Rochman, D. & Kennedy-Spaien (2007). OT Practice. Bethesda: Jul 30, 2007. 12(13), 9-16

Copyright American Occupational Therapy Association, Inc. Jul 30, 2007

Chronic Pain Management Approaches and Tools for Occupational Therapy

Chronic pain affects one in four Americans, or 50 million people¹. People living with uncontrolled chronic pain report an inability to work, exercise, socialize, sleep, have sex, or do chores.² It has been reported that 58% of people with chronic pain have coexisting depressive symptoms.³ Arthritis and back problems, both commonly associated with pain, continue to be the leading causes of disability in the United States.⁴ Still, only one in four people with pain reports satisfactory pain control,² up to 80% of nursing home residents have uncontrolled or untreated pain,⁵ and back pain is often unsatisfactorily managed in primary care settings.⁶ Some groups, such as women, the elderly, minorities, children, and people who are not able to speak for themselves are undertreated for pain at even higher rates.⁷ Uncontrolled pain has deleterious effects on occupational performance for families,⁸ children and adolescents,⁹ adults with disabilities,¹⁰ and the elderly.⁵ Occupational therapists evaluate the impact of pain on occupational performance and help people learn to live productively despite the presence of pain.¹¹

BARRIERS TO EFFECTIVE PAIN MANAGEMENT

Acute pain and chronic pain are different phenomena and need to be addressed in appropriately different ways. Acute pain is a symptom associated with tissue damage, inflammation, or a disease process. Chronic pain-that is, pain persisting beyond the usual healing time-becomes the symptom and a problem unto itself. In this context, "usual healing time" is circumstance-specific. For example, an elderly person or someone with diabetes will heal more slowly than a younger, healthy individual. Although there are many theories about why pain becomes chronic, according to S. Scrivani, DDS, associate professor at Tufts University School of Dental Medicine, Craniofacial Pain Center, it is generally accepted that changes within the nervous system (e.g., sensitization of nerve fibers; increased nerve membrane excitability; axonal sprouting; cell death; cortical reorganization; pain memories; changes in neuronal pathways that communicate with brain areas involved with fear, memory, and emotions), cause pain to persist. These changes, which begin as protective (acute pain) become destructive (chronic pain) over time. As pain persists, suffering (the emotional response to pain and its consequences) and pain behavior (the things people do to let others know they are hurting) become increasingly important in the evaluation and treatment of the pain problem. In fact, therapists who work with people with chronic pain primarily address the suffering and pain behaviors associated with the pain, not the pain itself.

MYTHS AND MISCONCEPTIONS

Despite advances in pain knowledge, mechanisms, and treatments, myths and misconceptions about pain and its relief pose significant challenges for health care workers and clients and their families (see Table 1). Inadequate coverage of pain topics across all health profession curricula has contributed to the undertreatment of pain.¹³ Although there have been initiatives to fill this gap, faulty knowledge and inappropriate attitudes about pain and its relief persist among health professionals, including occupational and physical therapists.¹⁴ Knowledge gained from evidence-based practice approaches help occupational therapists and occupational therapy assistants develop appropriate attitudes toward pain and its management.

APPROACHES TO TREATING CLIENTS WITH CHRONIC PAIN

Evidence-Based Practice and Client-Centered Care

Evidence-based practice is a professional mandate for all health care workers, including occupational therapists and occupational therapy assistants.¹⁵ In client-centered, evidence-based practice, three sources of information are used when the therapist and client collaborate on making decisions: information from research, clinical expertise, and client preferences and values. All three sources are considered and weighed in light of the client's needs and goals.¹⁶ Current evidence related to pain management provides us with therapy approaches that support improved outcomes for clients living with chronic pain.

