If there is one part of occupational therapy practice that gets more of my middle-aged grumpiness than any other, it’s occupational therapists using compensatory approaches for managing pain. And like anything, it’s complicated and nuanced. So here’s my attempt to work my way through the quagmire.
Compensatory approaches consist of a whole range of interventions that aim to “make up for” a deficit in a person’s occupational performance (see Nicholson & Hayward (2022) for a discussion of compensatory approaches in “functional neurological disorder”). The rationale for compensatory approaches is that by employing these strategies, a person is able to do what they need and want to do in daily life: the raison d’etre for occupational therapy (WFOT, 2012). End of story, right? If the person wants to be able to use the toilet independently, then a piece of equipment (a rail, a toilet seat, a long-handled wiper, easily removed and replaced clothing) makes sense, surely?
Short answer is no, not always. And long answer is – well, it depends.
First of all, let’s take a quick look at compensatory approaches used with people experiencing pain. Remember that people seeing occupational therapists may have acute post-surgical pain (eg post arthroplasty pain) or they may have long-term pain from conditions like osteoarthritis, rheumatoid arthritis, multiple sclerosis etc. In an acute hospital setting, it makes sense for someone to be helped to leave the hospital ward by providing them with a safe way to manage important daily life tasks such as using a toilet, shower/bath, getting dressed, making a meal. The intention behind using a compensatory approach is to give short-term strategies to foster independence, or to provide strategies to “make up for” functional deficits the person may never overcome.
The strategies can include adaptive equipment – I’ve mentioned the ubiquitous raised toilet seat and rails, but there are also chair raisers, bathboards, commodes, kitchen trolleys and so on. Strategies can also include “ergonomic”* approaches intended to reduce biomechanical demands, and often applied in the workplace such as adjustable office chairs, wrist rests, monitor height adjustment, sit/stand desks, lighting etc. Occupational therapists might discuss task simplification, where people are encouraged to consider whether a task needs to be done, needs to be done in a particular way, needs to be done right now, or needs to be done by that person. Activity pacing could be added to the list: choosing when and how to carry out various daily life tasks over the course of a day, a week, a month. So far, so good.
The problems arising from this approach lie in its long-term use, or use in a rehabilitation context. Let me unpack why.
In rehabilitation, our aims are to support a person to go through a process of change (relating to their health and the impact of a disease or disorder) that aims to enhance health outcomes including quality of life (Jehanne Dubouloz, et al., 2010). The person’s capabilities are in a state of flux during this process, and our intentions are (usually) to improve the person’s ability to do daily life tasks. Early rehabilitation might occur in a hospital setting, but generally the expectation is that the person will end up doing their daily life in their own context. In many cases, people don’t get admitted to a hospital, but receive all their rehabilitation as an outpatient, or in their own home.
In persistent pain management and rehabilitation, there are often two phases: 1) the secondary prevention phase, where the focus is on reducing or ameliorating the impact of pain on daily life and often focusing on reducing pain, increasing function, reducing healthcare use, reducing distress and enhancing quality of life. 2) the tertiary prevention phase, where the focus is less on reducing pain (although this is still part of the picture) and much more on helping the person do what matters in daily life in the presence of pain, increasing function, reducing healthcare use, reducing distress and enhancing quality of life. Good examples of occupational therapy for persistent pain are in the literature, although like most interventions, the results are equivocal (eg Nielsen, et al., 2021). The main distinction between these two phases lies in how much attention is paid to pain reduction or elimination. Perhaps this is where so many of our conversations about pain management and rehabilitation come unstuck, because the point at which we (the person and his or her clinician) discuss the likelihood of pain persisting despite all of our best efforts is pretty opaque. We simply don’t know, and we have very little to guide us, and furthermore, both clinicians and people living with pain are loath to talk about what is a highly challenging topic. More about that some other time!
