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Archive for the ‘Pain Alleviation’ Category


Experience of and Alleviation of Pain

Curator:  Larry H. Bernstein, MD, FCAP

 

A Thousand Words

Stories of medicine unfold on canvas

STEADY PROGRESS: Warren and Lucia Prosperi's <i>Ether Day</i> painting, which captures the first successful use of ether as an anesthetic, hangs in the domed amphitheater in which the historic event occurred more than 150 years ago.
STEADY PROGRESS: Warren and Lucia Prosperi’s Ether Day painting, which captures the first successful use of ether as an anesthetic, hangs in the domed amphitheater in which the historic event occurred more than 150 years ago.

In Carolus-Duran’s The Convalescent, a bearded man leans back, exhausted, into a pillow. Carolus-Duran, the name used by nineteenth-century French artist Charles Auguste Émile Durand, brings the viewer into the sickroom, rendering the emotions of illness through light, feature, and posture.

Studying this and other such paintings and recognizing elements of her own clinical experience in them has enriched Alice Flaherty’s appreciation of sickrooms and deathbeds. It is an appreciation that translates to the clinic.

“I was rounding on a woman who was dying of breast cancer,” says Flaherty ’90, an HMS associate professor of neurology at Massachusetts General Hospital. “I felt this empathic pain, so I asked her about her suffering. She calmly said she felt at peace, that she had been contemplating the quiet, lovely light in the room.”

“I realized that some of my empathy had been the projection of my own distress,” Flaherty continues. “Her description of the calm, empty, white spaces of her sickroom gave me the aesthetic distance that allowed me to see more of what was going on with her than I had seen when my eyes were screwed tight with imagined pain.”

Whether it’s a sickroom tableau, a portrayal of a surgery, or a portrait of a clinician or researcher, depictions of medicine in art have wide-ranging effects on those who view them. In addition to revealing the beauty in everyday clinical care, art inspired by medicine can connect doctors with the history of their profession, encourage them to confront ambiguities or consider alternative points of view, help situate their experiences within a larger context, soothe or sharpen emotions, and lead them to improve patient care in unexpected ways.

Alice Flaherty

Alice Flaherty

Artists, subjects, and viewers connect on another level when the process for reconstructing a historical event in medicine or capturing the character of a portrait subject entails the same meticulous collection of data and keen observational skills practiced in medicine. That physicians and painters should find one another kindred spirits is not surprising given the intertwined histories and philosophies of naturalist art, science, and medicine.

Nature Studies

Ask Massachusetts-based artists Warren and Lucia Prosperi whether they feel an affinity with physicians and scientists, and they will elaborate on how they share a fascination with the nature of the human experience. To capture this fascination in their paintings, they allow themselves to be endlessly curious about the subject, struggle to balance involvement with detachment, and pursue their desire to craft scientifically accurate images based on close observation.

“We’re empiricists,” says Warren, a painter who, in collaboration with his wife, a photographer, has produced dozens of paintings for HMS-affiliated institutions. Most notable, perhaps, is their Ether Day, a work completed in 2001 and displayed in a surgical amphitheater, dubbed the Ether Dome, in the Bulfinch Building at Mass General. In that room in 1846, the use of inhaled ether as a surgical anesthetic was first demonstrated successfully.

The Prosperis adhere to the principles of naturalism, a movement that arose in Europe in the mid-nineteenth century as writers, visual artists, and filmmakers, inspired by advances in natural science, sought to apply scientific methods to their work. Reacting against the idealism and symbolism of romanticism, naturalist painters presented realistic depictions of everyday life with as little distortion as possible. An example of this style, and one that is among the more pervasive images of the caring physician in art, is the late-nineteenth century painting The Doctor by British artist Sir Samuel Luke Fildes. In the work, Fildes portrays a pensive clinician keeping watch over an ailing girl while her parents look on helplessly.

Naturalist artists gather vast amounts of data to ensure accuracy, and the Prosperis are no exception. They spend hours talking with and photographing portrait subjects until they’re satisfied that they’ve captured not only minute physical details but also the person’s essential character. For posthumous portraits and historical scenes, they conduct exhaustive archival research, consult experts on the period, and interview anyone who might have known the person or experienced an event firsthand.

“They sucked my bone marrow for details,” says Donald Barnett, a former HMS assistant clinical professor of medicine and now curator of the Joslin Diabetes Center Historical Commission. Barnett has advised the Prosperis on seven paintings depicting landmarks in Joslin’s history.

ARTISTS-IN-RESIDENCE: Warren and Lucia Prosperi's studio contains several of the historical works on which they have collaborated, including <i>The First Casualty at Bunker Hill</i>, shown here, in part.

ARTISTS-IN-RESIDENCE: Warren and Lucia Prosperi’s studio contains several of the historical works on which they have collaborated, including The First Casualty at Bunker Hill, shown here, in part.

As a clinician, Barnett appreciates thorough information gathering. “Historical records tell the ‘what,’ not the ‘how,’” he says. “We brought in the details to turn a painting into a story, and we had a fanaticism for telling the story correctly.”

Details, Details

Demonstrating the effective use of ether during surgery launched U.S. medicine into the international spotlight. Little wonder that when planning to commemorate the 150th anniversary of that landmark event, the hospital’s service chiefs and physicians commissioned the Prosperis to paint a historically accurate version of what happened that day. The research the Prosperis undertook for Ether Day illustrates their dedication to telling stories correctly.

Although written documents and photographs yielded plenty of facts, crucial questions remained: Was surgeon John Collins Warren right- or left-handed? What was the nature of the incision he made? To what extent would red blood cells have oxidized and begun to separate from plasma in the basin used to capture the blood that flowed from the incision? Where would Warren and dentist William T. G. Morton, who administered the ether, have stood relative to the patient?

Over time, a detailed picture took shape. Whenever the Prosperis reached the limits of evidence, they and their consultants made logical deductions. Daguerreotypes in Harvard’s Fogg Museum, for example, show Warren holding his glasses in a manner that suggests he was right-handed. If true, that would mean he should be positioned to the patient’s right in the painting. The fact that blood would flow from the incision—this was a time before cauterization was used—meant someone would probably be there to sop it up, so given Warren’s position, the Prosperis put that person on the patient’s left along with a basin on a table. The possibility that ether wouldn’t work would have meant that the surgical team not only used restraints at the patient’s elbows and ankles but also assigned someone to hold the patient’s head still, likely from behind to remain out of Warren’s way. Thus, each decision about how to compose the scene helped another fall into place.

Reconstructing events feels like time travel, the Prosperis say, and that sense of witnessing the past with nearly photographic precision gets shared with the viewers.

“I remember being alone in the Ether Dome, feeling the history of that moment, and thinking that we had to do honor to what came before,” says Lucia. “It was a heavy responsibility.”

Adds Warren, “It was also great fun.”

Shades of Meaning

Beyond authenticity, the choices made in paintings of medical topics take on symbolic value and convey what it means to be a doctor, a patient, or part of an institution.

The doctor’s worried expression in Fildes’ iconic painting reminds practitioners that sometimes medicine reaches its limit and all it can offer is empathy with the human experience. When English artist John Collier turns the physician away from the viewer in his 1908 painting Sentence of Death, he is subtly directing the viewer’s gaze to the young male patient and his shocked expression, emphasizing how personally devastating the receipt of a terminal diagnosis can be. In Science and Charity, executed by the Spanish painter Pablo Picasso when he was 15 years old, the artist presents the doctor as the scientific observer of symptoms, focusing on his timepiece as he takes his patient’s pulse while a nurse provides compassionate care.

Paintings can also capture the moment a clinical procedure was first put into practice, such as the 1816 introduction of the stethoscope depicted in Ernest Board’s sunlit Laënnec Listening to the Chest of a Patient. In Board’s 1908 work, the early monaural cylinder itself and inventor René Laënnec take center stage. Although such paintings can boost present-day doctors’ and researchers’ confidence that their contributions could likewise change the course of medical history, artistic works can also be used to warn that not all new ideas pan out. For better or worse, French physician Simon Bernheim immortalized his hypothesis for curing tuberculosis using interspecies blood transfusions by hiring French naturalist artist Jules Adler to advertise his idea, which Adler did in The Transfusion of a Goat’s Blood.

EYE TO INNOVATION: In a mural for the Joslin Diabetes Center, Warren Prosperi depicted HMS faculty William Beetham, a surgeon; Lloyd Aiello, an ophthalmology professor; and Priscilla Holman, a nurse, performing a laser surgery procedure developed by Beetham and Aiello. The revolutionary procedure prevented bleeding-induced blindness in patients with diabetes.

EYE TO INNOVATION: In a mural for the Joslin Diabetes Center, Warren Prosperi depicted HMS faculty William Beetham, a surgeon; Lloyd Aiello, an ophthalmology professor; and Priscilla Holman, a nurse, performing a laser surgery procedure developed by Beetham and Aiello. The revolutionary procedure prevented bleeding-induced blindness in patients with diabetes.

When Barnett led the team choosing the subjects for the Joslin paintings, he tried to select caregivers and researchers who represented progress in diabetes research and treatment and to tell stories that embodied the Joslin’s values. One of the physicians selected was Priscilla White, a founding member of Joslin Clinic. White, who collected data from pregnant women for half a century, helped raise the survival rate of babies born to diabetic mothers from 56 percent to over 90 percent.

Another painting depicts a twentieth-century health care team conferring around the bed of a woman with diabetes and a foot infection. Although some people recoil from the “blood and guts” nature of the gangrenous limb, Barnett says, he believes it’s important to portray real patients who lose their legs to the disease. “Looking at the painting reminds doctors of the importance of taking care of the whole person,” he says.

Viewers’ reactions can be emotional as well as intellectual. For Barnett, standing in the Joslin lobby surrounded by the Prosperis’ paintings brings back fifty years of memories of caring for patients with juvenile diabetes.

“Tears would come to my eyes to see kids in their twenties going blind,” he says. “This art can make people aware of what it was like to be a patient or a doctor in those days, when diabetes was a war.”

