How occupational engagement might work in pain management
Intuitively, most of us know that when we’re actively involved in doing something we either enjoy or is sufficiently complex enough to need attention, we can lose awareness of things like hunger, thirst – or pain.  In the very early years of occupational therapy, this “distracting” factor of occupation was employed to good effect to while away the time needed to recover from serious trauma following the World Wars.  Over the years following, the positive effects of being involved in occupation were somehow overlo0ked in the desire to get scientific about the serious business of rehabilitation. Frivolous things like occupation for occupation’s sake was often left behind.

More recently we’ve begun to learn more about how occupation might be a good thing.  First came the cumulative findings that being in work was not only economically healthy, but also maintained physical and mental wellbeing.

Then we found that through positive psychology studies that the state of  “flow” popularised by Mihaly Csikszentmihalyi could bring about not only positive emotions (afterwards, not specifically during because during flow the focus is almost entirely on the doing rather than any emotion) but also greater creativity and integrated physical/emotional/mental performance.

Now studies are emerging to demonstrate how occupational engagement (not necessarily even flow experiences) may work in pain management.  This is interesting to me for several reasons – firstly there have been some inconsistent findings with respect to the usefulness of distraction per se, where in one study people experienced an increase in pain after being engaged in a distraction activity (Goubert, Crombez, Eccleston & Devulder, 2004).  Secondly, most of the research into coping with chronic pain has occurred without specific attention to the valued goals of the individual.

Let me explain: usually it’s recommended to maintain a consistent level of activity.  Sometimes this is called activity pacing.  Yet there are times when it’s appropriate to suspend the use of pacing – when there is a special event like Christmas, or when dealing with an important deadline (writing an exam over two hours).  We accommodate these events by varying the kind of strategy employed, maybe drawing on the use of additional relaxation in the day following Christmas, or using coping self statements during the exam.

Schrooten, VanDamme, Crombez, Peters, Vogt and Vlaeyen explored whether bias to attend to pain is impaired when an individual is engaged in a competing activity.  Participants in this experimental study with people who do not usually have pain, were given a spatial cueing task with pain cues and neutral cues.  Their attention bias towards pain was measured in terms of the speed with which they were able to identify whether a cue matched a stimulus.  Two different colours were used, one of which had been associated with a painful stimulus.  Usually, people respond more quickly to the stimulus that has been associated with pain than to a neutral stimulus because pain is a threat and our brains work hard to make sure we notice anything that might threaten our wellbeing.

To make this a little more exciting (well, for the researchers anyway!), half of the participants were also presented with a letter in the middle of the screen (the cues were randomly placed to either left or right of the screen) and asked to say the letter out loud.  If they got the letter correct, they were told they would be rewarded with money depending on the number of correct responses they made.  This was the “nonpain task goal”, or activity/occupation.

The results showed that when participants were distracted by the activity that might earn them money, they were slower at responding to the painful cue than when they were not distracted.  In other words, they were not as quick to respond to things that they had previously viewed as a potential threat.

This is a really interesting finding – while it’s a far cry from the kind of naturally rewarding activity we usually engage in when in the real world, the very structured and controlled nature of this experiment was able to demonstrate that there are measurable effects on how quickly our brains attend to things that we have learned might be a threat.

Another similar study using a different experimental study is by Bradshaw, Chapman, Jacobson and Donaldson (2012) in which music was used.  Their findings were that “engaging activities may prevent pain by creating competing constructions of reality that draw on the same processing resources as pain. ”

It looks like occupational therapists need to seriously get involved in the psychophysiological studies of why and how occupational engagement might work in pain management.

Schrooten, M., Van Damme, S., Crombez, G., Peters, M., Vogt, J., & Vlaeyen, J. (2012). Nonpain goal pursuit inhibits attentional bias to pain PAIN DOI: 10.1016/j.pain.2012.01.025

Goubert, L., Crombez, G., Eccleston, C., & Devulder, J. (2004). Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain. Pain, 110(1-2), 220-227.

Bradshaw, D.,Chapman, CR., Jacobson, RC.,  and Donaldson, G. (epub ahead of print). Effects of Music Engagement on Responses to Painful Stimulation. Clinical Journal of Pain.


  1. I seem to remember this being described years ago in terms of pleasurable/rewarding activities ‘closing the pain gate’ so that the pain signals ‘couldn’t get through’. Excellent news that the research is continuing as our understanding develops. Especially interesting, now that positive psychologist are researching the different aspects of happiness (eg Seligman), might be studying whether it makes a difference if the engaging activities are, say, simply pleasurable, or those giving a sense of accomplishment, or engaging of our interest, or having meaning for us or offering connection with others (to use Seligman’s model). Or the influence of strengths on pain perception…

    1. Good points – I think positive psychology has started to uncover things that many people have thought about, but not been able to demonstrate. I hope that we can build on this to help people with pain live better, more fulfilled lives. The pain gate has been superceded by the neuromatrix – which really invokes the whole central nervous system rather than just the spinal cord – as well as endocrine and other systems that are triggered by the neuromatrix in response to the brain’s detection of some sort of threat. Great stuff for clinicians using nonpharmacological approaches to managing pain, because it gives great scope to developing strategies that can be effective, with fewer side effects than drugs.

      1. As someone with ‘love of learning’ and curiosity’ as two of her signature strengths (Peterson), I couldn’t be happier with your helpful response. Lots for me to go study and learn!

  2. This is interesting, I work in pain management (as an OT) and now have my very own chronic pain condition that has been flaring badly, I find that pacing helps to an extent for work, but what seems to help more is to do something very absorbing and enjoyable that is both physical and mental, so I go fast hill walking and use mindfulness or do intense yoga til my body “sings”which makes me feel alive and also stimulates other parts of my body, I still need to take some hard core meds, but only at night and sleep is better and so pain is better. I do sometimes have “give in days” when i take the meds, watch films and eat ice cream, but after i have had a work out day so my body is relaxing not crashing. I am pretty fit and the pain is in my face not my limbs, I am not sure about recommending to patients to really push themselves so their body “sings” and then relax…. but it is certainly working for me…. And I tend to get pts to focus on doing more of what they like and to get as fit as they can as well as teaching mindfulness, which is a great way to develop the capacity to notice the joy and the pleasant as well as calming things.

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