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Occupational Therapy and Pain Rehabilitation

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Chronic pain is a major public health problem in the United States.  One in four Americans, or 116 million people, have some form of persistent pain. Chronic pain causes tremendous human suffering for its victims, their families, and society as a whole. The Institute of Medicine’s report (National Academies Press, 2011) estimated that costs of providing medical care and lost productivity due to pain are $560 to $625 billion dollars annually. This dollar amount exceeded the combined costs of heart disease, diabetes, and cancer. 

Chronic pain can lead to increased dependency on others, loss of worker and family roles, and difficulty participating in everyday activities. Sleep problems, depression, anxiety, social isolation, and overall reduced quality of life are common issues facing people with chronic pain. The pain is often intractable, and resistant to or not relieved by available medical approaches. A biopsychosocial, interdisciplinary approach has the greatest evidence base for efficacy, cost effectiveness, and preventing iatrogenic complications (Schatman, 2012).

Role of Occupational Therapy

Over time, chronic pain leads to a sense of disempowerment, and the loss of control to engage in daily activities. Using a self-management approach, occupational therapy focuses on helping individuals participate in daily activities in adaptive ways. Through the occupational therapy process, specific performance problems in daily living are assessed, valued activities are identified, and evidence-based therapeutic approaches are used to address the client’s goals. Occupational therapy is a necessary and core component of any comprehensive pain rehabilitation program.

Intervention Approaches

Education

Clients are often uninformed about the neurophysiology of the pain response, their specific pain diagnosis, and non-medical approaches used to manage pain. The process of informing clients about their pain, and clarifying treatment expectations and the self-management approach, prepares them for active participation in the rehabilitation process.

Functional Goal Setting

Clients are involved in identifying and setting goals for their own therapy. This process supports client motivation and participation while improving therapy outcomes.

Training

  • Proactive Pain Control: Clients are taught to independently and proactively use pain control modalities, such as heat or cold. When used safely and proactively (vs. reactively), increases in baseline pain levels can be avoided throughout the day, enabling participation in daily activities.
  • Safe Body Mechanics and Ergonomics: Clients often become fearful of pain with movement and subsequently avoid activities. Instruction in safe body mechanics, with opportunities to practice and receive feedback, promotes feelings of self-efficacy. Clients learn to safely perform basic activities of daily living, work, leisure, social, and community activities using techniques that reduce or prevent strain on body structures. Ergonomic assessments identify environmental factors that may be contributing to pain problems and that can be modified to improve function.
  • Neuromuscular Re-education: Over time, persistent pain leads to abnormal movement patterns and postural deviations. Occupational therapists retrain clients to perform tasks with the appropriate muscle groups using adjunctive modalities, such as electromyographic biofeedback, to prepare them to participate in valued activities.
  • Muscle Tension Reduction Training: Pain is a stressor on the body and mind. Learning to relax muscles and calm the mind allows the client to feel in control of his or her body while reducing pain levels.
  • Communication Skills Training: Chronic pain is an invisible disability. Assertive behavior (e.g., saying “no,” explaining needs and desires comfortably) enables clients to manage their disability with less conflict and frustration.  
  • Proactive Problem Solving: Previously avoided activities may be accomplished when clients are taught to be proactive problem solvers. This process involves anticipating potential problems and planning for challenges ahead of time.
  • Pacing Activities: Many clients with chronic pain have problems in self-regulating their activity levels. This often leads to flare ups whereby they experience higher than baseline levels of pain, for extended periods. Occupational therapists teach clients to pace their activities, such as taking breaks, changing the way an activity is done, or asking for help, as effective coping strategies.

Home Exercise Program

Self-management includes actively maintaining a healthy lifestyle, including home exercise programs. These programs are specifically tailored to meet the needs of individual clients and include physical movement, daily relaxation or meditation practice, proactive use of pain control modalities, etc.

Screening for Additional Referrals

Chronic pain can be accompanied by psychological, cognitive, emotional, and/or physical difficulties. When appropriate, therapists may refer clients for additional services to facilitate best practice and optimal therapy outcomes.

How and Where to Refer a Patient for Occupational Therapy Services

Occupational therapy to address chronic pain is best provided by therapists skilled in pain management and as part of an interdisciplinary team. Comprehensive pain management programs can be found in outpatient centers, although there are a few inpatient programs available in the United States. Additionally, occupational therapists may provide pain management services as part of palliative or hospice care or home health services. Early referral for services leads to better outcomes (i.e., before the pain leads to increasing levels of physical deconditioning, psychological distress, and overutilization of health care).

Conclusion

When pain becomes chronic, it leads to pain-related disability, human suffering, and tremendous economic costs. Evidence-based practice supports interdisciplinary and biopsychosocial approaches as the gold standard for managing chronic pain. Occupational therapy, focused on client-centered care and promoting optimal independence and satisfaction with performance, is an essential part of any comprehensive pain management program.

References

National Academies Press. (2011). Relieving pain in America. Washington, DC: Author.

Schatman, M. (2012). Interdisciplinary chronic pain management: International perspectives. IASP Clinical Updates, 20(7), 1–5.

By Deborah L. Rochman, MS, OTR/L, for the American Occupational Therapy Association. Copyright © 2014 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact copyright@aota.org.