Face Values

The walls of Flaherty’s office are papered with taped-up printouts of artwork by and about doctors and patients. Art books and sculptures crowd all available horizontal surfaces. Flaherty believes that repeated exposure to artistic renderings of bodies and illness can make them less threatening in reality, help health care practitioners process difficult clinical experiences, and reassure practitioners that their work fits into an older, larger context.

Nonetheless, she worries about putting too thick an aesthetic gloss on medicine.

“It makes our patients more interesting and less painful for us when we aestheticize their experience, but that also can over-anesthetize our ability to feel their pain,” she says.

Art, cautions Flaherty, can encourage doctors to ignore the messiness in real patients’ stories or to infer emotions that may not reflect patients’ actual experiences and feelings. It can, she adds, perpetuate an approach of treating patients like objects to be contemplated rather than as active participants in their own care.

At the same time, Flaherty is among those who believe that art serves doctors well when it “takes something that we encounter every day, and thought we knew, and makes us see that it is unique.”

Having witnessed physicians refer to a terrified-looking patient as “resting comfortably,” Flaherty thinks that art can teach doctors to pay attention.

“Doctors often see the jaundiced sclera but not the sad expression,” she says, “because it saves time if we ignore the pain. Looking closely at portraits can help us remember how to look at people.”

Flaherty says that close attention to facial expression helps her tell the impassivity of depression from that of Parkinson’s disease, Botox treatments, or simply personal demeanor. Occasional attempts to draw—Flaherty has taken some lessons from Warren Prosperi—have engaged her with patients’ affect even more. She has learned, for instance, that if an eyelid’s position changes by even a hundred microns, a face can be transformed from sadness to fear.

“I was talking to a patient once and said, ‘Oh, the light’s in your face,’ ” Flaherty remembers. “He said, ‘That’s so thoughtful of you.’ Don’t thank me, I thought, thank an artist.”

Stephanie Dutchen is a science writer in the HMS Office of Communications and External Relations.

Images: John Soares

 

 

Pain Management Overview

Pain management is important for ongoing pain control, especially if you suffer with long-term or chronic pain. After getting a pain assessment, your doctor can prescribe pain medicine, other pain treatments, or psychotherapy to help with pain relief.

Nearly any part of your body is vulnerable to pain. Acute pain warns us that something may be wrong. Chronic pain can rob us of our daily life, making it difficult and even unbearable. Many people with chronic pain can be helped by understanding the causes, symptoms, and treatments for pain – and how to cope with the frustrations.

You know your pain better than anyone — and as hard as it’s been to handle it, your experience holds the key to making a plan to treat it.

Each person and their pain are unique. The best way to manage your case could be very different from what works for someone else. Your treatment will depend upon things such as:

  • The cause
  • How intense it is
  • How long it’s lasted
  • What makes it worse or better

It can be a process to find your best plan. You can try a combination of things and then report back to your doctor about how your pain is doing. Together, you can tweak your program based on what’s working and what needs more help.

All Pain Is Not the Same

In order to make your pain management plan, your doctor will first consider whether you have sudden (“acute”) or long-term (“chronic”) pain.

Acute pain starts suddenly and usually feels sharp. Broken bones, burns, or cuts are classic examples. So is pain after surgery or giving birth.

Acute pain may be mild and last just a moment. Or it may be severe and last for weeks or months. In most cases, acute pain does not last longer than 6 months, and it stops when its underlying cause has been treated or has healed.

If the problem that causes short-term pain isn’t treated, it may lead to long-term, or “chronic” pain.

Chronic pain lasts longer than 3 months, often despite the fact that an injury has healed. It could even last for years. Some examples include:

  • Headache
  • Low back pain
  • Cancer pain
  • Arthritis pain
  • Pain caused by nerve damage

It can cause tense muscles, problems with moving, a lack of energy, and changes in appetite. It can also affect your emotions. Some people feel depressed, angry, or anxious about the pain and injury coming back.

Chronic pain doesn’t always have an obvious physical cause.

What Can I Do to Feel Better?

1. Keep moving. You might think it’s best to rest on the sidelines. But being active is a good idea. You’ll get stronger and move better.

The key is knowing what’s OK for you to do to get stronger and challenge your body, without doing too much, too soon.

Your doctor can let you know what changes to make. For instance, if you used to run and your joints can’t take that now because you have a chronic condition like osteoarthritis, you might be able to switch to something like biking or swimming.

2. Physical and occupational therapy. Take your recovery to the next level with these treatments. In PT, you’ll focus on the exact muscles you need to strengthen, stretch, and recover from injury. Your doctor may also recommend “occupational therapy,” which focuses on how to do specific tasks, like walking up and down stairs, opening a jar, or getting in and out of a car, with less pain.

3. Counseling. If pain gets you down, reach out. A counselor can help you get back to feeling like yourself again. You can say anything, set goals, and get support. Even a few sessions are a good idea. Look for a counselor who does “cognitive behavioral therapy,” in which you learn ways that your thinking can support you as you work toward solutions.

4. Massage therapy. It’s not a cure, but it can help you feel better temporarily and ease tension in your muscles. Ask your doctor or physical therapist to recommend a massage therapist. At your first appointment, tell them about the pain you have. And be sure to let them know if the massage feels too intense.

5. Relaxation. Meditation and deep breathing are two techniques to try. You could also picture a peaceful scene, do some gentle stretching, or listen to music you love. Another technique is to scan your body slowly in your mind, and consciously try to relax each part of your body, one by one, from head to toe. Any healthy activity that helps you unwind is good for you and can help you feel better prepared to manage your pain.

6. Consider complementary treatments such as acupuncture, biofeedback, and spinal manipulation. In acupuncture, a trained practitioner briefly inserts very thin needles in certain places on your skin to tap into your “chi,” which is an inner energy noted in traditional Chinese medicine. It doesn’t hurt.

Biofeedback trains you to control how your body responds to pain. In a session of it, you’ll wear electrodes hooked up to a machine that tracks your heart rate, breathing, and skin temperature, so you can see the results.

When you get spinal manipulation, a medical professional uses their hands or a device to adjust your spine so that you can move better and have less pain. Some MDs do this. So do chiropractors, osteopathic doctors (they have “DO” after their name instead of “MD”), and some physical therapists.

Are There Devices That Help?

Although there are no products that take pain away completely, there are some that you and your doctor could consider.

TENS and ultrasound. Transcutaneous electrical nerve stimulation, or TENS, uses a device to send an electric current to the skin over the area where you have pain. Ultrasound sends sound waves to the places you have pain. Both may offer relief by blocking the pain messages sent to your brain.

Spinal cord stimulation. An implanted device delivers low-voltage electricity to the spine to block pain.  If your doctor thinks it’s an option, you would use it for a trial period before you get surgery to have it permanently implanted. In most cases, you can go home the same day as the procedure.

What About Medicine?

Your doctor will consider what’s causing your pain, how long you’ve had it, how intense it is, and what medications will help. They may recommend one or more of the following:

These may include over-the-counter pain relievers such as acetaminophen, aspirin, ibuprofen, or naproxen. Or you may need stronger medications that require a prescription, such as steroids, morphine, codeine, or anesthesia.

Some are pills or tablets. Others are shots. There are also sprays or lotions that go on your skin.

Other drugs, like muscle relaxers and some antidepressants, are also used for pain. Some people may need anesthetic drugs to block pain.

Will I Need Surgery?

It depends on why you’re in pain. If you’ve had a sudden injury or accident, you might need surgery right away.

But if you have chronic pain, you may or may not need an operation or another procedure, such as a nerve block (done with anesthetics or other types of prescription drugs to halt pain signals) or a spinal injection (such as a shot of cortisone or an anesthetic drug).

Talk with your doctor about what results you can expect and any side effects, so you can weigh the risks and the benefits. Also ask how many times the doctor has done the procedure they recommend and what their patients have said about how much relief they’ve gotten.

WebMD Medical Reference

Reviewed by Jennifer Robinson, MD on September 20, 2015

Opioids, Pain, And Palliative Care [6.3.9]

Curator: Stephen J. Williams, Ph.D.

As written by Hrachya Nersesyan and Konstantin V Slavin in Current approach to cancer pain management: Availability and implications of different treatment options in Ther Clin Risk Manag. 2007 Jun; 3(3): 381–400

According to statistics published by the American Cancer Society in 2002, “50%–70% of people with cancer experience some degree of pain” (ACS 2002), which usually only intensifies as the disease progresses. Less than half get adequate relief of their pain, which negatively impacts their quality of life. The incidence of pain in advanced stages of invasive cancer approaches 80% and it is 90% in patients with metastases to osseous structures (Pharo and Zhou 2005).

Mediators of pain and inflammation are known to be secreted from tumor cells as well as infiltrating immune cells, activating and sensitizing primary afferent nociceptors (nociceptive pain) and damaging the nervous system (neuropathic pain). However, there has been difficulty in modeling cancer-induced pain in animals. This has hampered our understanding and therapeutic intervention of the clinical situation, especially concerning ovarian cancer patients.   It has been shown that 85% of ovarian cancer patients in palliative care (during last two months of life) still report severe pain although 54% of these women were given high intensity pain medications such as morphine, still the mainstream pain medication for severe cancer-associated pain. Admittedly, more research into the ability of cancer to provoke pain and sensitize the central nervous system, is warranted, as well as development of new methods of analgesia for cancer-associated pain at end-of-life. Therefore, in collaboration with several colleagues, in vivo models of nociceptive and neuropathic pain will be integrated with my co-developed in vivo tumor models of ovarian cancer. This tumor model allows for noninvasive monitoring of tumor burden without the need for anesthesia, as necessitated by imaging strategies to quantitate tumor burden, such as bioluminescence and MRI.

Even in an era of promising new cancer therapies, cancer pain is one of the highest concerns for the patient, their clinician, and surrounding loved ones, especially impacting quality of life during palliative care. Over half of cancer patients have reported severe pain in the course of their disease (List MA J Clin Oncol 2000 18:877-84) and the statistics are worse for ovarian cancer patients, regardless whether during treatment or in palliative care (see below review).

