Case study investigating effect of implementing strategies for reducing patient complaints in an outpatient pain clinic.

This case study explores the impact of improving communication for reducing complaints in an outpatient pain clinic. A retrospective review was conducted for two 6-month periods prior to and for 6 months after implementing a structured communication strategy that included changes in staff behavior and documentation. Most complaints were related to not receiving opioids as part of the treatment plan. In the first treatment period prior to implementation, 6 of 3,653 patients lodged complaints. In the second period prior to implementation, 8 of 3,992 patients lodged complaints. Following implementation, 3 of 3,879 patients lodged complaints. Using structured communication strategies appeared to reduce complaints and facilitate chart documentation when addressing difficult patient situations including opioid issues.

Including a range of outcome targets offers a broader view of fibromyalgia treatment outcome: results from a retrospective review of multidisciplinary treatment.

BACKGROUND: Fibromyalgia is associated with substantial functional disability. Current drug and non-drug treatments result in statistically significant but numerically small improvements in typical numeric measures of pain severity and fibromyalgia impact. OBJECTIVE: The aim of the present study was to evaluate additional measures of pain severity and functional outcome that might be affected by fibromyalgia treatment. METHODS: This retrospective review evaluated outcomes from 274 adults with fibromyalgia who participated in a six-week, multidisciplinary treatment programme. Pain and function were evaluated on the first and final treatment visit. Pain was evaluated using an 11-point numerical scale to determine clinically meaningful pain reduction (decrease ≥ 2 points) and from a pain drawing. Function was evaluated by measuring active range of motion (ROM), walking distance and speed, upper extremity exercise repetitions, and self-reports of daily activities. RESULTS: Numerical rating scores for pain decreased by 10-13% (p < 0.01) and Fibromyalgia Impact Questionnaire (FIQ) scores decreased by 20% (p < 0.001). More substantial improvements were noted when using alternative measures. Clinically meaningful pain relief was achieved by 37% of patients, and the body area affected by pain decreased by 31%. ROM showed significant improvements in straight leg raise and cervical motion, without improvements in lumbar ROM. Daily walking distance increased fourfold and arm exercise repetitions doubled. CONCLUSION: Despite modest albeit statistically significant improvements in standard measures of pain severity and the FIQ, more substantial pain improvement was noted when utilizing alternative measures of pain and functional improvement. Alternative symptom assessment measures might be important outcome measures to include in drug and non-drug studies to better understand fibromyalgia treatment effectiveness.

Milnacipran for fibromyalgia: a useful addition to the treatment armamentarium.

INTRODUCTION: Antidepressants are used to treat a variety of chronic pain conditions including peripheral neuropathy, headache, and more recently, fibromyalgia. The antidepressant milnacipran blocks the reuptake of norepinephrine and serotonin and is used for the management of fibromyalgia. AREAS COVERED: The article contains data primarily obtained from the MEDLINE database using a PubMed search of the keywords including milnacipran, fibromyalgia and depression. Of the available serotonin norepinephrine reuptake inhibitors, milnacipran has greater potency in inhibiting reuptake of norepinephrine relative to serotonin and is proposed to work by attenuating pain signals. Milnacipran is well tolerated and effective for fibromyalgia pain when given in divided doses of 100 - 200 mg daily. Studies show that milnacipran may be effective for fibromyalgia-associated symptoms including depression and fatigue. EXPERT OPINION: Milnacipran provides modest fibromyalgia pain relief and is best used as part of a multidisciplinary treatment approach. While milnacipran was not studied in fibromyalgia patients with major depression, it may be a wise choice for fibromyalgia patients with depressive symptoms and patients for whom sedation, dizziness, edema or weight gain with gabapentin and pregabalin is a problem. Milnacipran has been found to be beneficial for treating some troublesome fibromyalgia-associated symptoms, including fatigue and cognitive dysfunction.

Impact of animal-assisted therapy for outpatients with fibromyalgia.

OBJECTIVES: Animal-assisted therapy using dogs trained to be calm and provide comfort to strangers has been used as a complementary therapy for a range of medical conditions. This study was designed to evaluate the effects of brief therapy dog visits for fibromyalgia patients attending a tertiary outpatient pain management facility compared with time spent in a waiting room. DESIGN: Open label with waiting room control. SETTING: Tertiary care, university-based, outpatient pain management clinic. SUBJECTS: A convenience sample of fibromyalgia patients was obtained through advertisements posted in the clinic. INTERVENTIONS: Participants were able to spend clinic waiting time with a certified therapy dog instead of waiting in the outpatient waiting area. When the therapy dog was not available, individuals remained in the waiting area. OUTCOME MEASURES.: Self-reported pain, fatigue, and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. RESULTS: Data were evaluated from 106 therapy dog visits and 49 waiting room controls, with no significant between-group demographic differences in participants. Average intervention duration was 12 minutes for the therapy dog visit and 17 minutes for the waiting room control. Significant improvements were reported for pain, mood, and other measures of distress among patients after the therapy dog visit, but not the waiting room control. Clinically meaningful pain relief (≥2 points pain severity reduction) occurred in 34% after the therapy dog visit and 4% in the waiting room control. Outcome was not affected by the presence of comorbid anxiety or depression. CONCLUSIONS: Brief therapy dog visits may provide a valuable complementary therapy for fibromyalgia outpatients.

