The Role of Occupational Therapy in Intensive Interdisciplinary Pain Treatment
By Gabrielle Bryant MS, OTR/L
Department of Physical Therapy and Occupational Therapy Services
Boston Children’s Hospital
The American Occupational Therapy Association (2020) defines occupation as “everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life.” For youth with chronic pain, participation in daily occupations can be significantly altered over time. As pain persists, youth may present with a variety of physical, socioemotional, and cognitive challenges that interfere with participation in a wide variety of occupational domains, such as self-care, mobility, school, and leisure/play (Guite et al., 2007).
For example, guarded movements, deconditioning, difficulty with concentration and fear of pain can each result in disruption of occupational performance. In some cases, pain and its accompanying challenges may lead to avoidance of an occupation all together (Odell & Logan, 2013). Chronic pain can present itself in many diagnoses and locations (e.g., headache, abdominal pain, complex regional pain syndrome). With that, each individual presents with different barriers to participating in age-appropriate and personally meaningful occupations. Importantly, because the impact of pain upon performance in any given occupation can vary widely for youth with pain, individualized treatment planning is necessary. Within the Intensive Interdisciplinary Pain Treatment (IIPT) model, occupational therapists (OTs) play an integral role in restoring function in this patient-centered manner. Through a gradual reintegration approach, OTs help youth to re-establish meaningful roles, habits, and routines.
Using the International Classification of Functioning, Disability and Health, Children and Youth (ICF-CY) model, OTs can better understand the complex relationships between the factors that contribute to functional participation for youth with pain (WHO, 2001). When evaluating patients within the IIPT setting, OTs employ a patient-centered and holistic approach to assessing a patient’s level of engagement and functioning in daily occupations. Through patient and caregiver interviews, as well as subjective and objective outcome measures, OTs assess the activity demands and the factors (e.g., biological, psychological, and environmental) that influence how patients are participating in their occupations.
Additionally, understanding a patient’s historical performance in all daily activities before the onset of pain helps to further shape treatment goals and interventions. This is particularly important as a patient with chronic pain may alter the way in which they perform an activity to avoid or reduce pain. For example, a patient may appear to be independent in completing a task such as getting dressed; however, they may be modifying the way they are donning their pants to avoid clothing touching their foot. In sum, identifying the relevant biopsychosocial factors (and the extent to which a patient modifies participation in their occupations) helps OTs to target the specific skills necessary to maximize a patient’s ability to return to baseline level of functioning.
Occupation-based treatments are an essential element of OT practice, both in process and outcome, as engagement in meaningful activities can support generalization of skills across contexts and environments (Beisbier &, Laverdure, 2020). Participation in occupation-based activities can promote improved performance, as practitioners are able to help the patient to problem solve difficulties or obstacles in real time. During OT sessions within IIPT, a patient may work on activities of daily living (ADL’s), such as dressing, grooming, bathing, or completing chores. With an emphasis on using normal movement patterns and use of coping strategies, the patient learns how to complete the task without adapting or modifying their performance.
While interventions may vary, patients within the Mayo Family Pediatric Pain Rehabilitation Center (PPRC), an IIPT at Boston Children’s Hospital are universally provided with education on active pain management and how to use coping strategies to support their functional progress. Emphasis is placed on using strategies to promote engagement in rather than avoidance of activities. Hence, strategies such as massage, rest/lying down, and heat/ice are not recommended. Patients are given the opportunity to explore and practice movement, distraction, relaxation, and cognitive-behavioral strategies to facilitate completion of an activity, despite the presence of persistent pain. In conjunction with active strategies, patients are educated on ways to self-monitor and manage the thoughts, feelings, and actions that may impact regulation and influence participation in a challenging task. OTs work closely with patients and their families to develop individualized plans. These plans are focused on optimizing the use of self-management strategies across all occupations and settings.
In addition to teaching self-management strategies, OT intervention in IIPT includes addressing the body functions impacting engagement in occupation. This includes improving functional endurance through strengthening and aerobic exercise. Another common intervention utilized by OTs is tactile, visual, or auditory desensitization. OTs use a gradual exposure technique to re-introduce stimuli (e.g., touch, light, sound) that a patient has identified as painful and interfering with their participation in occupations (Harrison et al., 2019). The OT collaborates with the patient to identify stimuli within activities or environments which are impacting participation. Once these are identified, the patient and OT develop a hierarchy. From there, they collaborate to determine where to begin, who will administer the stimulus, and how long the stimulus will be applied. These exercises are progressed throughout a patient’s admission in the IIPT setting, both in duration and types of sensations. As tolerance to painful stimuli increases over time, patients can gradually increase their engagement in and independence with occupations previously avoided or modified due to pain (Simons et al., 2019; Odell & Logan, 2013; Harrison et al., 2019). Integrating the patient into the decision-making process is an important step to build a foundation of trust and rapport with the OT. This is essential, as patients are being asked to engage in activities that can elicit fear and pain (AOTA, 2020; Simons et al., 2013).