Journal of Pain and Symptom Management Volume 33, Issue 1 , Pages 24-31, January 2007

Pain Management in the Last Six Months of Life Among Women Who Died of Ovarian Cancer

Sharon J. Rolnick, PhD, MPH, Jody Jackson, RN, BSN, Winnie W. Nelson, PharmD, MS, Amy Butani, BA, Lisa J. Herrinton, PhD, Mark Hornbrook, PhD, Christine Neslund-Dudas, MA, Don J. Bachman, MS, Steven S. Coughlin, PhD

HealthPartners Research Foundation (S.J.R., J.J., A.B.), Minneapolis, Minnesota; Applied Health Outcomes (W.W.N.), Palm Harbor, Florida; Division of Research (L.J.H., D.J.B.), Kaiser Permanente Northern California, Oakland, California; Kaiser Permanente Center for Health Research (M.H.), Portland, Oregon; Josephine Ford Cancer Center (C.N.-D.), Henry Ford Health System, Detroit, Michigan; and National Center for Chronic Disease Prevention and Health Promotion (S.S.C.), Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Abstract Previous studies indicate that the symptoms of many dying cancer patients are undertreated and many suffer unnecessary pain. We obtained data retrospectively from three large health maintenance organizations, and examined the analgesic drug therapies received in the last six months of life by women who died of ovarian cancer between 1995 and 2000. Subjects were identified through cancer registries and administrative data. Outpatient medications used during the final six months of life were obtained from pharmacy databases. Pain information was obtained from medical charts. We categorized each medication based on the World Health Organization classification for pain management (mild, moderate, or intense). Of the 421 women, only 64 (15%) had no mention of pain in their charts. The use of medications typically prescribed for moderate to severe pain (“high intensity” drugs) increased as women approached death. At 5–6 months before death, 55% of women were either on no pain medication or medication generally used for mild pain; only 9% were using the highest intensity regimen. The percentage on the highest intensity regimen (drugs generally used for severe pain) increased to 22% at 3–4 months before death and 54% at 1–2 months. Older women (70 or older) were less likely to be prescribed the highest intensity medication than those under age 70 (44% vs. 70%, P<0.001). No differences were found in the use of the high intensity drugs by race, marital status, year of diagnosis, stage of disease, or comorbidity. Our finding that only 54% of women with pain were given high intensity medication near death indicates room for improvement in the care of ovarian cancer patients at the end of life.

Cancer pain is a complexity concerning not only the peripheral and central nervous systems but the cancer cell, the tumor microenvironment, and tumor infiltrating immune cells and inflammatory mediators. The goal of this article is to briefly introduce these factors governing pain in the cancer patient and a discussion of animal models of pain in relation to cancer.

Pain is considered as either termed nociceptive pain (activations and sensitization of primary afferent “nociceptor” neurons or neuropathic pain (damage to sensory nerves). Mediators of pain and inflammation are known to be secreted from tumor cells as well as infiltrating immune cells, activating and sensitizing primary afferent nociceptors (nociceptive pain) and damaging the nervous system (neuropathic pain).

For a great review please see Dr. Kara’s curation The Genetics of Pain: An Integrated Approach.

Palliative Care

For a good review please see the following LINK on Palliative Care 

Palliative Care_4.6

Please See VIDEOs on Cancer, Pain and Palliative Care

https://youtu.be/88ri3VNOd2E

 

https://youtu.be/B1_Ui3f4AI4

https://youtu.be/-KOSinGapUg

From ACS Guideline: Developing a plan for pain control

The first step in developing a pain control plan is talking with your cancer care team about your pain. You need to be able to describe your pain to your family or friends, too. You may want to have your family or friends help you talk to your cancer care team about your pain, especially if you’re too tired or in too much pain to talk to them yourself.

Using a pain scale is a helpful way to describe how much pain you’re feeling. To use the Pain Intensity Scale shown here, try to assign a number from 0 to 10 to your pain level. If you have no pain, use a 0. As the numbers get higher, they stand for pain that’s getting worse. A 10 means the worst pain you can imagine.

0 1 2 3 4 5 6 7 8 9 10
No pain Worst pain

For instance, you could say, “Right now, my pain is a 7 on a scale of 0 to 10.”

You can use the rating scale to describe:

  • How bad your pain is at its worst
  • What your pain is like most of the time
  • How bad your pain is at its least
  • How your pain changes with treatment

Tell your cancer care team and your family or friends:

  • Where you feel pain
  • What it feels like – for instance, sharp, dull, throbbing, gnawing, burning, shooting, steady
  • How strong the pain is (using the 0 to 10 scale)
  • How long it lasts
  • What eases the pain
  • What makes the pain worse
  • How the pain affects your daily life
  • What medicines you’re taking for the pain and how much relief you get from them

NCCN Adult Cancer-Associated Pain Guidelines (see PDF)NCCN adult pain guidelines

NCCN gives a comprehensive guideline to Cancer Patient Pain Management for Caregivers, physicians, and educational materials for patients.

The attached PDF gives information on

  • Pain Definition and Pain Management Principles
  • Pain Screening, Rating and Assessment Guidelines
  • Management of Patients with Differing Opioid Tolerance
  • Opioid Titration Guidelines
  • Adjuvant Analgesia
  • Psychosocial Support

Table. Important Points in NCCN Guidelines for Pain Management

Pain Severity (pain scale level) guideline
All pain levels – Opioid maintenance, – psychosocial support, – caregiver education
Severe Pain (7-10) – Reevaluate opioid titration
Moderate (4-6) – Continue opioid titration

– Consider specific pain syndrome problem and consultation

– continue analgesic titration

Mild (0-3) Adjuvant analgesics

The clinical presentation of cancer pain depends on the histologic type of cancer, the location of the primary neoplasm, and location of metastases. (for example pain in breast cancer patients have different pain issues than patients with oral.cancer).

However, high grade serous ovarian cancer, the most clinically prevalent of this disease, usually presents as an ascitic carcinomatosis, spread throughout the peritoneum and mesothelium.

Ovarian cancer stem cells and mediators of pain

Although not totally accepted by the field, a discussion of ovarian cancer stem cells is warranted, especially in light of this discussion. Cancer stem cells are considered that subpopulation of cells in the bulk tumor exhibiting self-renewing capacity, generally resistant to chemotherapy, and therefore repopulate the tumor with new tumor cells. In this case, ovarian cancer stem cells could be more pertinent to the manifestations of pain than bulk tumor, as these cells would survive chemotherapy. This may be the case, as ovarian cancer pain may not be associated with overall tumor burden? Are there PAIN MEDIATORS secreted from ovarian cancer cells?

Some Known Pain Mediators Secreted from Ovarian Tumor Cells

Endothelin-1

Proteases and Protease-Activated Receptors

Hoogerwerf WA, Zou L, Shenoy M, Sun D, Micci MA, Lee-Hellmich H, Xiao SY, Winston JH, Pasricha PJ

J Neurosci. 2001 Nov 15; 21(22):9036-42.

Alier KA, Endicott JA, Stemkowski PL, Cenac N, Cellars L, Chapman K, Andrade-Gordon P, Vergnolle N, Smith PA.J Pharmacol Exp Ther. 2008 Jan; 324(1):224-33.

Bradykinin

Sevcik MA, Ghilardi JR, Halvorson KG, Lindsay TH, Kubota K, Mantyh PW

J Pain. 2005 Nov; 6(11):771-5

Nerve Growth Factor

Tumor Necrosis Factor

 

Opioids: A Reference

Opioid analgesics: analgesia without loss of consciousness

Three main uses of opioids

  1. Analgesia
  2. Antitussive
  3. Diarrhea

1954 – nalorphine, partial antagonists had analgesic effect. Morphine: Morpheus – Greek God of dreams

1) opiates: opium alkaloids including morphine, codeine, thebaine, papavarine

2) synthetic: meperedine, methadone

Chemistry

  • Antagonist properties associated with replacement of the methyl substituent on nitrogen atom with large group (naloxone and nalorphine replaced with allyl group)
  • Pharmacokinetic properties affected by C3 and C6 hydroxyl substitutions
  • CH3 at phenolic OH at C3 reduces first pass metabolism by glucoronidation THEREFORE codeine and oxycodeine have higher oral availability
  • Acetylation of both OH groups on morphine : heroin penetrates BBB : rapidly hydrolyzed to give monoacetylmorphine and morphine

Pharmaookinetics

  • Well absorbed from s.c., i.m., oral
  • Codeine and hydrocodeine higher absorption from oral:parental ratio because of extensive first pass metabolism
  • Most opioids are well absorbed orally but DECREASE potency due to first pass
  • Variable plasma protein binding
  • Brain distribution is actually low but opioids are very potent
  • Well distributed and may accumulate in skeletal muscle
  • Fentynyl (lipophilic) may accumulate in fat

 

Metabolism

  • Most opioids converted to polar metabolites so excreted by kidney ;IMPORTANT prolonged analgesia in patients with renal disease
  • Esters like meperidine and herion metabolized by tissue esterases
  • Glucoronidated morphine may have analgesic properties

 

Receptors

All three (mu, kappa, and delta) activate pertussis toxin sensitive G protein {Gi}

Opioids quiet pain (nociceptive) neurons by inhibiting nerve conduction (decrease entry of calcium or increase entry of potassium)

There are four major subtypes of opioid receptors:[12]

Receptor Subtypes Location[13][14] Function[13][14]
delta (δ)
DOR
OP1 (I)
δ1,[15] δ2
kappa (κ)
KOR
OP2 (I)
κ1, κ2, κ3
mu (μ)
MOR
OP3 (I)
μ1, μ2, μ3 μ1:

μ2:

μ3:

  • possible vasodilation
Nociceptin receptor
NOP
OP4
ORL1
  • anxiety
  • depression
  • appetite
  • development of tolerance to μ-opioid agonists

Tolerance and Physical Dependence

Tolerance: gradual loss of effectiveness over repeated doses

Physical Dependence: when tolerance develops continued administration of drug required to prevent physical withdrawal symptoms

  • With opioids see tolerance most with the analgesic, sedative, and antitussive effects; not so much with antidiarrheal effects

Major effects of opioids on Organ Systems

  • CNS
    1. Analgesia – raise threshhold for pain
    2. Euphoria – pleasant floating feeling but sometimes dysphoria (agitation)
    3. Sedation –drowsiness but no amnesia; more frequent in elderly than young but can disrupt normal REM sleep
    4. Respiratory depression – ALL opioids produce significant resp. depression by inhibiting the brain stem; careful in patients with impaired respiratory function like COPD or increased intracranial pressure
    5. Cough suppression – tolerance can develop; may increase airway secretions
    6. Miosis – constriction of pupils; seen with ALL agonists; treat with atropine
    7. Rigidity – mostly seen with fentanyl; treat with opioid antagonist like nalozone
    8. Emesis; naseua, vomiting

 

  • Peripheral
    1. Cardiovascular – no real major effects; some specific compounds may have effects on blood pressure
    2. GI – Constipation most common; loperamide (Immodium); pentazocine may cause less constipation; problem for treating cancer patients for pain; opioid receptors do exist in the GI tract but effect may be CNS as well as local
    3. Biliary system – minor, may cause constriction of bile duct
    4. GU (genitourinary) – reduced urine output by increased antidiuretic hormone
    5. Uterus – may prolong labor
    6. Neuroendocrine – opioid analgesics can stimulate release of ADH, prolactin
    7. Other – opioid analgesics may cause flushing and warming of skin; release of histamine?

