Why are there not more occupational therapists in pain rehabilitation?


A question I’ve asked myself many times! As a small profession with a long history (as long as physiotherapy, TBH), it does seem odd that there are many, many pain rehabilitation services where never an occupational therapist has darkened the door.

Some of the reasons lie within the profession: in general, occupational therapists are busy being clinicians and have little time for research. In New Zealand, few occupational therapists pursue higher degrees, and many avoid statistical analyses, experimental design, randomised controlled studies. In fact, some occupational therapists have argued that the tailored approach used by therapists means randomised controlled trials are impossible – our interventions too complex, too individualised.

And it is difficult to describe occupational therapy in the kind of broad terms used to describe physiotherapy (movement), psychology (mind, emotions, behaviour), medicine or nursing. Occupational therapists often deal with the everyday. Things like organising a day or a week, getting a good night’s sleep, returning to work, managing household activities. Not sexy things with technical names!

So… what does a good occupational therapist offer in pain rehabilitation? These are only some of the things I’ve contributed over the years:

  • graded exposure in daily life contexts like the shopping mall, supermarket, walking at the beach, fishing, catching a bus, driving
  • self regulation using biofeedback, hypnosis, progressive muscle relaxation in daily life contexts like getting off to sleep, at work in between clients, while doing the grocery shopping, while driving
  • effective communication with partners, children, employers, co-workers, health professionals in daily life contexts
  • guided discovery of factors that increase and reduce pain in daily life contexts like the end of a working day, over the weekend, at the rugby, in the pub, on your own, in a crowd, at home
  • information on proposed neurobiological mechanisms as they influence pain and doing/participating in daily life contexts, things like attention capture, distraction, memory, emotions, stress, excitement
  • values clarification about what is important to a person’s sense of who they are in their daily life
  • progressive meaningful movement in daily life contexts
  • goal setting, planning, managing and progressing overall activity levels in daily life
  • positive, pleasurable activities to boost mood, reduce anxiety and live a life more like the person wants

What characterises all that I offer? It’s context. One of the major challenges in all our pain rehabilitation is that people feel safe when in safe surroundings, with people who elicit feelings of safety. When things are predictable – like in a clinic setting – and when clinicians are present, people feel OK to do things they simply can’t do (or won’t do) elsewhere.

Life is complex. Contexts are highly variable, often chaotic, multiple demands on attention, priorities, values – and when a skill is developed in a controlled environment, like a clinic or office, it’s nothing like the real world. This, folks, is the unique contribution of a good occupational therapist.

Someone posted an image once, on the one side was physical therapy. On the other was psychology. And the question was posed: who bridges the gap between these two professions? I say definitively that this is the occupational therapy space. We are knowledge translators. We are the bridge between clinic and daily life. It is our domain, the entire specialty area of this profession. And it has been since the professions’ inception, way back in the early 1900s.

There are occupational therapists who let us down. These are the therapists who focus exclusively on occupational participation without factoring in that we are also a rehabilitation profession. These occupational therapists provide equipment to people who are sore: the new bed, the shower stool and rails, the kitchen stool and trolley, the bed and chair raisers. Now there may be good reason for installing these gadgets – in the short term. They might keep someone safe in their environment so they can do what’s important. AT the same time they can, and do, reinforce the idea that this person cannot do, and certainly cannot change. While installing these things can mean a person is able to do – the person also learns to avoid doing these movements. This is such an important concept in pain rehabilitation – because progressively working towards being able to manage normal activities without aids is what we’re aiming for! An occupational therapist installing these things without reviewing and supporting the person to no longer need these things is just like a physiotherapist offering a person a back brace or splint and never reviewing whether it’s needed.

Why is it difficult to acknowledge occupational therapy’s contributions? Partly our rejection of a biomedical model based on diagnosing disease. Occupational therapists are about the person’s illness experience, our model is wholistic, biopsychosocial, integrative. It’s hard to articulate our contributions without using a lot of words! Or making it seem so dumbed down that people view the exterior actions (cleaning teeth, having a shower) without recognising the myriad contributing factors that influence whether this action is carried out successfully.

