internet-based mindfulness intervention. EEG and ERP data were collected from 64 generally healthy, mildly stressed older adults. Participants were randomized to an internet-based mindfulness-based stress reduction course (IMMI), an internet-based health and wellness education course, or a waitlist control condition. Attentional N2 and P3 evoked potentials were derived from active and passive auditory oddball paradigms. Participants in the IMMI group showed significantly greater differences in P3 peak-trough amplitude between the active and passive oddball paradigms at endpoint relative to controls. There were no significant relationships between the intervention and N2 potentials. Our data demonstrate a measurable increase in attentional control when discriminating or directing attention away from auditory stimuli for older adult participants who received mindfulness training. These findings lend support to the use of the P3 as a neurophysiological measure of meditation engagement and intervention efficacy.

Placebo response in degenerative cerebellar ataxias: a descriptive review of randomized, placebo-controlled trials

Placebo response in degenerative cerebellar ataxias (CAs) has never been studied despite the large number of randomized controlled trials (RCTs) that have been conducted. In this descriptive review, we aimed to examine the placebo response in patients with CAs. We performed a literature search on PubMed for RCTs on CAs that were published from 1977 to January 2020 and collected data on the changes from the baseline to the endpoint on various objective ataxia-associated clinical rating scales. We reviewed 56 clinical trials, finally including 35 parallel-group studies and excluding 21 cross-over studies. The included studies were categorized as follows: (1) studies showing significant improvements in one or more ataxia scales in the placebo groups (n = 3); (2) studies reporting individual placebo responders with improvements in one or more ataxia scales in the placebo groups (n = 5)-the overall proportion of placebo responders was 31.9%; (3) studies showing mean changes in the direction of improvement in at least one ataxia scale in the placebo groups, though not statistically significant (n = 19); (4) studies showing no placebo response in any of the ataxia scales in the placebo groups (n = 4); (5) studies where data on the placebo groups were unavailable (n = 9). This review demonstrated the placebo response in patients with CAs on various objective ataxia scales. Our study emphasizes that the placebo response should be considered when designing, analyzing, and interpreting clinical trials and in clinical practice in CA patients.

Energy Medicine treatments for hand and wrist pain: A pilot study

INTRODUCTION

The term "energy medicine" describes healing modalities that manipulate or channel purported subtle energies associated with the body. The objectives of this pilot study were to determine the feasibility of studying energy medicine for people with carpal tunnel pain and gathering relevant preliminary data.

METHODS

Following a prospective, within-participant design, participants were recruited to experience a 30 min treatment from one of 17 energy medicine practitioners. Of 374 adults experiencing carpal tunnel pain who were screened for the study, 190 received an energy medicine treatment. Practitioners delivered treatments at close distance, some with and some without light, stationary touch. Outcome measures were collected before, during, and immediately after the treatment, and three weeks later. The primary outcome measure was self-reported pain. Secondary subjective measures included credibility regarding energy medicine and expectancy regarding the efficacy of treatments, pain interference, sleep quality, well-being, mood, and sense of personal transformation. Physiological measures included median nerve conduction velocity, heart rate variability, heart rate synchrony (between the participant and practitioner), and expression levels of neuroinflammation-related genes.

RESULTS

On average, self-reported current pain scores decreased 2.0 points post-session and 1.3 points at three weeks compared to baseline values using a 0-10 point scale with 10 denoting worst pain (F(2, 565) = 3.82 p <0.000005). This effect was not influenced by the participants' level of expectancy or credibility regarding the energy medicine modality. Well-being, negative emotion, and sleep quality scores significantly improved at the follow-up visit. Multiple heart rate variability measures significantly changed reflecting increased parasympathetic activity which may indicate decreased stress. No other secondary outcome showed significant change.

DISCUSSION

Studying the administration of energy medicine to people with carpal tunnel pain is feasible, although requiring a documented carpal tunnel syndrome diagnosis proved to be prohibitive for recruitment. Our finding of preliminary evidence for positive effects in pain and pain-related outcomes after a single session of energy medicine warrants further controlled investigation.