 Specific Agents   

Strong Agonists

Phenanthrenes –all are used for analgesia

  • Morphine
  • Hydromorphone
  • Oxymorphone
  • Heroin

Phenylheptylamine

  • Methadone – longer acting than morphine; tolerance and physical dependency slower to develop than with morphine; low doses of methadone may be used for heroin addict undergoing withdrawal

Phenyllpiperidines

  • Meperidine
  • Fentanyl (also sufentanil) which is 5-7 more times potent than fentanyl. Negative inotropic (contractile force) effects on heart

Levorphanol

 

Mild to Moderate Agonist

Phenanthrenes – most given in combo with NSAID

  • Codeine – antitussive, some analgesia
  • Oxycodone
  • Dihydrocodone
  • Hydrocodone

Propoxyphene – Darvon, low abuse and low analgesia compared to morphine

Phenylpiperidines

  • Diphenoxylate –used for diarrhea; not for analgesia and no abuse potential
  • Loperamide – antidiarrheal (Imodium), low abuse potential

 

Mixed Agonist-Antagonist & Partial Agonists

  1. Nalbulphine – strong kappa agonist and mu antagonist.. Analgesic
  2. Buprenorphine – analgesic. Partial mu agonist has long duration. Slow dissocation from receptor makes resistant to naloxone reversal
  3. Buterphanol – analgesia with sedation, kappa agonist
  4. Pentazocine – kappa agonist with weak mu antagonism.Is an irritant so do no inject s.c.

Antagonists

  1. Naloxone – quick reversal of opioid agonist action (1-2 hours); not well absorbed orally; pure antagonist so no effects by itself; no tolerance problems; opioid antidote
  2. Naltrexone – well absorbed orally can be used in maintenance therapy because of long duration of action

Antitussives

  1. Codeine
  2. Dextromethorphan
  3. Levoproposyphen
  4. Noscapine

Other posts related to Pain, Cancer, and Palliative Care on this Open Access Journal Include 

Palliative Care_4.6

Requiem for Palliative Cardiology: The Voice of Dr. Esselstyn on Plant-Based Nutrition

Cancer and Nutrition

Thyme Oil Beats Ibuprofen for Pain Management.

Pain Management Drug Market: Insight Pharma Reports

New target for chronic pain treatment found

The Genetics of Pain: An Integrated Approach

 

What was the drug in Clinical Trial Tragedy In France Jan 2016

by DR ANTHONY MELVIN CRASTO Ph.D

09404-notw1-BIA2

BIA 10-2474

3-(1-(cyclohexyl(methyl)carbamoyl)-1H-imidazol-4-yl)pyridine 1-oxide

BIA 10-2474 is an experimental fatty acid amide hydrolase inhibitor[1] developed by the Portuguese pharmaceutical company Bial-Portela & Ca. SA. The drug was developed to relieve pain,[2][3] to ease mood and anxiety problems, and to improve movement coordination linked to neurodegenerative illnesses.[4] It interacts with the humanendocannabinoid system.[5][6] It has been linked to severe adverse events affecting 5 patients in a drug trial in Rennes, France, and at least one death, in January 2016.[7]

French newspaper Le Figaro has obtained Bial study protocol documents listing the the chemical name of BIA-10-2474 as 3-(1-(cyclohexyl(methyl)carbamoyl)-1H-imidazol-4-yl)pyridine 1-oxide.[8] A Bial news release described BIA-10-2474 as “a long-acting inhibitor of FAAH”.[9]

Fatty acid amide hydrolase (FAAH) is an enzyme which degrades endocannabinoid neurotransmitters like anandamide,[10] which relieves pain and can affect eating and sleep patterns.[11][12] FAAH inhibitors have been proposed for a range of nervous-system disorders including anxiety, alcoholism, pain and nausea.

The Portuguese pharmaceutical company Bial holds several patents on FAAH enzyme inhibitors.[12][13][14][15]

No target organ was identified during toxicology studies and few adverse clinical findings were observed at the highest dose tested. For the single ascending dose part [of the clinical trial], a starting dose of 0.25 mg was judged to be safe for a first-in-human administration.[8]

The protocol defines no starting dose for the multi-dose treatment groups, noting that this will be based on the outcome of the single dose portion of the trial (an approach known as adaptive trial design). The authors note that nonetheless, the starting dose will not exceed 33% of the maximum tolerated dose (MTD) identified in the single dose groups (or 33% of the maximum administered dose if the MTD is not reached).[8]

In July 2015 Biotrial, a contract research organization, began testing the drug in a human phase one clinical trial for the manufacturer. The study was approved by French regulatory authority, the Agence Nationale de Sécurité du Médicament (ANSM), on June 26, 2015, and by the Brest regional ethics committee on July 3, 2015.[20] The trial commenced on July 9, 2015,[21] in the city of Rennes, and recruited 128 healthy volunteers, both men and women aged 18 to 55. According to French authorities, the study employed a three-stage design with 90 of the volunteers having received the drug during the first two stages of the trial, with no serious adverse events being reported .[17][20] Participants of the study were to receive €1,900 and, in turn, asked to stay at Biotrial’s facility for two weeks during which time they would take the drug for ten days and undergo tests.[22]

In the third stage of the trial evaluating multiple doses, six male volunteers received doses by mouth, starting on 7 January 2016. The first volunteer was hospitalized at theRennes University Hospital on January 10, became brain dead,[17][23][24][25] and died on January 17.[26] The other five men in the same dosage group were also hospitalized, in the period of January 10 through January 13[27] four of them suffering injuries including deep hemorrhagic and necrotic lesions seen on brain MRI.[7] The six men who were hospitalised were the group which received the highest dose.[26] A neurologist at the University of Rennes Hospital Center, Professor Pierre-Gilles Edan, stated in a press conference with the French Minister for Health, that 3 of the 4 men who were displaying neurological symptoms “already have a severe enough clinical picture to fear that even in the best situation there will be an irreversible handicap” and were being given corticosteroids to control the inflammation.[27] The sixth man from the group was not showing adverse effects but had been hospitalized for observation.[25][28][29] Biotrial stopped the experiment on January 11, 2016.[4]

Le Figaro posted a 96-page clinical study protocol for BIA 10-2474 that the French newspaper procured from an unnamed source.

According to the document, BIA 10-2474 is 3-(1-(cyclohexyl(methyl)carbamoyl)-1H-imidazol-4-yl)pyridine 1-oxide.

BIA 10-2474 “is designed to act as a long-active and reversible inhibitor of brain and peripheral FAAH,” notes the protocol. The compound “increases anandamide levels in the central nervous system and in peripheral tissues.”

The clinical trial protocol also notes that the company tested BIA 10-2474 on mice, rats, dogs, and monkeys for effects on the heart, kidneys, and gastrointestinal tract, among other pharmacological and toxicological evaluations.

The clinical trial, conducted by the company Biotrial on behalf of the Portuguese pharmaceutical firm Bial, was evaluating a pain relief drug candidate called BIA 10-2474 that inhibits fatty acid amide hydrolase (FAAH) enzymes. Blocking these enzymes prevents them from breaking down cannabinoids in the brain, a family of compounds that includes the euphoria-inducing neurotransmitter anandamide and Δ9-tetrahydrocannabinol, the major psychoactive component of marijuana.

Phase I clinical trials are conducted to check a drug candidate’s safety profile in healthy, paid volunteers. In this case, the drug caused hemorrhagic and necrotic brain lesions in five out of six men in a group who received the highest doses of the drug, said Gilles Edan, a neurologist at the University Hospital Center of Rennes.

The French health minister has stated the drug acted on natural receptors found in the body known as endocannibinoids, which regulate mood and appetite. It did not contain cannabis or anything derived from it, as was originally reported. All six trial participants were administered the doses simultaneously.

The trial was being performed at Biotrial, a French-based firm that was formed in 1989 and has conducted thousands of trials. A message on the company’s website stated that they are working with health authorities to understand the cause of the accident, while extending thoughts to the patients and their families. Bial has disclosed the drug was a FAAH (fatty acid amide hydrolase) inhibitor, which is an enzyme produced in the brain and elsewhere that breaks down neurotransmitters called endocannabinoids. Two scientists from the Nottingham Medical School who have worked with FAAH tried over the weekend to try and identify the drug by examining a list of drugs Bial currently has in its pipeline. They believe the culprit is one identified by the codename BIA 10-2474.

While safety issues like this are rare, they are not unheard of. In 2006, a clinical trial in London left six men ill. All were taking part in a study testing a drug designed to fight auto-immune disease and leukemia. Within hours of taking the drug TGN1412, all experienced a serious reaction, were admitted to intensive care, and had to be treated for organ failure.

The Duff Report, written in response to the TGN1412 trial, noted the medicine should have been tested in one person at a time. It also helped to put additional safety measures in place. The Medicines and Health Products Regulatory Agency (MHRA) now requires committees to look at pre-clinical data to determine the proper initial dose, and rules are in place to stop the trial if unintended reactions occur.