Team Approach vs. Sole Practice

Due to the magnitude and complexity of problems encountered by individuals and their families who are affected by chronic pain, an interdisciplinary team approach using a biopsychosocial model of pain is the gold standard of pain rehabilitation¹⁷,¹⁸ and has been found to improve pain and function.¹⁹ A pain team includes, but is not limited to, professionals with expertise or specialized training in pain management, including dentists, physicians, psychologists, and occupational and physical therapists. Some pain clinics offer intensive interdisciplinary functional restoration programs. Clients are seen within a group context and immersed in an extended day program with others who have chronic pain. Occupational therapy groups address both the physical and psychosocial aspects of chronic pain. In this venue, clients glean knowledge and support from their peers as well as from staff. They begin to feel less isolated, recognizing that others are facing the same challenges and are finding ways to succeed. For therapists who are not part of an organized pain team, maintaining regular, ongoing dialogue between and among other team members ensures optimal outcomes for clients.

Cognitive-Behavioral Approaches

There is evidence to support the use of cognitive behavioral therapy (CBT) approaches in chronic pain management.^19-21 These approaches help clients gain awareness of how thoughts, feelings, and behaviors affect pain perception. CBT includes learning and using effective cognitive coping and behavioral strategies to manage pain. CBT, in combination with the actual practice of important activities, enables occupational performance and improved self-efficacy.^22,23 Self-efficacy, or the belief that one can control pain in particular circumstances, is central to effective pain management.²³ Although further study is needed to elucidate what variables are most salient and which clients will benefit from the variety of treatment options available, CBT approaches are becoming a standard of care for clients with chronic pain.

Self-Management: Active vs. Passive Approaches

Self-management emphasizes that clients should become knowledgeable about their condition, actively participate in decision making concerning their care, and ultimately manage their own care. Self-management of chronic pain should be the focus of all treatment efforts.^6,24 However, there will be exceptions, and it is imperative to consider individual client needs. For example, if a client has not been exposed to a passive, hands-on treatment and there are sound biomechanical indications to use it, it may be advantageous to do so. In these cases, however, the passive treatment must be used in conjunction with a functional activity (e.g., trigger point release before biofeedback retraining of shoulder muscles in preparation for work on a computer). Of course providing ongoing passive treatments without objective signs of improvement in function is always inappropriate.

EVALUATION: GAINING TRUST

People with chronic pain often feel stigmatized. Chances are that a new client with a diagnosis of fibromyalgia, repetitive strain injury, complex regional pain syndrome, chronic back pain, or any number of other chronic pain conditions has seen many professionals and has tried a variety of medications, exercises, modalities, and other treatments, with minimal or no success. The client may be discouraged or angry toward the medical system because of this history of treatment failures. Maybe he or she has been told that the pain is "all in your head," particularly if objective testing, such as X-rays or other studies, has been negative. So, how can the occupational therapist engender trust and hope in this client?

The first step is to reassure the client that you believe the pain is real. It is helpful to discuss the diagnosis and the physiologic basis for the pain. For example, for a client with myofascial or muscular pain, where objective tests are often negative, you can explain how active trigger points may result in pain. This is also an opportunity to explain how emotions and other factors, especially stress, affect pain perception and pain tolerance, emphasizing that this connection does not indicate that the pain is psychological. Define occupational therapy early on, letting the client know that you are going to work together to find ways to resume meaningful activities without increasing pain.

SETTING GOALS

It is not uncommon to hear that your client's primary goal is "to get rid of this pain." Unfortunately, this goal may not be achievable. Reducing pain as a primary goal of treatment may lead to frustration and ultimately impede the rehabilitation process. Helping your client make the cognitive shift from pain relief to pain management is challenging, but also empowering. Functional goal-setting, done in collaboration with your client, is key to this process (see Table 2). Help your client identify occupation-based goals by asking open-ended questions such as, "What are some activities you would like to be able to do more comfortably?" or "What activities have you stopped doing because of your pain?"

INTERVENTION: PROMOTING PARTICIPATION THROUGH EMPOWERMENT

For many clients, pain has become all encompassing and takes control over many, if not all, aspects of daily life. Occupational therapy practitioners help them regain control by teaching the use of specific tools to enable occupational performance, despite pain.