A case study of extended human capacity perception during Energy Medicine treatments using mixed methods analysis

INTRODUCTION

Some "energy medicine" modalities, such as Reiki, continue to show evidence for efficacy, but the underlying mechanisms of action are still uncertain. To help illuminate possible mechanisms, this exploratory mixed-method study using qualitative and quantitative analyses investigated: 1) How do energy medicine sessions function from the perspective of a seer, i.e., an individual trained in techniques to enable perception of purported subtle energies, and 2) Do any of these observations correlate with changes in participants' subjective pain?

METHOD

One seer reported observations during 30-minute energy medicine sessions delivered by 17 practitioners to participants experiencing chronic hand or wrist pain. Data were coded using an inductive approach, followed by thematic and descriptive analyses. Content analysis was used to assign whether each code was mentioned by the seer for each participant, generating 119 binary variables, one for each code. The relationship between these binary variables and change in participant pain scores after the energy medicine session and three weeks later were explored using linear regression models.

RESULTS

The qualitative thematic analysis identified six major themes from the seer's notes: "Experience of the Practitioner," "Experience of the Participant," "Space and Other Beings" (referring to the qualities of the physical space the energy medicine session occurred in and ostensible non-physical beings present during session), "Participant-Practitioner Relationship," "Healing Process," and "Attributes of Energy." The energy medicine methods used varied for each participant, according to the practitioners' perceptions of each individual's needs. The linear regression models yielded significant associations between changes in pain scores and various codes, including energy color, practitioner touch and the presence of ostensible non-physical beings supporting the session, although their significance did not persist after correction for multiple comparisons.

DISCUSSION

Future studies investigating the mechanisms of energy medicine may benefit from including perceptions by seers in their outcome measures.

Effects of bilateral transcranial direct current stimulation on working memory and global cognition in older patients with remitted major depression: A pilot randomized clinical trial

OBJECTIVES

To assess the effects of a 10-day course of bilateral anodal transcranial direct current stimulation (tDCS) of the dorsolateral prefrontal cortex (DLPFC) on working memory and global cognition in elderly participants with remitted major depressive disorder at 14 days (primary outcome) and 90 days (secondary outcome) post intervention.

DESIGN

Randomized double blind controlled trial (clinicaltrials.gov # NCT02212366).

SETTING

Community dwelling outpatient setting.

PARTICIPANTS

Sixty or older with previous single or recurrent episodes of major depression currently in full remission.

INTERVENTION

A 10 day course of active or sham bilateral DLPFC anodal tDCS.

MEASUREMENTS

(a) Working memory assessed by a computerized N back task, and (b) global cognition assessed by a standard paper and pencil neuropsychological test battery.

RESULTS

Thirty-three participants, (mean (SD) age = 66. 5 (5.7) year) were enrolled, out of which 18 (mean (SD) age = 66. 3 (5.8) year) were randomized to active tDCS and 15 (mean (SD) age = 66. 7 (5.8) years) to sham tDCS. All randomized participants except one from the sham group -completed the tDCS course. There were no differences between the groups on working memory performance or global cognition at 14 or 90 days post intervention. Both groups showed promising changes in working memory and global cognition over time.

CONCLUSIONS

tDCS was well tolerated in older patients with remitted MDD, however, as compared to the sham group, it did not improve working memory or global cognition. Future studies should investigate tDCS with alternative parameters to enhance cognition in this population.

Ayurveda and COVID-19: Where psychoneuroimmunology and the meaning response meet

The COVID-19 pandemic has led to high levels of psychological distress in the general public, including symptoms of anxiety and depression. Such distress is associated with alterations in immune function, including an elevated risk of viral respiratory tract infections. In this light, the possible effects of Ayurveda, a traditional system of medicine promoted by the Indian government as an "immune booster", are examined from the point of view of psychoneuroimmune mechanisms as well as the "meaning response" described by Moerman. It was found that many of the measures advocated in their guidelines could positively influence immunity either by direct effects on symptoms of depression or anxiety, or through their symbolic significance. Therefore, it is possible that such traditional practices could be beneficial both in terms of psychological quality of life, and in terms of moderating the risk of infection.

Salivary Cortisol Levels and Burning Symptoms in Patients with Burning Mouth Syndrome before and after Low Level Laser Therapy: a Double Blind Controlled Randomized Clinical Trial

Objectives

Burning mouth syndrome (BMS) is a disorder which is described as burning sensation of the oral mucosa without pathological changes. Most of the patients have some underlying stressful conditions. Stress induces an increase in secretion of different endocrine glands resulting in higher levels of glucocorticoids. One of the options for treatment of BMS includes low level laser therapy (LLLT). The aim of this research was to determine salivary cortisol levels and intensity of burning symptoms in BMS patients before and after LLLT.