Other pharmaceutical companies, including Merck, Pfizer, Johnson & Johnson, Sanofiand Vernalis, have previously taken other FAAH inhibitors into clinical trials without experiencing such adverse events (e.g. respectively, MK-4409,[35][36] PF-04457845,JNJ-42165279,[37] SSR411298 and V158866.[38][39] Related enzyme inhibitor compounds such as URB-597 and LY-2183240 have been sold illicitly as designer drugs,[40][41] all without reports of this type of toxicity emerging, so the mechanism of the toxicity observed with BIA 10-2474 remains poorly understood.

Clinical Trial Tragedy, France, Jan 2016, PHASE 1 | Categories: Uncategorized | URL:http://wp.me/p38LX5-4ut

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Failed pain relief drug candidate clinical trial

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

 

What was the drug in Clinical Trial Tragedy In France Jan 2016

by DR ANTHONY MELVIN CRASTO Ph.D

09404-notw1-BIA2

BIA 10-2474

3-(1-(cyclohexyl(methyl)carbamoyl)-1H-imidazol-4-yl)pyridine 1-oxide

BIA 10-2474 is an experimental fatty acid amide hydrolase inhibitor[1] developed by the Portuguese pharmaceutical company Bial-Portela & Ca. SA. The drug was developed to relieve pain,[2][3] to ease mood and anxiety problems, and to improve movement coordination linked to neurodegenerative illnesses.[4] It interacts with the humanendocannabinoid system.[5][6] It has been linked to severe adverse events affecting 5 patients in a drug trial in Rennes, France, and at least one death, in January 2016.[7]

French newspaper Le Figaro has obtained Bial study protocol documents listing the the chemical name of BIA-10-2474 as 3-(1-(cyclohexyl(methyl)carbamoyl)-1H-imidazol-4-yl)pyridine 1-oxide.[8] A Bial news release described BIA-10-2474 as “a long-acting inhibitor of FAAH”.[9]

Fatty acid amide hydrolase (FAAH) is an enzyme which degrades endocannabinoid neurotransmitters like anandamide,[10] which relieves pain and can affect eating and sleep patterns.[11][12] FAAH inhibitors have been proposed for a range of nervous-system disorders including anxiety, alcoholism, pain and nausea.

The Portuguese pharmaceutical company Bial holds several patents on FAAH enzyme inhibitors.[12][13][14][15]

 

No target organ was identified during toxicology studies and few adverse clinical findings were observed at the highest dose tested. For the single ascending dose part [of the clinical trial], a starting dose of 0.25 mg was judged to be safe for a first-in-human administration.[8]

The protocol defines no starting dose for the multi-dose treatment groups, noting that this will be based on the outcome of the single dose portion of the trial (an approach known as adaptive trial design). The authors note that nonetheless, the starting dose will not exceed 33% of the maximum tolerated dose (MTD) identified in the single dose groups (or 33% of the maximum administered dose if the MTD is not reached).[8]

 

In July 2015 Biotrial, a contract research organization, began testing the drug in a human phase one clinical trial for the manufacturer. The study was approved by French regulatory authority, the Agence Nationale de Sécurité du Médicament (ANSM), on June 26, 2015, and by the Brest regional ethics committee on July 3, 2015.[20] The trial commenced on July 9, 2015,[21] in the city of Rennes, and recruited 128 healthy volunteers, both men and women aged 18 to 55. According to French authorities, the study employed a three-stage design with 90 of the volunteers having received the drug during the first two stages of the trial, with no serious adverse events being reported .[17][20] Participants of the study were to receive €1,900 and, in turn, asked to stay at Biotrial’s facility for two weeks during which time they would take the drug for ten days and undergo tests.[22]

In the third stage of the trial evaluating multiple doses, six male volunteers received doses by mouth, starting on 7 January 2016. The first volunteer was hospitalized at theRennes University Hospital on January 10, became brain dead,[17][23][24][25] and died on January 17.[26] The other five men in the same dosage group were also hospitalized, in the period of January 10 through January 13[27] four of them suffering injuries including deep hemorrhagic and necrotic lesions seen on brain MRI.[7] The six men who were hospitalised were the group which received the highest dose.[26] A neurologist at the University of Rennes Hospital Center, Professor Pierre-Gilles Edan, stated in a press conference with the French Minister for Health, that 3 of the 4 men who were displaying neurological symptoms “already have a severe enough clinical picture to fear that even in the best situation there will be an irreversible handicap” and were being given corticosteroids to control the inflammation.[27] The sixth man from the group was not showing adverse effects but had been hospitalized for observation.[25][28][29] Biotrial stopped the experiment on January 11, 2016.[4]

 

Le Figaro posted a 96-page clinical study protocol for BIA 10-2474 that the French newspaper procured from an unnamed source.

According to the document, BIA 10-2474 is 3-(1-(cyclohexyl(methyl)carbamoyl)-1H-imidazol-4-yl)pyridine 1-oxide.

BIA 10-2474 “is designed to act as a long-active and reversible inhibitor of brain and peripheral FAAH,” notes the protocol. The compound “increases anandamide levels in the central nervous system and in peripheral tissues.”

The clinical trial protocol also notes that the company tested BIA 10-2474 on mice, rats, dogs, and monkeys for effects on the heart, kidneys, and gastrointestinal tract, among other pharmacological and toxicological evaluations.

 

The clinical trial, conducted by the company Biotrial on behalf of the Portuguese pharmaceutical firm Bial, was evaluating a pain relief drug candidate called BIA 10-2474 that inhibits fatty acid amide hydrolase (FAAH) enzymes. Blocking these enzymes prevents them from breaking down cannabinoids in the brain, a family of compounds that includes the euphoria-inducing neurotransmitter anandamide and Δ9-tetrahydrocannabinol, the major psychoactive component of marijuana.

Phase I clinical trials are conducted to check a drug candidate’s safety profile in healthy, paid volunteers. In this case, the drug caused hemorrhagic and necrotic brain lesions in five out of six men in a group who received the highest doses of the drug, said Gilles Edan, a neurologist at the University Hospital Center of Rennes.

The French health minister has stated the drug acted on natural receptors found in the body known as endocannibinoids, which regulate mood and appetite. It did not contain cannabis or anything derived from it, as was originally reported. All six trial participants were administered the doses simultaneously.

 

The trial was being performed at Biotrial, a French-based firm that was formed in 1989 and has conducted thousands of trials. A message on the company’s website stated that they are working with health authorities to understand the cause of the accident, while extending thoughts to the patients and their families. Bial has disclosed the drug was a FAAH (fatty acid amide hydrolase) inhibitor, which is an enzyme produced in the brain and elsewhere that breaks down neurotransmitters called endocannabinoids. Two scientists from the Nottingham Medical School who have worked with FAAH tried over the weekend to try and identify the drug by examining a list of drugs Bial currently has in its pipeline. They believe the culprit is one identified by the codename BIA 10-2474.

 

While safety issues like this are rare, they are not unheard of. In 2006, a clinical trial in London left six men ill. All were taking part in a study testing a drug designed to fight auto-immune disease and leukemia. Within hours of taking the drug TGN1412, all experienced a serious reaction, were admitted to intensive care, and had to be treated for organ failure.

 

The Duff Report, written in response to the TGN1412 trial, noted the medicine should have been tested in one person at a time. It also helped to put additional safety measures in place. The Medicines and Health Products Regulatory Agency (MHRA) now requires committees to look at pre-clinical data to determine the proper initial dose, and rules are in place to stop the trial if unintended reactions occur.

 

Other pharmaceutical companies, including Merck, Pfizer, Johnson & Johnson, Sanofiand Vernalis, have previously taken other FAAH inhibitors into clinical trials without experiencing such adverse events (e.g. respectively, MK-4409,[35][36] PF-04457845,JNJ-42165279,[37] SSR411298 and V158866.[38][39] Related enzyme inhibitor compounds such as URB-597 and LY-2183240 have been sold illicitly as designer drugs,[40][41] all without reports of this type of toxicity emerging, so the mechanism of the toxicity observed with BIA 10-2474 remains poorly understood.

Clinical Trial Tragedy, France, Jan 2016, PHASE 1 | Categories: Uncategorized | URL:http://wp.me/p38LX5-4ut

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Occupational Therapy

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

Definition of Occupational Therapy

Occupational therapy is a client-centred health profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement.(WFOT 2012)

Read the Statement on Occupational Therapy

In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do.

Definition of Occupational Therapy Practice for the AOTA Model Practice Act

http://www.aota.org/-/media/Corporate/Files/Advocacy/State/Resources/PracticeAct/Model%20Definition%20of%20OT%20Practice%20%20Adopted%2041411.ashx

The practice of occupational therapy means the therapeutic use of occupations, including everyday life activities with individuals, groups, populations, or organizations to support participation, performance, and function in roles and situations in home, school, workplace, community, and other settings. Occupational therapy services are provided for habilitation, rehabilitation, and the promotion of health and wellness to those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. Occupational therapy addresses the physical, cognitive, psychosocial, sensory-perceptual, and other aspects of performance in a variety of contexts and environments to support engagement in occupations that affect physical and mental health, well-being, and quality of life. The practice of occupational therapy includes:

A. Evaluation of factors affecting activities of daily living (ADL), instrumental activities of daily living (IADL), rest and sleep, education, work, play, leisure, and social participation, including:

1. Client factors, including body functions (such as neuromusculoskeletal, sensory-perceptual, visual, mental, cognitive, and pain factors) and body structures (such as cardiovascular, digestive, nervous, integumentary, genitourinary systems, and structures related to movement), values, beliefs, and spirituality.

2. Habits, routines, roles, rituals, and behavior patterns.

3. Physical and social environments, cultural, personal, temporal, and virtual contexts and activity demands that affect performance.

4. Performance skills, including motor and praxis, sensory-perceptual, emotional regulation, cognitive, communication and social skills.

B. Methods or approaches selected to direct the process of interventions such as:

1. Establishment, remediation, or restoration of a skill or ability that has not yet developed, is impaired, or is in decline.

2. Compensation, modification, or adaptation of activity or environment to enhance performance, or to prevent injuries, disorders, or other conditions.