Pain Control Modalities

A combination of pharmacologic and non-pharmacologic strategies has been shown to yield optimum pain control.⁵ Ice massage, cold packs, and acupressure self-massage techniques are just a few examples of pain control techniques that clients can use independently. Many of these tools are portable and easily integrated into home, work, or community tasks. Clients are taught to use the techniques proactively, as part of a daily schedule, rather than waiting for the pain to get severe. Using these tools in this manner exemplifies the difference between acute pain management and self-management of chronic pain (i.e., when treating a client with acute pain, the clinician might administer pain control techniques to or for the client, versus chronic pain management in which the client is taught to use the tool independently).

Functional Body Mechanics Retraining

Occupational therapists evaluate activity demands and teach clients how to perform them using safe body mechanics. An activity analysis for each problematic activity allows the therapist and client to find an optimal biomechanical strategy to perform it without increased pain or injury. Commonly, therapists find that clients avoid engaging in activities due to fear of pain. Fear avoidance has been shown to predict disability²⁶ and can be a significant barrier to improving activity levels in clients with chronic pain. With practice, the client's confidence in his or her ability to safely complete activities (self-efficacy) is gained.

Pacing

Teaching clients to shift from a "can I do this activity?" to a "how can I do this activity without increasing pain?" mind-set is paramount to successful pain management. Many clients have an all-or-nothing approach: They either complete the activity and suffer later, or they avoid the offending activity altogether. Pacing teaches clients to break tasks into smaller, manageable sets of activities. Simple techniques, such as using a timer and taking "mini breaks" before pain levels rise, allow comfortable completion of tasks. For example, if a client with a sitting tolerance of 30 minutes goes to a movie, he or she can set a cell phone to vibrate every 25 minutes as a reminder to get up and stretch. If cold relieves discomfort, the client can bring a Ziploc bag to fill with ice from the concession stand, place it over the painful body part, and enjoy the show with enhanced comfort.

Muscle Tension Reduction

Muscles around an injury will reflexively tense and splint the area. Muscle guarding serves as a protective response with an acute injury but has an adverse effect on chronic pain conditions. To reverse this response, clients need to learn to recognize and release ineffective muscle tensing and reduce or reverse compensatory patterns in other body areas. To facilitate this muscle reeducation, biofeedback, adaptive tai chi, or relaxation training may be appropriate. Relaxation training, a cognitive-behavioral treatment approach,²⁷ is commonly used to help clients self-regulate muscle tension and relaxation patterns throughout the body. Before initiating this training, therapists should inquire about what has worked, what hasn't worked, and client preferences. Offering choices of techniques allows the client to find what best suits his or her needs. As skill and confidence with the technique are attained, clients can practice and use it in more challenging settings and during a variety of activities. Here, as in other areas of pain management, there is often overlap across disciplines. Occupational therapists can develop their skills through continuing education, but need to adhere to local licensure and reimbursement standards.

Assertiveness Training

Assertive behavior, or the appropriate and effective expression of needs, wants, and feelings, may be an essential coping skill for a client with chronic pain.²⁸ Being able to assertively refuse requests or ask for help can reduce or eliminate the use of indirect or ineffective ways of getting what one needs. Assertiveness training uses behavioral methods of education, modeling, and role-playing and is often done in groups.

MONITORING OUTCOMES

Occupational therapists select reliable, valid, and sensitive measures to document the effects of therapeutic interventions. For example, the Canadian Occupational Performance Measure (COPM)²⁹ is appropriate for use in chronic pain management. The COPM, a client-centered outcome measure, documents the client's perception of satisfaction with occupational performance. The use of psychometrically sound outcome measures provides evidence that what we do makes a difference in the daily lives of our clients.

DEALING WITH CHALLENGING BEHAVIORS

Inconsistent behaviors are often noted when treating clients with chronic pain. For example, they may demonstrate grimacing, guarding, and limited active range of motion when asked to raise their arm above their head, but when observed donning a jacket, they move easily and with greater range. Does this mean these clients are malingering? Generally, the answer is no. Malingering, or consciously displaying symptoms to achieve some gain, is rare. The behavior may be indicative of secondary gain, but most likely it represents a client's fear of movement or increased pain perception when focused on moving a painful limb. At times these inconsistencies can cause even the most patient of practitioners to become frustrated. It is helpful to remember that clients are not doing this intentionally, and they probably want to progress in therapy. Often this behavior is best addressed in the positive: "You just did a great job moving your arm more freely when you put on your coat" rather than: "I know you can lift your arm higher, you did it when you put on your coat."