Materials and Methods

Twenty-three participants were allocated by randomization in two groups: 12 patients in the study group and 11 patients in the placebo group. Cortisol levels in all patients were analyzed from the sample of saliva collected without stimulation. In both groups, the LLLT was performed once a day for ten consecutive days (excluding weekend) with Ga-Al-As light-emitting diode type of laser, with a wavelength of 685nm. In the control group, LLLT was done with inactive laser probe which was only emitting audio signal. The intensity of burning symptoms was measured by a visual analogue scale (VAS). The VAS and unstimulated saliva were measured at baseline and on the last day of the LLLT. A quantitative analysis of saliva was performed using competitive commercial ELISA-kit.

Results

VAS scores and salivary cortisol levels were significantly lower in both groups after LLLT.

Conclusions

LLLT can be useful in patients with BMS for reducing burning symptoms and salivary cortisol level. Future studies on a larger number of patients should clarify whether the positive results are an outcome of laser effectiveness or of placebo effect.

Maximizing placebo response in neurological clinical practice

The placebo effect is a widely recognized phenomenon in clinical research, with a negative perception that it could hide the "true" drug effect. In clinical care its positive potential to increase known drug effects has been neglected for too long. The placebo and nocebo responses have been described in many neurologic disorders such as Parkinson's, Huntington's and Alzheimer's diseases, restless leg syndrome, tics, essential tremor, dystonia, functional movement disorders, neuropathic pain, headaches, migraine, amyotrophic lateral sclerosis, myasthenia gravis, chronic inflammatory demyelinating polyneuropathy, multiple sclerosis and epilepsy. Knowledge regarding placebo mechanisms and their consequences on clinical outcome have greatly improved over the last two decades. This evolution has led to reconsiderations of the importance of placebo response in the clinic and has given several clues on how to improve it in daily practice. In this chapter, we first illustrate "why," e.g. the reasons (relevance to clinical practice, help in differential diagnosis/treatment of psychogenic movements, clinical impact, proven neurobiological grounds, health economic potential), and "how," e.g. the means (increase patients' knowledge, increase learning, improve patient-doctor relationship, increase Hawthorne effect, increase positive/decrease negative expectations (the Rosenthal effect), personalize placebo response), the placebo should be maximized (and nocebo avoided) in neurological clinical practice. Future studies regarding more specific neurobiological mechanisms will allow a finer tuning of placebo response in clinical practice. The use of placebo in clinical practice raises ethical issues, and a recent expert consensus regarding placebo use in the clinic is a first step to future guidelines necessary to this field.

Determinants of placebo effects

Determinants of placebo effects and placebo response can be considered from multiple intrinsic and extrinsic perspectives. Intrinsic factors may influence the patient and the clinician/researcher. Patient expectations and previous experiences are considered two of the major intrinsic determinants of placebo response. Other patient determinants include the neural systems under treatment/study, situational factors and reactions to the environment, and personality traits. Clinician/researcher determinants of placebo response include personality factors such as empathy, perceived expertise, the clinical relationship with the patient, and the clinician's belief in the efficacy of the treatment. Extrinsic determinants include the type of study design, influence of advertising or branding, and forces expressed by the cultural milieu. These determinants do not act in isolation, but rather form a complex interaction that ultimately impacts the promotion or deterrence of the placebo effect in clinical and research settings.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

A Prospective, Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to Mild‐to‐Moderate Traumatic Brain Injury

Objectives

Materials and Methods

Results

Conclusions

Platelet rich plasma for treatment of osteochondral lesions of the talus: A systematic review of clinical trials

BACKGROUND

The ankle is the second most frequent site, following the knee, that requires cartilage repair. Osteochondral lesion of the talus (OLT) is common among athletes and is a result of talar cartilage detachment with or without subchondral bone fragmentation after a traumatic event. Treatment strategies for OLT can be classified as reparative or replacement interventions, with the former taking precedence. Recent studies show that the growth factors and bioactive components in platelet rich plasma (PRP) could improve cartilage regeneration. The prospect of using autologous blood to obtain a product that could enhance regeneration in damaged cartilage has been regarded as innovative, as it could circumvent the need for a replacement, and potentially join the ranks of first line reparative interventions against cartilage diseases.