3. Retention and enhancement of skills or abilities without which performance in everyday life activities would decline.

4. Promotion of health and wellness, including the use of self-management strategies, to enable or enhance performance in everyday life activities.

5. Prevention of barriers to performance and participation, including injury and disability prevention.

C. Interventions and procedures to promote or enhance safety and performance in activities of daily living (ADL), instrumental activities of daily living (IADL), rest and sleep, education, work, play, leisure, and social participation, including:

1. Therapeutic use of occupations, exercises, and activities.

2. Training in self-care, self-management, health management and maintenance, home management, community/work reintegration, and school activities and work performance.

3. Development, remediation, or compensation of neuromusculoskeletal, sensory-perceptual, visual, mental, and cognitive functions, pain tolerance and management, and behavioral skills.

4. Therapeutic use of self, including one’s personality, insights, perceptions, and judgments, as part of the therapeutic process.

5. Education and training of individuals, including family members, caregivers, groups, populations, and others.

6. Care coordination, case management, and transition services.

7. Consultative services to groups, programs, organizations, or communities.

8. Modification of environments (home, work, school, or community) and adaptation of processes, including the application of ergonomic principles.

9. Assessment, design, fabrication, application, fitting, and training in seating and positioning, assistive technology, adaptive devices, and orthotic devices, and training in the use of prosthetic devices.

10. Assessment, recommendation, and training in techniques to enhance functional mobility, including management of wheelchairs and other mobility devices.

11. Low vision rehabilitation.

12. Driver rehabilitation and community mobility.

13. Management of feeding, eating, and swallowing to enable eating and feeding performance.

14. Application of physical agent modalities, and use of a range of specific therapeutic procedures (such as wound care management; interventions to enhance sensory-perceptual, and cognitive processing; and manual therapy) to enhance performance skills.

15. Facilitating the occupational performance of groups, populations, or organizations through the modification of environments and the adaptation of processes.

Adopted by the Representative Assembly 4/14/11 (Agenda A13, Charge 18)

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Pain Management

Larry H Bernstein, MD, FCAP, Curator

LPBI

 

Pain Management Health Center

http://www.webmd.com/pain-management/

 

Pain Management Overview

Pain management is important for ongoing pain control, especially if you suffer with long-term or chronic pain. After getting a pain assessment, your doctor can prescribe pain medicine, other pain treatments, or psychotherapy to help with pain relief.

Nearly any part of your body is vulnerable to pain. Acute pain warns us that something may be wrong. Chronic pain can rob us of our daily life, making it difficult and even unbearable. Many people with chronic pain can be helped by understanding the causes, symptoms, and treatments for pain – and how to cope with the frustrations.

You know your pain better than anyone — and as hard as it’s been to handle it, your experience holds the key to making a plan to treat it.

Each person and their pain are unique. The best way to manage your case could be very different from what works for someone else. Your treatment will depend upon things such as:

  • The cause
  • How intense it is
  • How long it’s lasted
  • What makes it worse or better

It can be a process to find your best plan. You can try a combination of things and then report back to your doctor about how your pain is doing. Together, you can tweak your program based on what’s working and what needs more help.

All Pain Is Not the Same

In order to make your pain management plan, your doctor will first consider whether you have sudden (“acute”) or long-term (“chronic”) pain.

Acute pain starts suddenly and usually feels sharp. Broken bones, burns, or cuts are classic examples. So is pain after surgery or giving birth.

Acute pain may be mild and last just a moment. Or it may be severe and last for weeks or months. In most cases, acute pain does not last longer than 6 months, and it stops when its underlying cause has been treated or has healed.

If the problem that causes short-term pain isn’t treated, it may lead to long-term, or “chronic” pain.

Chronic pain lasts longer than 3 months, often despite the fact that an injury has healed. It could even last for years. Some examples include:

  • Headache
  • Low back pain
  • Cancer pain
  • Arthritis pain
  • Pain caused by nerve damage

It can cause tense muscles, problems with moving, a lack of energy, and changes in appetite. It can also affect your emotions. Some people feel depressed, angry, or anxious about the pain and injury coming back.

Chronic pain doesn’t always have an obvious physical cause.

What Can I Do to Feel Better?

1. Keep moving. You might think it’s best to rest on the sidelines. But being active is a good idea. You’ll get stronger and move better.

The key is knowing what’s OK for you to do to get stronger and challenge your body, without doing too much, too soon.

Your doctor can let you know what changes to make. For instance, if you used to run and your joints can’t take that now because you have a chronic condition like osteoarthritis, you might be able to switch to something like biking or swimming.

2. Physical and occupational therapy. Take your recovery to the next level with these treatments. In PT, you’ll focus on the exact muscles you need to strengthen, stretch, and recover from injury. Your doctor may also recommend “occupational therapy,” which focuses on how to do specific tasks, like walking up and down stairs, opening a jar, or getting in and out of a car, with less pain.

3. Counseling. If pain gets you down, reach out. A counselor can help you get back to feeling like yourself again. You can say anything, set goals, and get support. Even a few sessions are a good idea. Look for a counselor who does “cognitive behavioral therapy,” in which you learn ways that your thinking can support you as you work toward solutions.

4. Massage therapy. It’s not a cure, but it can help you feel better temporarily and ease tension in your muscles. Ask your doctor or physical therapist to recommend a massage therapist. At your first appointment, tell them about the pain you have. And be sure to let them know if the massage feels too intense.

5. Relaxation. Meditation and deep breathing are two techniques to try. You could also picture a peaceful scene, do some gentle stretching, or listen to music you love. Another technique is to scan your body slowly in your mind, and consciously try to relax each part of your body, one by one, from head to toe. Any healthy activity that helps you unwind is good for you and can help you feel better prepared to manage your pain.

6. Consider complementary treatments such as acupuncture, biofeedback, and spinal manipulation. In acupuncture, a trained practitioner briefly inserts very thin needles in certain places on your skin to tap into your “chi,” which is an inner energy noted in traditional Chinese medicine. It doesn’t hurt.

Biofeedback trains you to control how your body responds to pain. In a session of it, you’ll wear electrodes hooked up to a machine that tracks your heart rate, breathing, and skin temperature, so you can see the results.

When you get spinal manipulation, a medical professional uses their hands or a device to adjust your spine so that you can move better and have less pain. Some MDs do this. So do chiropractors, osteopathic doctors (they have “DO” after their name instead of “MD”), and some physical therapists.

Are There Devices That Help?

Although there are no products that take pain away completely, there are some that you and your doctor could consider.

TENS and ultrasound. Transcutaneous electrical nerve stimulation, or TENS, uses a device to send an electric current to the skin over the area where you have pain. Ultrasound sends sound waves to the places you have pain. Both may offer relief by blocking the pain messages sent to your brain.

Spinal cord stimulation. An implanted device delivers low-voltage electricity to the spine to block pain.  If your doctor thinks it’s an option, you would use it for a trial period before you get surgery to have it permanently implanted. In most cases, you can go home the same day as the procedure.

What About Medicine?

Your doctor will consider what’s causing your pain, how long you’ve had it, how intense it is, and what medications will help. They may recommend one or more of the following:

These may include over-the-counter pain relievers such as acetaminophen, aspirin, ibuprofen, or naproxen. Or you may need stronger medications that require a prescription, such as steroids, morphine, codeine, or anesthesia.

Some are pills or tablets. Others are shots. There are also sprays or lotions that go on your skin.

Other drugs, like muscle relaxers and some antidepressants, are also used for pain. Some people may need anesthetic drugs to block pain.

Will I Need Surgery?

It depends on why you’re in pain. If you’ve had a sudden injury or accident, you might need surgery right away.

But if you have chronic pain, you may or may not need an operation or another procedure, such as a nerve block (done with anesthetics or other types of prescription drugs to halt pain signals) or a spinal injection (such as a shot of cortisone or an anesthetic drug).

Talk with your doctor about what results you can expect and any side effects, so you can weigh the risks and the benefits. Also ask how many times the doctor has done the procedure they recommend and what their patients have said about how much relief they’ve gotten.

WebMD Medical Reference

Reviewed by Jennifer Robinson, MD on September 20, 2015

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Music Therapy

Larry H. Bernstein, MD, FCAP, Curator

LPBI

 

What is Music Therapy

http://www.musictherapy.org/about/listserv/

http://www.musictherapy.org/about/musictherapy/

What is Music Therapy?

Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.

Music Therapy is an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals. After assessing the strengths and needs of each client, the qualified music therapist provides the indicated treatment including creating, singing, moving to, and/or listening to music. Through musical involvement in the therapeutic context, clients’ abilities are strengthened and transferred to other areas of their lives. Music therapy also provides avenues for communication that can be helpful to those who find it difficult to express themselves in words. Research in music therapy supports its effectiveness in many areas such as: overall physical rehabilitation and facilitating movement, increasing people’s motivation to become engaged in their treatment, providing emotional support for clients and their families, and providing an outlet for expression of feelings.

https://www.youtube.com/watch?feature=player_embedded&v=UlqWw36onD4

 

Fact Sheets for Music Therapy with Individual Populations:

AMTA Strategic Priorities for Specific Populations:

References and Bibliographies:

 

History of Music Therapy

The idea of music as a healing influence which could affect health and behavior is as least as old as the writings of Aristotle and Plato. The 20th century profession formally began after World War I and World War II when community musicians of all types, both amateur and professional, went to Veterans hospitals around the country to play for the thousands of veterans suffering both physical and emotional trauma from the wars. The patients’ notable physical and emotional responses to music led the doctors and nurses to request the hiring of musicians by the hospitals. It was soon evident that the hospital musicians needed some prior training before entering the facility and so the demand grew for a college curriculum. A very brief historical glimpse of this fascinating profession follows, below.

 Earliest references

The earliest known reference to music therapy appeared in 1789 in an unsigned article in Columbian Magazine titled “Music Physically Considered.” In the early 1800s, writings on the therapeutic value of music appeared in two medical dissertations, the first published by Edwin Atlee (1804) and the second by Samuel Mathews (1806). Atlee and Mathews were both students of Dr. Benjamin Rush, a physician and psychiatrist who was a strong proponent of using music to treat medical diseases. The 1800s also saw the first recorded music therapy intervention in an institutional setting (Blackwell’s Island in New York) as well as the first recorded systematic experiment in music therapy (Corning’s use of music to alter dream states during psychotherapy).