For occupational therapists, offering compensatory equipment during the secondary prevention phase might be where we come unstuck. While they help the person do what matters to them, if they are not reviewed and gradually removed, they can foster remaining stuck with that technique or strategy with all its inherent limitations.
What are those limitations? Well, take the example of a raised toilet seat – great when it’s available for use in a person’s home, but pretty darned useless when that person is out doing the grocery shopping, visiting another family member, going to a restaurant or the cinema. Toilet seat raisers are not the easiest thing to carry around! Similarly with a cushion to make sitting easier: fabulous for reducing discomfort, but then you have to carry the thing around wherever you go!
My point is that when a person’s capabilities are changing, so must our solutions. Occupational therapists need to be responsive to changes in a person’s function, and change compensatory strategies accordingly. When this doesn’t occur, we risk working at odds with the rehabilitative approach used by other team members.
Am I saying don’t use compensatory approaches? Not at all! I’ll be very happy to use task simplification or a shower stool if I return home following hip or knee arthroplasty. And if my cognitive capabilities are limited as they were when I had post-concussion syndrome, I’m very happy to incorporate activity management, fatigue management and compensatory ‘aide memoirs’ (my ever-handy lists and diary!) as part of my life – until I don’t need them any more. Thankfully I had great therapists who helped fade or withdraw the range of compensatory supports I used as my recovery progressed.
Soon I’ll be writing about a framework occupational therapists (and other rehabilitation and pain management clinicians) can use to review their therapeutic approaches. In the meantime, it’s crucial for occupational therapists to take the time to understand the factors contributing to a person’s difficulty doing daily life. If those factors are able to be changed, and if the context is not constrained by “we must get this person out of hospital”, then perhaps we need to stop and think carefully about when, where and whether a compensatory approach is useful.
*I use the term “ergonomic” in quotes because technically, ergonomic approaches are not just about office equipment, but is actually a larger and almost philosophical practice of ensuring that work fits the person/humans doing the tasks. It sprang from work undertaken during the Second World War when it was found that dashboards on aeroplanes, and the machines that fabricated parts for them, did not work for most people. Essentially, it is a systems-based approach to ensuring human capabilities and limitations are considered during the design of workplaces to minimise errors, maximise productivity, reduce cognitive load, and enhance performance.
Jehanne Dubouloz, C., King, J., Ashe, B., Paterson, B., Chevrier, J., & Moldoveanu, M. (2010). The process of transformation in rehabilitation: what does it look like?. International Journal of Therapy and Rehabilitation, 17(11), 604-615.
Nicholson, C., Hayward, K. (2022). Occupational Therapy: Focus on Function. In: LaFaver, K., Maurer, C.W., Nicholson, T.R., Perez, D.L. (eds) Functional Movement Disorder. Current Clinical Neurology. Humana, Cham. https://doi.org/10.1007/978-3-030-86495-8_24
Nielsen, S. S., Christensen, J. R., Søndergaard, J., Mogensen, V. O., Enemark Larsen, A., Skou, S. T., & Simonÿ, C. (2021). Feasibility assessment of an occupational therapy lifestyle intervention added to multidisciplinary chronic pain treatment at a Danish pain centre: a qualitative evaluation from the perspectives of patients and clinicians. International Journal of Qualitative Studies on Health and Well-being, 16(1), 1949900.
World Federation of Occupational Therapists. Statement of occupational therapy. 2012. http://www.wfot.org/about-occupational-therapy.