METHODS

Literature searches were performed across seven search engines for randomized controlled trials using PRP to treat patients with OLT. Outcomes extracted included ankle function and pain measures. Level of evidence and methodological quality were evaluated using relevant guidelines.

RESULTS

Four studies met the eligibility criteria and were systematically appraised. Two studies scored Level 1 and 2 scored Level 2 based on the LOE assessment. MQOE evaluation revealed one study with excellent quality, and three with good quality. Overall results showed that PRP, as an adjunct to microfracture surgery, significantly improved function and reduced pain compared to microfracture surgery alone. Intra-articular PRP injection also demonstrated significantly enhanced recovery of function, and decreased pain scores compared to HA.

CONCLUSION

PRP improves joint function, and reduces pain in patients with OLT regardless of the method of implementation. In addition, inter-study comparison demonstrated that patients that received surgery along with PRP injections improved more than those that received PRP only. The studies that corroborate this conclusion have high levels of evidence with satisfactory methodological quality.

LEVEL OF EVIDENCE

Level 2, systematic review of Level 1 and 2 studies.

Differential impact of mindfulness practices on aggression among law enforcement officers

Objectives

Home-based mindfulness practice is a common component of formal mindfulness training (MT) protocols. Obtaining objective data from home-based mindfulness practice is challenging. Interpreting associations between home-based mindfulness practice and clinically impactful outcomes is complicated given the variability in recommendations in length, frequency, and type of practice. In this exploratory study, adherence to home-based practices of Mindfulness-Based Resilience Training (MBRT) was studied in order to evaluate associations with clinical outcomes.

Methods

Home practices from 24 (92% male, non-Hispanic white, aged M = 43.20 years) law enforcement officers (LEOs) from the urban Pacific Northwest enrolled in a feasibility and efficacy trial of MBRT were studied using an objective tracking device and self-report data. Outcomes included adherence to home-based mindfulness practices and self-reported aggression.

Results

Participants completed 59.12% of the frequency amount of practice assigned in the MBRT curriculum. Frequency of practice was associated with decreased aggression, adjusted R ² = .41, F(3,23) = 6.14, p = .004. Duration of practice also predicted decreased aggression, adjusted R ² = .33, F(3,23) = 4.76, p = .011.

Conclusions

Home-based MBRT practices for LEOs, even at low rates of adherence, may reduce aggression. MTs may show beneficial effects for other populations presented with challenges to engage in regular MT practices.

Sequential parallel comparison design with two coprimary endpoints

A placebo-controlled randomized clinical trial is required to demonstrate that an experimental treatment is superior to its corresponding placebo on multiple coprimary endpoints. This is particularly true in the field of neurology. In fact, clinical trials for neurological disorders need to show the superiority of an experimental treatment over a placebo in two coprimary endpoints. Unfortunately, these trials often fail to detect a true treatment effect for the experimental treatment versus the placebo owing to an unexpectedly high placebo response rate. Sequential parallel comparison design (SPCD) can be used to address this problem. However, the SPCD has not yet been discussed in relation to clinical trials with coprimary endpoints. In this article, our aim was to develop a hypothesis-testing method and a method for calculating the corresponding sample size for the SPCD with two coprimary endpoints. In a simulation, we show that the proposed hypothesis-testing method achieves the nominal type I error rate and power and that the proposed sample size calculation method has adequate power accuracy. In addition, the usefulness of our methods is confirmed by returning to an SPCD trial with a single primary endpoint of Alzheimer disease-related agitation.

Follow-up results of a randomized clinical trial for low-level laser therapy in painful TMD of muscular origins

Objective: To characterize short- and long-term assessment of the low-intensity laser therapy (LLLT) effectiveness in women with TMD of muscular origins and to evaluate whether the information about the treatment received (active or placebo) modifies the pain intensity.Methods: Forty-one women with painful TMD (31.7 ± 5.2 years) were divided into laser (n = 20) and placebo (n = 21) groups. The pain intensity was measured at the baseline, after the LLLT (T8), 6 and 12 months. At the 6-month follow-up, the groups received information about the active or placebo treatment.Results: At T8 and 6-month, both active and placebo LLLT were effective in reducing pain (p < .05). After one year, the groups showed similar pain. Active LLLT was more effective in reducing pain palpation (p = .001) and referred pain (p = .04) in the region of the TMJs. The information about the treatment modified the perceived pain intensity.Conclusion: Active and placebo LLLT are effective for painful TMD of muscular origins in the short-term. Information about the treatment impairs the subjective perception of pain.