Early Associations

Interest in music therapy continued to gain support during the early 1900s leading to the formation of several short-lived associations. In 1903, Eva Augusta Vescelius founded the National Society of Musical Therapeutics. In 1926, Isa Maud Ilsen founded the National Association for Music in Hospitals. And in 1941, Harriet Ayer Seymour founded the National Foundation of Music Therapy. Although these organizations contributed the first journals, books, and educational courses on music therapy, they unfortunately were not able to develop an organized clinical profession.

Early Educational Programs and Advocates

In the 1940s, three persons began to emerge as innovators and key players in the development of music therapy as an organized clinical profession. Psychiatrist and music therapist Ira Altshuler, MD promoted music therapy in Michigan for three decades. Willem van de Wall pioneered the use of music therapy in state-funded facilities and wrote the first “how to” music therapy text,Music in Institutions (1936). E. Thayer Gaston, known as the “father of music therapy,” was instrumental in moving the profession forward in terms of an organizational and educational standpoint. The first music therapy college training programs were also created in the 1940s. Michigan State University established the first academic program in music therapy (1944) and other universities followed suit, including the University of Kansas, Chicago Musical College, College of the Pacific, and Alverno College.

National Association for Music Therapy

The National Association for Music Therapy (NAMT) was founded at a meeting in New York City on June 2, 1950. NAMT succeeded where previous music therapy associations previously failed by creating a constitution and bylaws, developing standards for university-level educational and clinical training requirements, making research and clinical training a priority, creating a registry and, later, board-certification requirements, and publishing research and clinical journals.

Music Therapy Around the World and on the Web  

Music Therapy ENews

Music Therapy ENews is an announcement-only, electronic newsletter published by the American Music Therapy Association. It is not a discussion listserv. ENews brings timely information on music therapy to its subscribers, focusing on conferences, music therapy education and training opportunities, media alerts, on-line resources, and other information important to the profession of music therapy. Members are welcome to submit announcements and other materials for consideration by emailing the editor at ENews@musictherapy.org. AMTA reserves editorial rights on all submissions. ENews subscription is free.

The Music Therapy ListServ

The Music Therapy ListServ is a discussion forum where people can discuss the use of music to restore, maintain, and improve mental and physical health.

To join the ListServ, send an E-mail, including your first and last name, to the list owners: Alexandra Mesquita-Baer(alex.baer@comcast.net) or Lynne Hockenbury (LynneHock@aol.com) For AMTA members, please include your membership number to speed up the process.

It is a free service and you can cancel your subscription at any time. To cancel, send an email to listproc@ukans.edu without a subject or signature. In the body of your message, type:

UnsubMUSTHP-L

This ListServ is run independently of AMTA.

Music Therapy Around the World

AMTA’s International Relations Committee

The purpose of the AMTA International Relations Committee is to promote networking between music therapists around the world and to facilitate awareness of international issues among AMTA members both within the United States and abroad. Information below is provided to share information on national music therapy organizations throughout the world. If you are familiar with websites of national organizations which are not included here, feel free to send their contact us and suggest they be included.

Worldwide Music Therapy Organizations
International Music Therapy Associations
Sharing Organizations
A Music Therapy Moment   
Every music therapist has a wealth of stories about that exquisite musical/clinical moment when art and science come together to create an awareness, an accomplishment, a breakthrough. These stories – poignant, insightful, or humorous – show the power and effect of music therapy, and can help to build understanding of the benefits and applications of music therapy.  These stories – along with the latest news and research in music therapy – bring the power of music therapy to people around the world, helping to educate and inspire and ensure access to quality music therapy services for every child, teen, and adult.

The Transformative Power of Working with People Who Are Facing Death

Our work as music therapists never stops giving us powerful experiences and lessons. This seems to be magnified when spending one’s days with people who are facing death. With this experience, music therapists are sensitized to the extreme emotions surrounding death, and can empathize with these patients and their families.

I had the privilege of working with an older man, who I’ll refer to as Mr. Smith, and who dearly touched my heart. Countless patients of mine have touched me, but Mr. Smith will remain in my memory as vividly as I saw him in the very hours we spent together.

At the end of life, there is a certain amount of one’s will that determines when one dies. I have seen people hold on to their lives with extreme pain and labored breathing, for weeks, just to reconcile a broken relationship with a loved one. That being said, there is simply no substitute for the beautiful and seamless opportunity that music therapy provides for people to complete their lives with dignity.

Music allowed Mr. Smith to die peacefully. The two songs that he specifically requested conveyed the messages he needed to share before departing from this world. Music therapy provided him the crucial opportunity or medium to express what he felt.

Since Mr. Smith was in a great deal of pain at the end of his life, we never engaged in very formal lyric analysis; however, Mr. Smith naturally expressed his analysis of these songs in small, intermittent statements during our sessions.

The first song he requested was Send In The Clowns, by Stephen Sondheim. This song, to Mr. Smith, highlighted the gross irony that, in stark contrast to the beauty and potential happiness in this world, there is often great emotional and physical pain in our final hours. The grand exit and culmination of our lives is often marked “not with a bang, but a whimper,” as T.S. Elliot so poignantly writes. It is a cold reality; a cruel joke that often leaves us bitter. Send in the Clowns validated and beautifully conveyed feelings for Mr. Smith when he could not. He said “I used to be able to sing and dance, and now-” he paused and closed his eyes, wincing from a shooting pain- “well, I’m here in this place.” “This place” was where people came to die. Mr. Smith knew that, because, in addition to being fully alert and oriented, he had a sister who had passed away there just two years before.

The second song he requested was “Try to Remember,” from the Broadway musical The Fantastiks. This is a beautiful song that he particularly wanted his family to hear. There are several lines in this song that Mr. Smith highlighted by mouthing the words to his wife:

“Try to remember… and follow.”
“Without a hurt the heart is hollow.”

“Deep in December it’s nice to remember the fire of September that made us mellow.”

I’ve wondered what Mr. Smith’s room would’ve been like without music therapy. Mr. & Mrs. Smith had four children- one who’d been estranged- all of whom were quite anxious. No one’s anxiety exceeded that of his wife, however. I was able to witness the facilitation of tears, hugs, and precious family interactions by our music therapy sessions together.

I’ve also wondered how my life would be without the experience and privilege of working with Mr. Smith. It is impossible to know for sure, but I can say that I am better able to keep an eye on the big picture of my life after working with him.

My time with Mr. Smith instilled in me a powerfully transformative thought. The music of our lives remains long after our bodies pass away; the love contained therein is eternal and will last beyond our pain.

Written by Sharon Graham, MM, MT-BC

 

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Factors in Patient Experience

Larry H. Bernstein, MD, FCAP, Curator

LPBI

Defining Patient Experience

http://www.theberylinstitute.org/?page=definingpatientexp

“The definition will allow me as a driver in improving the patient experience at our organization to include those key elements (interactions, current culture, perceptions, across the continuum of care) in our discussions to encourage a more integrated, quality experience that exceeds the expectations of each patient.”

To develop the Institute’s definition of patient experience, we formed a work group of patient experience leaders from a cross-section of healthcare organizations. The group shared perspectives, insights and backgrounds on what patient experience means to them and collaboratively created this definition. We believe it provides a terrific starting point for the conversation around this important issue.

Critical to the understanding and application of this definition is a broader explanation of its key elements:

Interactions Culture Perceptions Continuum of Care
The orchestrated touch-points of people, processes, policies, communications, actions, and environment The vision, values, people (at all levels and in all parts of the organization) and community What is recognized, understood and remembered by patients and support people. Perceptions vary based on individual experiences such as beliefs, values, cultural background, etc. Before, during and after the delivery of care

The History of Patient Experience

Hear perspectives from two leading Patient Experience thought leaders. Wendy Leebov, Partner at Language of Caring, and Mary Malone, President of Malone Advisory Services, discuss the history of patient experience and its growth in the healthcare industry. Perfect as tools to share with growing patient experience professionals or to reenergize efforts for experienced leaders, learn about the many influences that led to the existing patient experience movement and how we all have an impact in this emerging field.

Learn more about the history of patient experience in the PX Body of Knowledge History course where you will grasp the core foundation of patient experience and review the evolving role of patient experience in healthcare today.

https://youtu.be/_kwZ-xeOj8Y

Defining Patient Experience

Authors: Jason A. Wolf PhD, Victoria Niederhauser DrPH, RN, Dianne Marshburn PhD, RN, NE-BC, Sherri L. LaVela PhD, MPH, MBA
Publication: Patient Experience Journal

In recent years, perceptions of performance and quality of healthcare organizations have begun to move beyond examining the provision of excellent clinical care, alone, and to consider and embrace the patient experience as an important indicator. There is a need to determine the extent to which clear and formal definitions exist, have common overarching themes, and/or have unique, but important constructs that should be considered more widely. In this article, we provide a 14-year synthesis of existing literature and other sources (2000-2014) that have been used to define patient experience. A total of 18 sources (articles or organizational websites) were identified that provided a tangible, explicit definition of patient experience. A narrative synthesis was undertaken to categorize literature (and other sources) according to constructs of the definitions provided. The objectives of the synthesis were to: (1) identify the key elements, constructs, and themes that were commonly and frequently cited in existing definitions of ‘patient experience,’ (2) summarize these findings into what might be considered a common shared definition, and (3) identify important constructs that may be missing from and may enhance existing definition(s). The overarching premise was to identify and promote a working definition of patient experience that is applicable and practical for research, quality improvement efforts, and general clinical practice. Our findings identified several concepts and recommendations to consider with regard to the definition of patient experience. First, the patient experience reflects occurrences and events that happen independently and collectively across the continuum of care. Also, it is important to move beyond results from surveys, for example those that specifically capture concepts such as ‘patient satisfaction,’ because patient experience is more than satisfaction alone. Embedded within patient experience is a focus on individualized care and tailoring of services to meet patient needs and engage them as partners in their care. Next, the patient experience is strongly tied to patients’ expectations and whether they were positively realized (beyond clinical outcomes or health status). Finally, the patient experience is integrally tied to the principles and practice of patient- and family- centered care. As patient experience continues to emerge as an important focus area across healthcare globally, the need for a standard consistent definition becomes even more evident, making it critical to ensure patient experience remains a viable, respected, and highly embraced part of the healthcare conversation.