Although consistent attendance in treatment and follow-through with home programs are necessary to make gains, cancellation rates and inconsistent home program compliance may be high with this population. One strategy is to have clients sign a treatment agreement, limiting the number of allowable absences and stating, "pain is not an excuse for canceled appointments." The agreement can include consistent follow-through outside of treatment sessions. Reviewing the agreement with the client gives therapists an opportunity to explain the value of coming to treatment even when pain is elevated. This agreement also allows the client and therapist to work together on flare-up management. The lives of many of our clients are in chaos. There may be a multitude of appropriate reasons why they are canceling appointments or are not able to follow through with their home program. Unfortunately, if they are unable to attend sessions and follow through, the benefits from treatment will be limited. Explaining to these clients in a nonjudgmental way that "this may not be the right time" to pursue treatment may either help them commit fully or allow them to take a hiatus until they can be consistent.

CASE EXAMPLE

Jane is a 20-year-old college student with diagnoses of chronic wrist tendinitis and myofascial pain syndrome. A year ago, pain symptoms began in her wrists, neck, and midscapular areas and were reportedly associated with intensive bouts of typing. The pain progressed and spread to her shoulders, arms, and back. Objective tests were negative. Previous therapy had been unsuccessful in controlling her pain and Jane was growing increasingly more frustrated, depressed, and functionally limited.

Jane was referred for outpatient interdisciplinary pain rehabilitation, which included meetings with a psychologist, trigger point injections, and physical therapy for strengthening and cardiovascular conditioning. In occupational therapy Jane presented with decreased grip strength, intact sensation, active trigger points, and muscle guarding. Despite the use of a scribe at school, Jane reported that she was failing. Limited tolerance for computer use reduced her productivity for schoolwork. At home, any repetitive use of her arms (e.g., grooming, housework, gardening) evoked pain in her upper body and impaired her performance. Socially, Jane was feeling isolated. She had been withdrawing from her friends and social activities because of pain. Additionally, her limits regarding housework were causing strife with her roommates. With the use of the COPM, Jane identified her goals: "Continue in school and be able to go to law school, drive for 1 hour, and sit through a movie comfortably."

In occupational therapy, Jane was instructed in autogenics meditation (a training program of self-regulation whereby the client uses verbal commands to effect psychophysiological changes) to increase peripheral blood flow to her hands and arms and to relax her arm muscles. Jane's home program included daily meditation practice and regularly scheduled ice self-massage to proactively control pain. Self-care, writing, reading, and driving tasks were practiced using safe body mechanics, positioning, and pacing. A worksite evaluation resulted in ergonomic modifications to Jane's workstation. Biofeedback muscle reeducation of her wrist and shoulder muscles allowed Jane to decrease excessive muscle tension in these areas. COPM scores at time of discharge from occupational therapy demonstrated achievement of Jane's goals and satisfaction with the outcomes of her therapy.

CONCLUSION

The consequences of chronic pain for individuals and families can seem insurmountable, but advances in pain research and pain care have increased our understanding of these complex problems. Medical professionals have available an armamentarium of pharmaceutical and nonpharmaceutical tools and approaches to reduce pain and suffering in our clients. Finding the "just right" combination for individual clients is the best care the pain team can provide and will result in the best outcomes.

Pain management is still a young science. Practitioners need access to current advances in the field. Occupational therapists who wish to obtain leadership roles in pain management can pursue additional training and certification (see For More Information). However, advanced training or certification is not necessary to contribute to this body of knowledge. By using systematic documentation and monitoring treatment effects with valid outcome measures, occupational therapists and occupational therapy assistants can help identify which treatments, under what conditions, and for which clients, yield the best outcomes.

Despite the challenges of working with people who have chronic pain, the rewards are worth it. Occupational therapy practitioners bring a unique perspective to the client and the pain team. We focus on function while considering the psychosocial and physical dimensions of pain. It is both exciting and rewarding to assist persons with chronic pain in resuming meaningful roles and productive activity, thus making a significant impact on their quality of life.

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