Nicotinic treatment of post-chemotherapy subjective cognitive impairment: a pilot study

PURPOSE

Persistent chemotherapy-related cognitive impairment (pCRCI) is commonly reported following cancer treatment and negatively affects quality of life; however, there is currently no pharmacological treatment indicated for pCRCI. This pilot study obtained preliminary data regarding the use of transdermal nicotine patches as a therapeutic strategy for women with pCRCI to (1) reduce subjective cognitive complaints and (2) enhance objective cognitive performance in breast, colon, lymphoma, or ovarian cancer survivors with pCRCI.

METHODS

Participants were randomized to either placebo (n = 11) or transdermal nicotine (n = 11) for 6 weeks, followed by 2 weeks of treatment withdrawal for a total of 8 weeks. Participants were assessed using both subjective and objective measures of cognitive functioning at five visits before, during, and after treatment.

RESULTS

Over the course of the study, women in both groups improved substantially in severity of self-reported cognitive complaints measured by Functional Assessment of Cancer Therapy-Cognitive Function Perceived Cognitive Impairments regardless of treatment arm. Additionally, objective cognitive performance measures improved in both groups; however, there was no significant difference in improvement between groups.

CONCLUSIONS

Due to a large placebo response, we were unable to determine if a drug effect was present. However, we did observe substantial improvement in self-reported cognitive symptoms, likely resulting from factors related to participation in the trial rather than specific drug treatment effects.

TRIAL REGISTRATION

The study was registered with clinicaltrials.gov (trial registration: NCT02312943).

IMPLICATIONS FOR CANCER SURVIVORS

These results suggest that women with pCRCI can exhibit improvement in subjective cognition, with attention paid to symptoms and close follow-up over a short period of time.

Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury

Objective

To compare the efficacy of high- and low-frequency noninvasive translingual neurostimulation (TLNS) plus targeted physical therapy (PT) for treating chronic balance and gait deficits due to mild-to-moderate traumatic brain injury (mmTBI).

Design

Participants were randomized 1:1 in a 26-week double-blind phase 1/2 study (NCT02158494) with 3 consecutive treatment stages: in-clinic, at-home, and no treatment. Arms were high-frequency pulse (HFP) and low-frequency pulse (LFP) TLNS.

Setting

TLNS plus PT training was initiated in-clinic and then continued at home.

Participants

Participants (N=44; 18-65y) from across the United States were randomized into the HFP and LFP (each plus PT) arms. Forty-three participants (28 women, 15 men) completed at least 1 stage of the study. Enrollment requirements included an mmTBI ≥1 year prior to screening, balance disorder due to mmTBI, a plateau in recovery with current PT, and a Sensory Organization Test (SOT) score ≥16 points below normal.

Interventions

Participants received TLNS (HFP or LFP) plus PT for a total of 14 weeks (2 in-clinic and 12 at home), twice daily, followed by 12 weeks without treatment.

Main Outcome Measures

The primary endpoint was change in SOT composite score from baseline to week 14. Secondary variables (eg, Dynamic Gait Index [DGI], 6-minute walk test [6MWT]) were also collected.

Results

Both arms had a significant (P<.0001) improvement in SOT scores from baseline at weeks 2, 5, 14 (primary endpoint), and 26. DGI scores had significant improvement (P<.001-.01) from baseline at the same test points; 6MWT evaluations after 2 weeks were significant. The SOT, DGI, and 6MWT scores did not significantly differ between arms at any test point. There were no treatment-related serious adverse events.

Conclusions

Both the HFP+PT and LFP+PT groups had significantly improved balance scores, and outcomes were sustained for 12 weeks after discontinuing TLNS treatment. Results between arms did not significantly differ from each other. Whether the 2 dosages are equally effective or whether improvements are because of provision of PT cannot be conclusively established at this time.

