What do occupational therapists add to pain management/rehabilitation?


Coming from a small profession that has side-stepped (more or less) a conventional biomedical model, I’ve found my inclusion in pain management and rehabilitation is not always easily understood by other clinicians. It doesn’t help that occupational therapists practice in very diverse settings, and what we do may look superficially like handing out raised toilet seats, playing with kids, doing work-site assessments or hand therapy!

Today I hope to remedy this a bit, and extend a challenge to clinicians from other professions to sum up what your profession adds in 25 words or less (the first sentence in this definition below is fewer than 25 just sayin’).

“Occupational therapy is a client-centred health profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement. (WFOT 2012)

In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do.

In other words, although we may often be found dragging adaptive equipment around a hospital, our work is really about what people need and want to do – every day, and in every way.

One of the major impacts of pain for people is on their capability for doing, whether this is short-term, or becomes a long-term change.

How and what we do in daily life is influenced by individual values, the various contexts we interact with, temporal changes over the days and as we develop and mature, our culture and what helps us express who we are. The choices of what we wear, how we spend our work life, what we do for fun and leisure, how we communicate, how we navigate health systems, what we choose to eat and how we prepare it – all of these reflect our self concept. Occupational therapists focus on helping people resume or develop ways to do all of these things, so when someone develops pain that interferes with daily doing, it’s our job to help them do what matters in their life.

Something that many clinicians seem unaware of is that occupational therapy training covers both physical health and mental health (not that I think it’s possible to divide them!). As a profession we’re able to use (almost) any therapeutic approach that we can use to enable participating in a person’s occupations. We also employ occupations as therapies – such as dog walking for exercise, or blogging to develop executive functioning skills, or going to the mall for graded exposure to sensory input, or preparing an evening meal as part of applying pacing skills.

In fact, given that daily life is occupational therapy’s “domain of concern”, one way you could define the profession’s contribution to pain management and rehabilitation is to call us knowledge translators. Our job is to help people embed what can often be “theoretical” concepts developed in physiotherapy or psychology, into the daily life contexts of people being seen. It’s an occupational therapist’s work to help establish whether pacing, for example, can actually be used in a conveyer-belt process job. It’s an occupational therapist’s job to look at when and where and how a person can integrate their home exercise programme in light of all the other responsibilities a person has. It’s an occupational therapist’s joy to help someone discover the many ways a father can “be a good Dad” even in the presence of low back pain that means playing rough and tumble isn’t a good thing right now.

What’s the evidence for occupational therapy? Well, one way to consider this is to think about how we might study what are bespoke solutions tailored to suit an individual in his or her home/work/leisure context. I personally don’t think RCTs are the best strategy because those individually-tailored solutions don’t lend themselves to being applied in a recipe-like way. I know that people may change their expectations (and therefore their goals) as they move through pain management, so the end point shifts, making standardised outcome measures especially of function/disability not especially useful.

Another way we can think about this is whether the techniques/strategies themselves require further research to validate their usefulness. Given the enormous literature on, for example, exercise for chronic pain, the conclusion I’ve come to is that the form of exercise is less important than that it gets done. And in the case of ongoing pain, we know that movement practices will need to be done – yep, for life! This means they need variety (plenty of options), they need intrinsic motivation (the “why” is so important), they need to be embedded into a person’s routines (so they get done), and there needs to be room for future change. And all of these are within occupational therapy’s scope of practice.

When it comes to dealing with the demoralisation, stigma and perhaps even low mood and sense of loss of self that’s associated with pain, doing what matters at the right level of intensity, complexity and expression is intrinsically part of therapy. Psychological therapies such as ACT, CBT, EMDR, graded exposure, trauma management, mindfulness, relaxation training, effective communication – these are all bread and butter for occupational therapists – in the context of taking the person from the clinic office into their daily life. After all, the most effective way to find out what’s going through someone’s mind when they’re starting to do movements they’ve been worried about is to – oh yeah, do it in real time in the real world. Similarly, doing things that help people feel productive, capable, creative and “back to normal” are all part of occupational therapy’s remit.

Wondering about the training and competence? Some readers might be surprised that occupational therapy training is equivalent to physiotherapy, nursing, social work, and indeed any of the other allied health. Many occupational therapists hold occupational therapy master’s degrees, and there are a growing number of us with PhDs. We come from backgrounds including psychology, physiotherapy, nursing, teaching…What is most important, according to the OTBNZ, our NZ Regulatory Body, is that occupational therapists adhere to the requirements for competence. There are five broad areas, and every occupational therapist must undertake both supervision and maintain a Portfolio of ongoing learning and reflection. CPD “points” and “hours” are irrelevant: what matters is that occupational therapists reflect on what they learn and consider how it might influence their practice. Finally, in Aotearoa/New Zealand, our profession has embraced bicultural practice, and you’ll find occupational therapists equally at home calling themselves kaiwhakaora ngangahau. Whakaora means to restore to health and ngangahau is an adjective meaning – active, spirited, zealous. In choosing this translation, the Maori Language Commission is conveying the idea of reawakening, or restoring to health one’s activeness, spiritedness and zeal – occupational therapy.

My plea to clinicians working in pain management and rehabilitation is to take some time to listen to your occupational therapist colleagues. Understand where they’re coming from and why they offer what they do – and take up the challenge I made at the beginning of this post: sum up what you offer in 25 words or less.

6 comments

  1. Thanks so much Dene! There will be a few of these coming in the next few weeks – some being critical of current practice, some about interprofessional teamwork, and at least one about a meta-model of the purpose of rehabilitation and pain management.

  2. I am also an occupational therapist but mainly with a hand therapy background. I’ve only been focusing purely on pain for the last 10 months. It was therefore wonderful to have my own professions input in this sphere outlined so beautifully. Thanks for another great blog article Bronnie. Keep ’em coming 🙂

    1. Thanks so much Rosie. I’m trying to articulate what we offer in a way that shows that what you can see from the outside is nothing like what we’re actually doing from the inside! It’s highly complex and uses what other professions may have researched, but implementing those approaches in the contexts that are supported by our occupational therapy and occupational science research.

  3. Bravo, an excellent summary of OT’s skills and ability to work effectively with people with chronic pain. An essential team member in any chronic pain service, I say.

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