Patient Experience Journal 2014;  1:(1), Article 3.
Available at: http://pxjournal.org/journal/vol1/iss1/3

In practice and research the concept of patient experience has had varied uses and is often discussed with little more explanation than the term itself. Although very little has been published about the complexities with regard to defining patient experience, the 2009 HealthLeaders Media Patient Experience Leadership Survey 3 discovered that when it comes to defining patient experience, there are widely divergent views within the healthcare industry. They found that 35% of respondents agreed that patient experience equals “patient-centered care,” 29% agreed it was “an orchestrated set of activities that is meaningfully customized for each patient,” and 23% said it involved “providing excellent customer service.” The remaining responses reflected patient experience meant, “creating a healing environment,” being “consistent with what’s measured by HCAHPS,” or “other” than the options provided in the survey. In asking the question, “Does your organization have a formal definition of patient experience?” of healthcare organizations in its recent Patient Experience Benchmarking Study, The Beryl Institute discovered that on average 45% of US-based hospitals1 and 35% of non US-based healthcare organizations reported having a formal definition. The question this raises is that as patient experience is identified as a priority item, would healthcare efforts be best served by having a formally accepted definition of patient experience?

The efforts that shaped The Beryl Institute’s definition came from the voices of practice and a review of current research and use in 2010. A workgroup of healthcare leaders from a variety of patient experience roles identified the key elements shaping their work in the patient experience. Within individual organizations, inquiries were made of peers and patients to identify key themes and these larger concepts were pulled together in collective data that was aligned around main themes. The four themes that emerged were personal interactions, organization culture, patient and family perceptions, and across the care continuum. From the themes, a definition was created and then validated through the broader Institute community for further feedback and refinement. The definition is currently being used (with or without adaptations) by a number of healthcare facilities globally as their own definition of patient experience. However, there is much ground yet to be covered in moving towards alignment around a clear and shared definition of patient experience. The purpose of this article was to provide a 14-year synthesis of existing literature and other sources that have been used to define patient experience. Given the breadth and depth of information, we aimed to examine key concepts and compare/contrast multiple definitions, and ultimately to recommend a working definition that we feel can be used to across healthcare settings to capture the patient experience.

Need for Definition We identified 18 sources (websites or articles) that explicitly provide a definition for the patient experience (Table 1). The latest data from both the most recent HeathLeader’s survey and The Beryl Institute’s State of Patient Experience benchmarking research identified patient experience as a top priority; however they also identify there is a divergent nature of patient experience and need for a clear and concise definition. In the article “What is the Patient Experience”? from the Gallup Business Journal, the authors’ suggest that the ideal patient experience is created by meeting four basic emotional needs: confidence, integrity, pride and passion, ultimately asserting that experience is about engaging patients. The author offers in closing, “Engaged healthcare is better healthcare, for everyone. And that’s the best definition of the patient experience”.6

Continuum of Care Several authors argue that the patient experience is not just one encounter, but spans over time and includes many touch points. In a recent publication, Deloitte LLP’s Health Sciences Practice7 contends that organizations need to focus on the patient experience to gain and maintain a competitive advantage. They define the patient experience as much broader than the care itself, describing specific touch points or times when there is interaction with the organization and the patient. Their definition, “The Patient Experience refers to the quality and value of all of the interactions—direct and indirect, clinical and nonclinical—spanning the entire duration of the patient/provider relationship” represents a continuum of interactions. In a recent article, although Stempniak8 does not define patient experience directly, he does offer two quotes that provide some insight. The first from Pat Ryan, CEO of Press Ganey who said, “Let’s look at the patient experience in total as reducing suffering and reducing anxiety… across the entire continuum of care, from the first phone call to the patient’s being discharged.” The second is a statement from Dr. Jim Merlino, Chief Experience Officer at the Cleveland Clinic who admits, the biggest challenge in this effort is figuring out where to start, and defining exactly what the “patient experience” means. Pemberton & Richardson9 provide an overview of a development process of a patient experience vision, told through a story and framed by a series of six active steps a patient goes through during an episode of care, which included: reputation, arrival, contract, stay, treatment and after stay. While there is no direct statement of how they defined the patient experience, they identified the importance of culture and staff engagement in driving an effective patient experience effort.

Beyond Survey Results Several articles argue that the patient experience should be defined more broadly than just using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey domains.

Aligned with Patient-Centered Care Principles Other definitions focus on patient-centered care principles. Weiss and Tyink13 discuss the opportunity to provide the ideal patient experience through creating a patient-centric culture. The components of a patientcentric culture encompass competent, high-quality care, personalized care, timely responses, care coordination, and are reliable and responsive. They suggest that the patient experience is about a brand experience and is driven by what happens at the point of contact between the patient, the practice, and the provider.

Focus on Expectations

Focus on Individualized Care

More than Satisfaction

As our review of literature and sources showed, there is an absence of a commonly used definition around patient experience in healthcare. While there has been increasing numbers of articles, research and writing on the subject in recent years, little has been seen in the way of coalescing around an accepted statement. Much of this is due to the reality that in all but a few cases a truly concise, applicable and replicable definition was not offered. Other influences may be the competing interests that influence the day-today operations of healthcare overall.

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Patient Satisfaction with Hospital Experience

Curator: Larry H. Bernstein, MD, FCAP

 

 

Getting It Right: The Link Between the Patient Experience and Hospital Reputation

Katie Johnson, Ph.D., Director of Research and Analytics, National Research: 02/21/2014 –
See more at: http://www.nationalresearch.com/blog/33/#sthash.z8OlwguT.dpuf

 

When you get your daily vanilla latte, you know what to expect every single time—a great cup of Joe. And because of your positive morning (or afternoon) experience, you’ll keep going back. Does this same notion apply in healthcare? Absolutely.

But if you had a poor experience at your hospital, would you go back? Probably not.

It’s not rocket science that when you have a positive, favorable consumer experience with a product or service, you will keep going back for more—you may even adopt brand loyalty. However, as simple as this sounds, healthcare providers are not always “getting it right.”

According to a study by the National Research Corporation Market Insights Survey, the largest healthcare consumer survey in the U.S., eight percent of patients said their hospital experience was poor enough to not recommend the healthcare facility to family or friends. In addition, nine percent of patients rated their overall hospital care and services poorly.

When patients have a highly engaged, positive experience with their hospital, it’s a win-win situation. Hospital reputation is everything. And this rings true even more so today, since the patient experience is tied to hospital reimbursements. Below is a list of research-based evidence that explains why reputation matters:

    • Patient experience is important. It’s important because treating patients well is the right thing to do. It’s important because a positive patient experience is related to better health outcomes (including lower readmission rates). It’s important because Value Based Purchasing has tied Medicare reimbursement to HCAHPS scores. It’s also important, we have found, because of its impact on hospital reputation.

 

    • Hospital reputation is important. Why should hospitals care about their reputations? Hospital reputation plays a part in the selection process among would-be patients. Approximately nine in 10 people indicate that reputation is important when selecting a hospital. Further, once an individual selects and utilizes a hospital, he or she is more likely to utilize that same facility for future healthcare needs (pending a positive experience, of course).

 

    • Hospital reputation is related to patient experience. Our research has shown that hospitals providing positive patient experiences have better reputations. In other words, hospitals that are rated highly by their discharged patients are also rated highly by the general public (whether they’ve had a direct hospital experience or not).

 

    • We’ve found evidence to support an important chain of events. Patient experience drives reputation. Reputation drives utilization. Utilization drives future utilization.

 

    • Some aspects of reputation are more closely related to patient experience than others. The top five correlates, in descending order, are:
      • most personalized care
      • best accommodations
      • highest patient safety
      • best nurses
      • best overall quality

 

    • Today’s patient experience is related to tomorrow’s reputation. It takes time for reputations to form and change, and there is evidence of lag-time in the relationship between patient experience and hospital reputation. Correlations are strongest when patient experience is measured at the first time, and reputation is measured at the second time and six months later. This lag relationship indicates that the quality of the patient experience being administered in a hospital today is significantly related to the reputation of that hospital six months from now.

 

    • “Bad” hospital reputations are even more important. Facilities delivering poor patient experiences are four times more likely to have poor reputations than facilities delivering good patient experiences. Bad news travels fast and wide. In order to improve a poor reputation brought on by a poor patient experience, facilities would be wise to turn their attention inward and focus on improving the experiences they provide their patients.

 

  • We have a roadmap. The figure below is designed for healthcare leaders who would like to explore potential improvement strategies based on where their facilities are situated on the continuum of patient experience and reputation. While all strive to be in the top right category, scoring well on both patient experience and reputation, the reality is that the majority of facilities will find themselves located in one of the other three groups. Facilities in the top or bottom groups on the left side would do well to focus on the patient experience first and foremost. As we’ve learned, if the quality of patient experience is low, there is little that can be done effectively in terms of marketing and advertising. Facilities in the bottom right quadrant (high quality patient experience, but with reputations not reflective of that), should put resources into spreading the word and advertise the strength of their patient experience. It’s important that those in the community are made aware of the high-caliber care being delivered.

 

http://www.nationalresearch.com/uploads/Image/blog/BlogPic2-21-14.jpg

 

Research Brief: The Link Between the Patient Experience and Hospital Reputation

Hospitals and health systems across the United States are focusing increased effort on the delivery of superior patient experience, and with good reason. The provision of top-notch patient care translates to tangible benefits to both patients and their families, as well as to the healthcare facility itself.

In a research brief published by National Research Corporation in February 2014, The Link Between Patient Experience and Hospital Reputation, Dr. Katie Johnson presents findings showing how the patient experience is directly tied to a hospital or health system’s reputation. Research is derived from the National Research Market Insights Survey, the largest online healthcare consumer survey in the United States.

 

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