By Helen Roome, Clinician, Speaker and Author of YOUR PAIN PLAYBOOK
Chairperson of the OT pain management group (OTPMG) whose mission is to advocate for the role of OT in pain management; continually educate OTs already engaged in pain management; and collaborate with other members of the broader pain community.
It seems to me that somewhere along the way we have split people in half.
As occupational therapists, we can tend to treat everything from the waist up and leave the remaining half for physiotherapy (or other) interventions. Meaning that, at least in practice, we assume physiotherapists will focus on the back and legs – with more ‘physical’ symptoms of chronic low back pain and sciatica; whilst we give our attention to heads and hands – and more ‘psychological’ symptoms, like the depression of Fibromyalgia and distress of Complex Regional Pain Syndrome (CRPS).
In addition to this artificial anatomical and functional division of the person, I think we may also have slipped into silos of specialised knowledge and practice (e.g. mental health, neuro, hand therapy) and lost something of our unique role as ‘expert generalists’. When we do dare to wander into the field of pain management, we might become intimidated by its complexity and chronicity and quickly withdraw! All of which means we can find ourselves lacking in confidence and competence to manage pain and overlooked in interdisciplinary pain management teams.
The complex reasons for why we got here are probably less important than the simple steps I recommend for moving forward. The first step is to update ourselves on the current pain science and evidence-based approaches to pain management. I believe this reveals how compatible pain management is with OT principles, philosophies, models and frameworks; and how much we already have in our ‘therapeutic toolbox’ to go some way towards fulfilling our role and responsibilities in pain management.
Pain impacts the whole person.
According to the International Association for the Study of Pain (IASP), pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.1 In revising their definition of pain in 2020, IASP captured the progress of pain science over the last decades: there has been a shift from a simplistic, biomedical model in which pain could be described as a sensory symptom of damage to a part of the body, to a biopsychosocial model that recognises pain as a complex, whole-person experience that is not as closely associated with the state of bodily tissues as we thought.
Not only is the experience of pain multifaceted but its ‘causes’ are multifactorial: 2
- Biological – including genetics and epigenetic lifestyle influences (like diet, physical activity and sleep).
- Psychological – such as past learning, beliefs, expectations and mood.
- Social/contextual – like past trauma, isolation, physical environment and lack of access to services.
Pain is a truly biopsychosocial phenomenon and is most effectively managed with a biopsychosocial approach 2.
So, effective pain management is biopsychosocial.
Most clinical guidelines recommend integrating many diverse modalities (offered by a range of healthcare disciplines) to treat the multiple biopsychosocial aspects of pain.2
These include modalities that are ‘top-down’ and ‘bottom-up’; invasive and non-invasive; pharmacological and non-pharmacological; and may necessitate the person being a passive recipient or more actively engaged in treatment.3
‘Top-down’ modalities are those that target specific brain areas involved in processing biopsychosocial inputs; as well as the descending spinal pathways of facilitation or inhibition. Apart from specific central-acting medications and physical activity; psychological and cognitive interventions like pain education, mindful meditation, activity participation, Graded Motor Imagery and more, can impact these.
‘Bottom-up’ modalities refer to those that influence the sensory, chemical and other inputs to the brain that contribute to pain production. Again, some medications (e.g. anti-inflammatories) play a role alongside manual therapies, progressive muscle relaxation, ergonomic adaptations, sensory regulation, and more.
The combination and extent of the modalities likely to be most effective for a person, may depend on whether they are experiencing acute or chronic pain and on the type/s of pain with which they present. In general, with chronification of pain (e.g. chronic primary pain conditions, like Fibromyalgia) comes a greater emphasis on ‘top-down’, less-invasive, non-pharmacological modalities, that the person performs themselves with the support of the interdisciplinary team.4
Pain impacts each person uniquely.
IASP accompanied their revised definition of pain with some key notes.1 These highlight the personal nature of pain; how it is learned and shaped by unique life experiences; and the need for healthcare practitioners to respect the report (or expression) of an experience as pain – regardless of the capacity of the person to communicate it verbally.1
It is not only that each person brings a unique backstory to their pain experience, but also that each person may present with different types of pain (nociceptive, neuropathic and/or nociplastic) and many different contributory mechanisms (e.g. inflammation, central sensitisation, cortical upregulation).3
So, effective pain management is personalised.
Evidence-based modalities such as pain education, exercise/physical activity, CBT – or ACT-based strategies and sleep hygiene usually make up the core of comprehensive pain management programmes. Nevertheless, given the uniqueness of each person’s pain experience, their application is always tailored to the individual’s needs, preferences and values; as well as to the mechanistic targets contributing to their particular pain presentation.3 Even the most effective pain management plans cannot just be duplicated, they need to be designed for each person.
Pain has significant functional impact.
