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.

The role of volunteer services at cancer centers.

Volunteer services can be effectively used to provide valuable supportive services to patients with cancer and their family. Providing companionship, a sense of self-worth, information, and respite care are among the important services typically provided by volunteers through outpatient, inpatient, and hospice services. Supportive benefits have been linked with reduced symptoms and may even enhance survival. Offering inpatient and outpatient respite services provides needed relief for family caregivers. Complementary therapies may also be provided through volunteer services, with research studies consistently showing benefits from Reiki and animal-assisted therapy offered through volunteer care.

Vestibular migraine: clinical aspects and pathophysiology.

Vestibular migraine is becoming recognised as a distinct clinical entity that accounts for a high proportion of patients with vestibular symptoms. A temporal overlap between vestibular symptoms, such as vertigo and head-movement intolerance, and migraine symptoms, such as headache, photophobia, and phonophobia, is a requisite diagnostic criterion. Physical examination and laboratory testing are usually normal in vestibular migraine but can be used to rule out other vestibular disorders with overlapping symptoms. The pathophysiology of vestibular migraine is incompletely understood but plausibly could include neuroanatomical pathways to and from central vestibular structures and neurochemical modulation via the locus coeruleus and raphe nuclei. In the absence of controlled trials, treatment options for patients with vestibular migraine largely mirror those for migraine headache.

Sumatriptan : treatment across the full spectrum of migraine.

INTRODUCTION: Triptans are the first-line treatment for moderate-to-severe migraine headaches. Sumatriptan , the first triptan, is available in different formulations, including subcutaneous (SQ), intranasal, transdermal, oral, and suppository options. AREAS COVERED: Sumatriptan formulations have different pharmacokinetic, efficacy, and adverse event profiles. The fastest and most complete migraine relief occurs with SQ dosing; a needle-free option is available for patients fearful of injections. Oral administration is generally preferred by patients, although variability with absorption limits efficacy, especially for more severe attacks. Intranasal, transdermal, and suppository formulations are options for patients with nausea who do not require or prefer to avoid SQ administration. Transdermal treatment may be limited in some cases by skin irritation. EXPERT OPINION: Patients should use an attack-based treatment approach for their migraine attacks to balance the speed of relief, efficacy, and tolerability. Different sumatriptan formulations allow its use as both first-line and rescue therapies, with additional treatment if needed. This article develops a treatment algorithm that offers suggested roles for different formulations of sumatriptan based on attack severity and response to initial sumatriptan therapy.

Brief, self-report fibromyalgia screener evaluated in a sample of chronic pain patients.

OBJECTIVE: To validate a self-report fibromyalgia screener in a chronic pain population. DESIGN: Adults with chronic pain were evaluated with a six-item, self-report fibromyalgia screening tool based on revised American College of Rheumatology (ACR) fibromyalgia diagnostic criteria, with fibromyalgia diagnosed when patients experienced chronic pain and scored ≥13 on the ACR fibromyalgia symptom severity scale. Patients were independently assigned clinical diagnoses by treating clinicians. SETTING: University-based, tertiary care pain clinic. SUBJECTS: Three hundred thirty-seven mixed chronic pain patients. RESULTS: Agreement between the clinical diagnosis and screener diagnosis was good (P < 0.001), with 76% sensitivity and 82% specificity. CONCLUSION: A self-administered, brief fibromyalgia screening questionnaire can effectively identify chronic pain patients who will likely have clinical fibromyalgia.

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.

The science behind animal-assisted therapy.

Animal-assisted therapy is a complementary medicine intervention, typically utilizing dogs trained to be obedient, calm, and comforting. Several studies have reported significant pain relief after participating in therapy dog visits. Objective reports of reduced pain and pain-related symptoms are supported by studies measuring decreased catecholamines and increased endorphins in humans receiving friendly dog visits. Mirror neuron activity and disease-perception through olfactory ability in dogs may also play important roles in helping dogs connect with humans during therapeutic encounters. This review will explore a variety of possible theories that may explain the therapeutic benefits that occur during therapy dog visits.

Fibromyalgia family and relationship impact exploratory survey.

BACKGROUND: Fibromyalgia is frequently associated with impairments in activities of daily living and work disability. Limited data have investigated the impact of fibromyalgia on relationships with family and friends. OBJECTIVES: This exploratory study was designed to survey a large community sample of adults with fibromyalgia about the impact on the spouse/partner, children and close friends. METHODS: A 40-question, multiple-choice survey was made available online for a two-month period, with potential participants recruited through fibromyalgia and migraine community websites. Items included questions about demographics, fibromyalgia symptoms, comorbid mood disturbance and relationship impact, including the Relationship Assessment Scale. RESULTS: The survey was completed by 6,126 adults who had been diagnosed with fibromyalgia. Using updated diagnostic criteria from the American College of Rheumatology, 91% satisfied the criteria for fibromyalgia (Fibromyalgia Severity score ≥13 and pain ≥3 months). Half of participants endorsed that fibromyalgia had mildly to moderately damaged relationship(s) with their spouse(s)/partner(s) or contributed to a break-up with a spouse or partner. Half of participants scored as not being satisfied with their current spouse/partner relationship, with satisfaction negatively affected by the presence of mood disturbance symptoms and higher fibromyalgia severity. Relationships with children and close friends were also negatively impacted for a substantial minority of participants. CONCLUSIONS: In addition to physical impairments that are well documented among individuals with fibromyalgia, fibromyalgia can result in a substantial negative impact on important relationships with family and close friends.