Occupational therapists have relied on qualitative research to examine the lived experience of people dealing with persistent pain. Rather than pointing to randomised controlled trials of broad concepts like “exercise”, we’ve tended to describe the individual and unique experiences of people as they regain their sense of self. Not something easily measured like range of movement or cardiovascular fitness, or even simple measures of disability and self efficacy. Peek behind these descriptions you’ll find synthesised strategies that integrate values, committed actions, sense of self, cognitive defusion, behavioural approaches – messy things that aren’t readily translated into simple cause and effect experiments. Multifactorial approaches that recognise that life is a contextual experience.

I contend that one of the major failings in pain rehabilitation is helping people reclaim their sense of self again. Self concept is ignored in favour of changing a person from a couch spud to a gym attender. Even psychologists can forget that when instilling new strategies, the person in front of them has to learn to integrate these new things into their world – and that means adjusting their sense of who they are. That’s the hidden work people living with persistent pain have to do, rarely supported. And yet it’s the thing people most want to resolve when they’re dealing with this experience. Who am I? Can I be me again? If I can’t be the old me, can I at least get something of what was important to me back again?

What I’d like to see are more occupational therapists being confident about what our profession offers, being willing to step up and be the resource we know is needed. We don’t need to be defensive about this – but we do need to be sure about the validity and relevance of why our contribution is so important. I think the results from research showing how short-lived positive results of pain rehabilitation really are speak for themselves. Maybe the missing link is knowledge translation into daily life contexts?

11 comments

  1. Thank you Bronnie for this wonderful post. A great reminder of the important and valuable work of the profession of OT, just before OT Week too!

  2. A wonderful reminder of the immense contribution we can offer people with pain!! Articulation of the wonder that is OT. Thanks !!!!

  3. Hi Bronnie, what a lovely article! I’m an osteopath working in pain rehab but I am on the point of applying to train as an OT for all the reasons you list here. At the moment I feel very constrained and limited to a physical approach (and I struggle with patients expectations that I will ‘fix’ them) but in the last few years I have realised that BPS approaches are so much more effective. To me, becoming an OT is the best way to marry those two sides. Thank you!

    1. So lovely to read your thoughts about transferring to occupational therapy. It’s interesting because two of my favourite osteopaths are working in pain management (one in Australia, one in Canada) using mainly CBT and similar approaches! I think osteopaths are drawn to this whole person approach, and it’s great to see osteopathy coming away from some of the myths of the founding father(s) towards a strongly evidence-based treatment. Good luck with your studies!

  4. Bronnie, I really support what Dene has said above, I would like to circulate this article on some local (South Australian) networks. Are you OK about this?

      1. I have sent it to the OT Australia Connections newsletter. We need more OT’s in general to reflect on this important area of practise that is such a good fit for us.

      2. Super excited!!! Yes please, we need to keep the profile up. BTW Jo Hughes and I are working on practice standards for occupational therapists working in pain rehabilitation. This is because of instances of very poor and non-evidence-based practice, and very junior occupational therapists working in the area with limited support from occupational therapists with experience in the field. It’s not enough to be supervised by an experienced occupational therapist, IMHO, because this is how poor practice gets transferred like some sort of virus. The supervisor must be experienced and preferably educated in effective persistent pain management.

  5. Thank you Bronnie, your article warms my heart. This is something I’ve struggled with for the almost 20 years I’ve worked in CP management. Why are there not more OT’s working in this area? This area of medicine is simply made for OT. We are the whole person therapists working with the client to figure out how to make sense of it all and give the science and theory real life meaning. In an effort to do something about this we (myself, Sue and Linda) decided to take the plunge a few years ago and put on two day workshops around Canada exclusively for OT’s in an effort to drum up the passion and knowledge. It’s been a lot of learning and a ton of fun. We are doing a tour of Eastern Canada (unashamed plug) soon. Sponsored by CAOT. BTW Bronnie, we talk about you a lot in our workshops! Thanks again.

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