Although pain typically serves an adaptive role of warning us of actual or potential threats to our person, it may adversely affect wellbeing and functioning.1 Particularly in the case of chronic pain, the impact on occupations and quality of life can be significant – affecting almost everything from the ability to move and sleep, to performing work and maintaining relationships.5
Pain’s interference with functioning can also result in a ‘vicious cycle’ in which decreasing functioning is significantly associated with increasing pain severity.6 Ultimately, though, it is the suffering induced by the loss of functioning, life-roles and quality of life associated with chronic pain that motivates people to seek healthcare.7
So, effective pain management focuses on improving function…
It is widely accepted that best pain management practice is to focus on improving the functioning and quality of life of the person with chronic pain.8 This is because, for many people with chronic pain, these might be more realistic outcomes than achieving significant reductions in their pain severity.3
Occupations and activities do, however, have the potential to do more than improve functioning. By necessitating whole-person engagement and learning by association and experience; occupations also have the potential to reduce pain severity and improve other health outcomes in a sustained way.9
… And supporting self-management.
As with other chronic conditions, chronic pain comes with high ‘costs’ for individuals, institutions and society at large. It has therefore become increasingly important to ensure that pain management facilitates and supports self-management.10
Self-management includes everything a person living with chronic pain (with the support of others) does to manage their condition; whilst continuing to achieve what they can and move towards a wellness perspective.11
Different types of interventions (e.g. education) and combinations of techniques (e.g. pacing, mindfulness-based interventions, goal-setting) can be used to equip people with chronic pain with the knowledge, skills and confidence to manage their condition themselves.
Supported self-management can lead to improved health outcomes and quality of life.11
Enter: Occupational therapy!
We are a person-centred healthcare profession, steeped in the biopsychosocial framework and with many diverse modalities to offer people with pain. Furthermore, with occupations as both our means and end, and our existing skills in supporting self-management, we are essential to achieving the overarching pain management goals of improving functioning and quality of life.
I hope this overview of the current understanding of pain, and the evidence-based approaches to managing it, presents a convincing argument for the suitability of occupational therapists for pain management.
We can have confidence to face the complexity and challenges of pain management and engage ourselves in interdisciplinary pain management teams.
This encouragement comes with a few closing cautions…
Cautions for OTs
- It can be easy to ‘talk’ biopsychosocial but still ‘do’ biomedical! People living with pain (and the colleagues working with us on the team), need us to be the ‘expert generalists’ who see people as whole persons. We must remain vigilant about not narrowing down our therapeutic modalities to only ‘top-down’ or psychological interventions (e.g. mindfulness techniques) nor only ‘bottom-up’ or physical ones (e.g. ergonomic positioning or splinting), neither of which are sufficient on their own to address pain.
- Whilst OTs have broad knowledge and have developed wonderful analytical and problem-solving skills, we still have more about pain science and practice to learn and need to continue to cultivate our curiosity and humility when approaching the complexity of pain.
- Although we have numerous transferable skills and modalities suitable for pain management (especially those from the field of psychology), we must continue to practise evidence-based care and identify what mechanisms and types of pain we are targeting with them.9
- There is so much we can do for someone living with pain but we cannot do it all alone. We need to find or work our way into interdisciplinary teams and, once there, use our communication and collaboration skills to enhance the quality of care the team can provide to the person with pain.3
For more information: www.otpmg.co.za or info@otpmg.co.za
References
- International Association for the Study of Pain Terminology Working Group. IASP Revises Its Definition for the First Time Since 1979. International Association for the Study of Pain. 2020 [accessed 2022 Mar 20]:1. https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
- American Occupational Therapy Association. (2021). Role of occupational therapy in pain management. The American Journal of Occupational Therapy, 75 (Supplement_3), 7513410010.
- Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on burden, best practices, and new advances. The Lancet, 397(10289), 2082-2097.
- AOTA from Breeden, K. L. (2011). Opioid guidelines and their implications for occupational therapy. Medicine, 1.
- Dorfman C. Impact of Pain on the Daily Life of Older Adults. The American Journal of Occupational Therapy. 2018;72(4_Supplement_1):7211500010p1-7211500010. doi:https://doi.org/10.5014/ajot.2018.72S1-PO2003
- J. Reid, J. Harker, M. M. Bala et al., “Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact,” Current Medical Research and Opinion, vol. 27, no. 2, pp. 449–462, 2011.
- Loeser, J. D. (2000). Pain and suffering. The Clinical journal of pain, 16(2), S2-S6.
- Cheng J, Rutherford M, Singh VM. The HHS pain management best practice inter-agency task force report calls for patient-centered and individualized care. Pain Medicine (United States). 2020;21(1):1–3. doi:https://doi.org/10.1093/pm/pnz303
- Robinson, N. Kennedy, and D. Harmon, “Is occupational therapy adequately meeting the needs of people with chronic pain?” American Journal of Occupational Therapy, vol. 65, no. 1, pp. 106–113, 2011.
- Lorig K. Self-management of chronic illness: a model for the future. Generations: Journal of the American Society on Aging. 1993;17(3):11–14.
- Therapeutic patient education: an introductory guide. Copenhagen: WHO Regional Office for Europe; 2023. License: CC BY-NC-SA 3.0 IGO
Last Updated on 28 October 2024 by HPCSA Corporate Affairs