Animal-assisted therapy at an outpatient pain management clinic.

OBJECTIVE: The objective of this study was to evaluate the effects of brief therapy dog visits to an outpatient pain management facility compared with time spent in a waiting room. DESIGN: The design of this study is open-label. Setting. This study was conducted in a university tertiary care adult chronic pain outpatient clinic. SUBJECTS: The subjects of this study include outpatients, adults accompanying outpatients to their appointments, and clinic staff. Intervention. Participants were able to spend clinic waiting time with a certified therapy dog instead of waiting in the outpatient waiting area. When the therapy dog was not available, individuals remained in the waiting area. OUTCOME MEASURES: Self-reported pain, fatigue, and emotional distress were recorded using 11-point numeric rating scales before and after the therapy dog visit or waiting room time. RESULTS: Two hundred ninety-five therapy dog visits (235 with patients, 34 family/friends, and 26 staff) and 96 waiting room surveys (83 from patients, 6 family/friends, and 7 staff) were completed over a 2-month study period. Significant improvements were reported for pain, mood, and other measures of distress among patients after the therapy dog visit but not the waiting room control, with clinically meaningful pain relief (decrease ≥2 points) in 23% after the therapy dog visit and 4% in the waiting room control. Significant improvements were likewise seen after therapy dog visits for family/friends and staff. CONCLUSIONS: Therapy dog visits in an outpatient setting can provide significant reduction in pain and emotional distress for chronic pain patients. Therapy dog visits can also significantly improve emotional distress and feelings of well-being in family and friends accompanying patients to appointments and clinic staff.

Perimenstrual eletriptan prevents menstrual migraine: an open-label study.

OBJECTIVE: To prospectively evaluate the efficacy of perimenstrual prophylaxis with eletriptan to reduce headaches in women identified with menstrual migraine (MM). METHODS: Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM. Women prospectively diagnosed with ICHD-II MM were treated for 3 consecutive months with perimenstrual eletriptan 20 mg 3 times daily starting 2 days prior to the expected onset of menstruation and continued for a total of 6 days. Headache activity was compared during the 3 months of recording prior to eletriptan therapy and 3 months with eletriptan perimenstrual prevention therapy. RESULTS: Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 74%, with pure MM in 7%. Among those women diagnosed with ICHD-II MM, 61 completed at least 1 treatment month. Overall change in headache activity was a 46% decrease. The mean percentage of treated menses without migraine occurring during the 6 days of treatment was 71%. The percentage of subjects with 1, 2, and 3 migraine-free menstrual periods (no migraines occurring 2 days before menses through the first 3 days of menstruation) with eletriptan, respectively, were 14%, 19%, and 53%. Among those subjects who remained headache-free during the 6 days of eletriptan treatment, migraine occurred during the 3 days immediately after discontinuing eletriptan for 9%. Perimenstrual eletriptan was generally tolerated and no abnormalities were identified on the 6(th) day of treatment using either blood pressure recording or electrocardiogram. CONCLUSIONS: Among patients with prospectively identified MM, eletriptan 20 mg 3 times daily effectively reduced MM. A significant reduction in headache activity occurred for 53% of patients.

A prospective comparison between ICHD-II and probability menstrual migraine diagnostic criteria.

OBJECTIVE: To prospectively evaluate the diagnosis of menstrual migraine (MM) by comparing 2 diagnostic systems. METHODS: Female migraineurs self-reporting a substantial relationship between migraine and menses were evaluated with 3 consecutive months of daily headache recording diaries. A relationship between menses and migraine was evaluated using International Classification of Headache Disorders (ICHD-II) criteria and a probability model called Probability MM. RESULTS: Three months of pretreatment prospective diaries were completed by 126 women. ICHD-II menstrually related migraine was diagnosed in 73.8% with pure MM in 7.1%. ICHD-II and Probability diagnoses agreed for all cases of ICHD-II non-MM and pure MM, with disagreement among women diagnosed with ICHD-II menstrually related migraine, only half of whom were identified as having a relationship with menses greater than chance alone using the Probability model. Interestingly, 20% of those women self-reporting a substantial relationship between migraine and menses were not prospectively diagnosed with MM using either diagnostic system. Differences in menstrual vs nonmenstrual headaches were greater when using the Probability model. CONCLUSIONS: Prospective headache diaries are needed to diagnose MM. A probability-based method, which considers the chance occurrence of headaches during the menstrual cycle, identifies fewer women as having menstrually related migraine compared with the diary-based methods recommended by the current ICHD-II candidate criteria.

A possible role for zonisamide in treating neuropathic pain: a case of idiopathic polyneuropathy.

Anti-epilepsy medications have frequently been used in the treatment of neuropathic pain to reduce the transmission of nociceptive signals.(1,2) Zonisamide is a sulfonamide drug that was approved in 2000 for the adjunctive treatment of partial seizures in adults. Because of the unique combination of mechanisms through which zonisamide functions, it has potential to be a useful option in the treatment of refractory neuropathic pain. We present the case of a patient with refractory neuropathic pain related to idiopathic polyneuropathy, who responded to adjunctive treatment with zonisamide.