Once patients demonstrate understanding of active pain management strategies and tolerance to increased activity or sensations, OTs support patients in applying these skills to their natural contexts. Using the occupation-based approach, OTs help patients to prepare for re-integration to typical daily activities such as school, sports, community outings, or social/leisure activities (AOTA, 2020). Simulations of occupations provide an opportunity for patients to build confidence before fully reintegrating to a given occupation and are typically based on individualized treatment goals. For example, OTs often support school reintegration, especially through the development and implementation of full-day school simulations. Aspects of an individualized school simulation can include participation in didactic learning for a full day (following a patient’s typical school schedule), wearing a backpack when transitioning between classes, and/or listening to classroom noise in the background. Through activity simulation in treatment sessions, participation in home exercise programs, and the establishment of daily routines, patients practice generalizing the self-management skills learned in the clinic to the home and community settings. The long-term goal of these simulations (and of IIPT in general) is to improve independence with the use of self-management skills and maximize functional participation without the use of modifications, even in the presence of pain.
Within IIPT, OTs collaborate with many disciplines (e.g., psychologists, physical therapists, pain physicians) to improve performance skills and maximize functioning in all the occupations one needs and wants to do. While empirical research on OT-specific intervention for youth with chronic pain is certainly limited, such evidence for IIPT (which includes OT) exists. Logan and colleagues (2012) demonstrated that occupational participation and performance improved for youth with Complex Regional Pain Syndrome following completion of IIPT. In fact, in this study, 89% of youth demonstrated a significant change in their perceived performance and satisfaction in their valued occupations, from admission to discharge, as measured by the Canadian Occupational Performance Measure (Law et al., 1990). Additionally, IIPT has been shown to yield long-term benefits in pain reduction and functioning. Randall and colleagues (2018) found that youth with chronic pain maintained their post-treatment functional gains, such as attending school and participating in valued occupations, and reported a significant reduction in pain, five years after completing IIPT.
OTs play a unique and valuable role in IIPT treatment. The holistic nature of the profession, paired with the expertise on activity analysis and restoring function, makes OTs an exceptional addition to the interdisciplinary pain treatment team. By improving performance skills (e.g., strength, tolerance to stimuli, coping, self-regulation), and facilitating engagement in developmentally appropriate and patient-centered roles and routines, OTs are experts at helping youth with chronic pain maximize their functional participation in meaningful occupations.
- Beisbier, S., & Laverdure, P. (2020). Occupation- and activity-based interventions toimprove performance of instrumental activities of daily living and rest and sleep for children and youth ages 5–21: A Systematic Review. American Journal of Occupational Therapy, 74(2), 7402180040p1. https://doi.org/10.5014/ajot.2020.039636
- Guite, J. W., Logan, D. E., Sherry, D. D., & Rose, J. B. (2007). Adolescent self-perception: Associations with chronic musculoskeletal pain and functional disability. The Journal of Pain, 8(5), 379-386. doi:10.1016/j.jpain.2006.10.006
- Huguet, A., & Miro, J. (2008). The severity of chronic pediatric pain: an epidemiologicalstudy. The Journal of Pain, 9(3), 226-236
- Harrison, L. E., Pate, J. W., Richardson, P. A., Ickmans, K., Wicksell, R. K., &Simons, L. E. (2019). Best-evidence for the rehabilitation of chronic pain Part 1:Pediatric pain. Journal of Clinical Medicine, 8(9), 1267.
- Law, M., Baptiste, S., McColl, M. A., Opzoomer, A., Polatajko, H., & Pollock, N. (1990). The Canadian Occupational Performance Measure: An Outcome Measure for Occupational Therapy. Canadian Journal of Occupational Therapy, 57(2), 82–87. https://doi.org/10.1177/000841749005700207
- Logan, D. E., Carpino, E. A., Chiang, G., Condon, M., Firn, E., Gaughan, V. J.,Hogan, M., Leslie, D. S., Olson, K., Sager, S., Sethna, N., Simons, L. E., Zurakowski, D., & Berde, C. B. (2012). A Day-hospital approach totreatment of pediatric complex regional pain syndrome. The Clinical Journal of Pain, 28(9), 766–774. https://doi.org/10.1097/ajp.0b013e3182457619
- Occupational Therapy Practice Framework: Domain and Process—Fourth Edition.(2020). American Journal of Occupational Therapy, 74(Supplement_2),7412410010p1. https://doi.org/10.5014/ajot.2020.74s2001
- Odell, S., & Logan, D. (2013). Pediatric pain management: The multidisciplinary approach. Journal of Pain Research, 785.https://doi.org/10.2147/jpr.s37434
- Randall, E. T., Smith, K. R., Conroy, C., Smith, A. M., Sethna, N., & Logan,D. E. (2018). Back to living. The Clinical Journal of Pain, 34(10), 890 899. https://doi.org/10.1097/ajp.0000000000000616
- Simons, L. E., Harrison, L. E., O'Brien, S. F., Heirich, M. S., Loecher, N.,Boothroyd, D. B., Vlaeyen, J. W., Wicksell, R. K., Schofield, D.,Hood, K. K., Orendurff, M., Chan, S., & Lyons, S. (2019). Graded exposure treatment for adolescents with chronic pain (GET living):Protocol for a randomized controlled trial enhanced with single case experimental design. Contemporary Clinical Trials Communications, 16, 100448. https://doi.org/10.1016/j.conctc.2019.100448
- World Health Organization. (2001). International classification of functioning, disability, and health : ICF. World Health Organization.