Clinical Features at Baseline Cannot Predict Symptom Response to Placebo in Patients With Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease characterized by ≥15 eosinophils per high-power field (eos/hpf) and esophageal dysfunction.¹ One confounder in the assessment of drug efficacy in clinical trials for EoE² and other gastrointestinal diseases^3,4 has been the symptomatic response to placebo. In placebo-controlled, randomized trials of EoE therapies, placebo response rates as high as 78% have been reported.² To mitigate placebo effect, a phase 2, randomized, double-blind, placebo-controlled trial of budesonide oral suspension (BOS) was designed with a single-blind, placebo run-in to attempt to screen out placebo responders before randomization.⁵ The aim of this post hoc analysis was to identify clinical factors associated with a symptom response during the placebo run-in.

The first-generation phosphodiesterase 5 inhibitors and their pharmacokinetic issue

Background

Erectile dysfunction (ED) is a relatively frequent disease that negatively impacts the overall quality of life, well‐being, and relationships. Although the use of phosphodiesterase 5 inhibitors (PDE5is) has revolutionized the treatment of ED, a high percentage of ED patients discontinue PDE5i treatment.

Objectives

(i) To analyze the reasons for patient dissatisfaction leading to PDE5i discontinuation; (ii) analyze the pharmacokinetics of new formulations focusing on the time needed to reach an effective plasma concentration of PDE5is (T_onset) following drug intake; and (iii) summarize the physicochemical properties of sildenafil to understand which excipients may increase the absorption rate.

Material and methods

An online PubMed literature search was conducted to identify English language publications from inception to January 2019.

Results

The main reasons for patient dissatisfaction when using PDE5is on demand are the relatively long T_onset after taking vardenafil and sildenafil, including formulations such as film‐coated tablets, fine granules, orally disintegrating tablets (ODTs), and oral thin films (ODFs). The relatively long T_onset, further worsened when accompanied by eating, highlights the following: (i) the need for planning intercourse, determining partner‐related issues; (ii) issues when having sex before the maximum effect of the drug; and (iii) lower drug‐related placebo effects. Some data suggest that sildenafil is a ‘difficult’ molecule, but T_onset can be improved following absorption by buccal mucosa using appropriate excipients.

Conclusions

We conclude that several ODT and ODF formulations can improve the ‘discretion’ issue because they are taken without water, but they have similar pharmacokinetics to corresponding film‐coated tablet formulations. One ODF formulation of sildenafil was characterized by a shorter T_onset and could potentially increase patient satisfaction following treatment. However, more clinical studies are needed to confirm the findings. Surfactants and ascorbic acid appear to be crucial excipients for achieving a high absorption rate, but more studies are needed.

Correlation of Pain Reduction with fMRI BOLD Response in Osteoarthritis Patients Treated with Paracetamol: Randomized, Double-Blind, Crossover Clinical Efficacy Study

Objective

To assess the relationship between the analgesic efficacy of extended-release paracetamol (ER-APAP) and brain blood oxygen level–dependent (BOLD) signal activation in response to painful stimulation measured by functional magnetic resonance imaging (fMRI) in patients with osteoarthritis of the knee.

Methods

This placebo-controlled, double-blind, crossover, randomized trial (N = 25) comprised three treatment periods in which patients received four doses of an eight-hour ER-APAP caplet (2 x 665 mg), four doses of matched placebo, and no treatment. Pain intensity of the knee was measured before and after painful stimulation at the knee with osteoarthritis and before and after fMRI.

Results

ER-APAP significantly reduced prestimulation osteoarthritis knee joint pain compared with baseline (P < 0.003) and placebo (P < 0.004). ER-APAP and placebo significantly reduced knee joint pain after stimulation (P = 0.014 and P = 0.032, respectively); however, pain reduction with ER-APAP was 35% greater than placebo. ER-APAP was associated with significant reductions in BOLD signal activation after stimulation compared with control in the sensory cortex (P = 0.002) and supramarginal gyrus (P = 0.003). Reduction in BOLD signal activation after stimulation for placebo was significantly greater than control in the subgenual prefrontal cortex (P < 0.001), frontal cortex (P < 0.001), insula (P < 0.003), and sensory cortex (P < 0.001).

Conclusions

ER-APAP had a significantly greater effect than placebo and no treatment in reducing knee pain, which was associated with reduced BOLD signal activations in pain pathways, including the sensory cortex and supramarginal gyrus. BOLD observations after placebo treatment may shed light on the role of the brain regions potentially involved in placebo response in clinical trials investigating pain therapies.