Pain

     Chronic pain impacts nearly 100 million people in the US at a cost of $560-635 billion per year. Arthritis impacts nearly half of adults over 65, can lead to chronic pain and functional deficits, and is notably difficult to treat. Chronic pain has been linked with increased depression, anxiety, sleep issues, cognitive deficits, and functional and mobility impairments. Causes of pain may be known, such as neuropathy, or idiopathic (Ambrose & Golightly, 2015). A biopsychosocial model of assessment and intervention is recommended to help understand and treat the full scope of pain. The most effective treatment strategies to address chronic pain include a combination of pharmacological and nonpharmacological strategies and occupational therapists should be a key team member addressing the latter.

 

Role of Occupational Therapy. Occupational therapy has been identified as a key part of the team needed to effectively treat pain and help address the ongoing opioid epidemic (Parsons, 2018). Occupational therapists use multiple treatment methods to address pain. Biomechanical interventions can include the use of modalities, massage, strengthening, stretching, and aerobic exercise. Occupational therapists are trained in using physical agent modalities such as electrotherapeutic agents, superficial and deep thermal agents, and mechanical devices. However, it should be noted that the use of modalities by itself is not considered occupational therapy, but rather it is used as a preparatory technique to support participation in occupations (AOTA, 2012). Occupational therapists are also trained in cognitive-behavioral approaches including coping skills training, which is an important treatment approach for many participants with chronic pain.

 

Assessment. Self-report remains the gold-standard of assessing pain when a person is able to report (Gordon, 2015). However, while the visual analogue scale, or other similar rating scales, have been used for years to assess pain, many call for a more comprehensive assessment. The 0-10 scale has even been cited by some as contributing to the opioid epidemic and worse clinical outcomes (Gordon, 2015). Other methods of assessing pain include looking at objective signs (vital signs, facial expressions, breathing, vocalizations, guarding, limping, etc), the functional impact (e.g. ability to perform ADLs, work, sleep, leisure, relationships and social participation), and the psychosocial impact of pain (e.g. depression, anxiety, decreased self-efficacy). Pain can also be experienced differently due to cultural or gender factors and clinicians should be sensitive to this.

     Realistic client-centered goal setting is an essential part of the assessment process. This will likely involve education regarding pain and effective treatment strategies. Particularly with chronic conditions such as arthritis, neuropathy, or fibromyalgia, some level of pain will likely be present and having a goal of no pain may be unrealistic. Education and cognitive reframing can be useful in those with unrealistic expectations (Ambrose & Golightly, 2015).

     The Clinically Aligned Pain Assessment (CAPA) pain scale is one example of a more comprehensive tool to assess pain. It is designed to be completed through a conversation with the participant and looks at comfort, change in pain, pain control, functioning, and sleep (Topham & Drew, 2017).

     One example of an assessment tool for clients with dementia who cannot report their pain levels, is the Pain Assessment in Advanced Dementia (PAIN-AD). This is an observational assessment that looks at breathing, negative vocalization, facial expression, body language, and consolability and yields a 0-10 score (The University of Iowa, 2019).

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Directions can be accessed here: https://geriatricpain.org/assessment/cognitively-impaired/painad/pain-assessment-advanced-dementia-painad-tool

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Intervention. There is strong support for the use of activity and exercise to help manage chronic pain regardless of etiology. Any intensity of aerobic exercise has benefits, so finding the right intensity to match the abilities of each individual and a program that can be realistically maintained can be a key role of the occupational therapist. Strength training and flexibility exercises have also shown to improve chronic pain. A variety of exercises is recommended for optimal outcomes; however, the focus should be on finding an exercise program that the participant is likely to maintain. Even if the intensity is low and the duration is shorter than recommended guidelines, supporting physical activity throughout a person’s day can lead to improvements in pain (Ambrose & Golightly, 2015).

      Patients who received cognitive-behavioral therapy or mindfulness-based stress reduction saw more improvements in chronic low back pain compared to usual care (Cherkin et al., 2016). Helping participants cope with the psychosocial impacts of pain through cognitive-behavioral interventions and coping skills training has been shown to be an effective component of pain management intervention. Depression can accompany chronic pain and can make adherence to treatment challenging for some individuals. Occupational therapists can be instrumental in addressing the impact of depression and also identifying if this is a barrier that needs further referral back to the primary care provider or specialist.  Self-efficacy also plays an important role in a person’s ability to establish and maintain a pain management routine and occupational therapists should be addressing self-efficacy in their interventions.

     Increased pain levels are associated with impaired sleep and fatigue, which can subsequently make pain worse (Ambrose & Golightly, 2015). Occupational therapists should address both the pain and sleep in their interventions (Goorman, Dawson, Schneck, & Pierce, 2019). Regular exercise, including Tai Chi, have been shown to improve sleep. Pacing, or preplanning when and how to complete tasks to address the limitations caused by pain, can help with fatigue, joint stiffness, and allow the person to more consistently engage in activity. Current research does not support pacing as a learned to strategy to directly reduce pain levels (Guy, McKinstry, & Bruce, 2019). However, teaching participants how to modify task performance using strategies such as energy conservation, learning proper body mechanics, and modifying the environment to support participation, can have a direct and meaningful impact on occupational performance. As chronic pain often leads to avoiding tasks and decreased occupational participation, this should be a main focus in occupational therapy intervention.