Symptomatic improvement reported after receiving Reiki at a cancer infusion center.

OBJECTIVE: To evaluate patient-perceived benefits from receiving Reiki at a cancer infusion center. METHODS: During a 6-month period, adults at a university hospital receiving Reiki through volunteer services were invited to complete a survey asking about perceived changes after Reiki. Changes in pain, mood, distress, sleep, and appetite were rated on a 5-point scale from no benefit to great benefit. Surveys were distributed after completing treatment and were returned in postage-paid envelops. RESULTS: A total of 145 surveys were completed (34.5% response rate), with 47 participants seen in the cancer infusion center and 98 in other areas of the hospital. Reiki was rated as a positive experience by 94% at the cancer center and 93% of others, with 92% at the cancer center and 86% of others interested in receiving additional Reiki sessions. Symptomatic improvement was similar for people at the cancer center and others, respectively, with much to great improvement for 89% and 86% for relaxation, 75% and 75% for anxiety/worry, 81% and 78% for improved mood, 43% and 35% for improved sleep, 45% and 49% for reduced pain, 38% and 43% for reduced isolation/loneliness, 75% and 63% for improved attitude, and 30% and 30% for improved appetite. Response was unaffected by previous exposure to Reiki, massage, or other touch therapy. CONCLUSION: Reiki results in a broad range of symptomatic benefits, including improvements in common cancer-related symptoms.

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.

Survey of migraine sufferers with dogs to evaluate for canine migraine-alerting behaviors.

OBJECTIVES: Anecdotal reports suggest that changes in dog behavior might be used to predict impending migraine episodes. This survey was designed to investigate how companion dogs react to migraines that occur in their owners. DESIGN: Online survey was available from January 4-31, 2012. SETTINGS/LOCATION: Survey was conducted through SurveyMonkey, with links to the survey posted at Migraine.com and promoted through social media. SUBJECTS: Adults ≥18 years old who experience migraine episodes and live with a dog were eligible to participate. INTERVENTIONS AND OUTCOME MEASURES: Participants completed an 18-question online survey that asked about participant demographics, migraines, and their dog's behavior before or during migraine episodes. RESULTS: The survey was completed by 1029 adult migraineurs (94.9% women), with migraines typically occurring ≤8 days per month in 63.4% of participants. A recognized change in the dog's behavior prior to or during the initial phase of migraine was endorsed by 552 participants (53.7%), most commonly unusual attentiveness to the owner (39.9%). Among the 466 participants providing details about their dog's behavior with their migraines, 57.3% were able to identify dog alerting behavior before symptoms of a migraine attack would typically begin, with changes usually noticed within 2 hours before the onset of initial migraine symptoms. The dog's behavior was considered to be often or usually linked with the development of a migraine for 59.2% of migraineurs, and 35.8% of migraineurs endorsed beginning migraine treatments after the dog's behavior was recognized and before migraine symptoms had started. Participant demographics, migraine frequency, and breed of dog in the home were similar between the 470 participants with no alerting behavior endorsed and the 466 participants providing detailed alerting information. CONCLUSIONS: About one in four migraineurs living with a companion dog endorsed recognizing a change in their dog's behavior before recognizing initial symptoms of a migraine attack.

Migraine and motion sensitivity.

PURPOSE OF REVIEW: This article describes vestibular migraine and motion sensitivity. Migraine headache is often accompanied by dizziness or unsteadiness. A diagnosis of vestibular migraine requires that a patient meet International Headache Society criteria for migraine headache, have episodic or fluctuating symptoms highly suggestive of a balance disorder, have no recognized alternative neuro-otologic diagnosis, and experience migrainous symptoms during episodes of vertigo or imbalance. This article discusses these diagnostic criteria; the epidemiology of vestibular migraine; laboratory abnormalities in vestibular migraine; the pathophysiology of vestibular migraine; the treatment of vestibular migraine; comorbidities and overlap with other neuro-otologic disorders, including basilar artery migraine, Ménière disease, and anxiety disorders; and the genetics of vestibular migraine. This review also discusses motion sickness and motion sensitivity, including their relationship with migraine, pathophysiology, and treatment. RECENT FINDINGS: Recent findings regarding vestibular migraine include new nomenclature for the disorder, validation of diagnostic criteria, new ideas regarding pathophysiology, and reviews of small treatment trials. SUMMARY: Vestibular migraine is becoming the preferred designation for a neuro-otologic disorder with a migrainous etiology that causes dizziness and disequilibrium. Criteria have been established for diagnosing this disorder. Although pathophysiology is as yet uncertain and randomized trials are lacking, treatment recommendations can be made. Motion sickness represents a condition often associated with migraine that can reduce quality of life.

Complementary medicine in cancer care: adding a therapy dog to the team.

Animal-assisted therapy, including visits from certified therapy dogs, offer a valuable and often underutilized resource for addressing unmet needs in cancer patients. Prospective research studies have documented symptomatic benefits for reducing pain, psychological distress, and fatigue in a variety of patient populations, including cancer patients. Utilizing consistent policies minimizes patient risk and infection control concerns associated with animal visits.

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.