HealthSkills Blog 
Once again I found this so useful. I’m currently studying a course run by a tertiary pain management service – but it is being delivered to hand therapist who are working in a secondary prevention phase or early intervention with their clients. A lot of these therapists are new and this might be the first training they have had on persistent pain. I noticed some of us are struggling with the ‘pessimistic’ messaging we are encouraged to give to patients about not expecting chronic pain to get better, but instead focusing on managing it. I can now see that part of the problem is that the trainers from the chronic pain service are used to treating patients at a very different phase to what the hand therapists are used to. I am starting to appreciate a bit more why the chronic pain service has this approach, but I still don’t understand why the chronic pain service can’t encourage clients to work on ‘managing’ pain whilst simultaneously encouraging the person to do what they can to treat the problem holistically and reduce pain. I am in remission for my third chronic pain state (one was 13 years, one 20 and the other about 7). I’m sure glad I always strove for remission and not just trying to ‘manage’. I’ve grown so much from this striving and I’m healthier than I’ve ever been. If I had a different personality, less health literacy….if I was told by a health professional I looked up to, to stop striving for remission I might have believed them and not kept striving for better health. I would likely still be that unhealthy and unhappy suffering individual or worse. Why remove patient’s hope? In the end it was non-expensive lifestyle changes and practices I made myself as well as mental and emotional shifts that step by step moved me in the direction of remission. Greatly looking forward to your next blog Bronnie and thank you!
Rosie, it is SO complex to know when to help people move from pain reduction to pain management – and to be fair, I don’t think it should be “our” choice as clinicians. We know the odds of pain reduction/elimination are increasingly poor over the course of a pain problem, and intensity depends on many factors.
What we can take from qualitative literature is that people with pain WANT to know that it’s OK to stop searching for “a cure”, AND they want health professionals to be honest with them and tell them that they will likely have ongoing pain. It doesn’t remove hope, it frees the person up to begin considering what they want their new life alongside pain to look like.
The bits we don’t know are how to do this sensitively, and when is the right time. We know more about what not to say than what TO say!
WRT it not being our decision as clinicians, this is because we don’t know where the person is at in their process of learning about pain. From my research, it looks like people need to “make sense” of some sort AND they need to have a “why” (what matters in my life), before they’re willing to begin considering life with pain. And all of this in the presence of someone clinical who is there to be their cheerleader. If the person wants to carry on looking for pain reduction, the conversation is then about the good and the not-so-good of focusing on this, alongside the good and not-so-good of beginning to move forward with pain. And these aren’t decisions we can make on behalf of the person with pain.
Thank you for your brilliant reply. This makes a lot of sense. I’m grateful to be having this discussion with someone like you who has looked at the research and has done (and is still doing) the hard yards in the field with patients. I haven’t felt willing to bring this topic up in my course as I didn’t want to come across as if I am being critical of the very experienced teachers. That and I don’t want to be failed 😀 I’m glad you made me aware of the qualitative research around what patients want. This is helpful. I agree that deciding to stop working towards a “cure” or remission should be a patients decision and that us health professionals need to be the cheerleaders for whatever they want to be working on. I’m sure it is my personal experience of the powerfully life changing benefits of getting into remission after very long hard battles with my own persistent pain states, that are feeding my strong feelings of ?possible outrage at worst and indignation at best about mainly pain specialist doctors I suspect telling patients that there is no known cure and that they should stop attempting to reduce their pain and work instead on managing it. I’ve never been in the room with a pain specialist during this conversation so perhaps this is not actually how they mean it to come across and I have been misrepresenting them in my own head. Mmmm one day I’m going to discuss this with pain specialist Doctors. Would make a great poster presentation at a pain conference right? Would this also be a good qualitative research topic interviewing health professionals about their thoughts/beliefs/emotions and behaviours around this trick area? It would also be interesting to see how health professionals treating pain change with this over time. I can see myself changing as I understand all the different sides to the equation better.
I haven’t found much research to inform us about when to “stop focusing on reducing pain”. The problems are that for many people, reducing pain becomes a big part of the problem. It’s an excellent area for research, and I would really like to see an experimental design for how best to go about this. With a greater understanding of how to have this conversation, and what helps/doesn’t help, we would be in a better position to do it sensitively. Currently it seems to be like a poorly-kept secret – people with pain wish there was a “cure” and try a whole lot of ways to reduce pain that are often unhelpful, all the while knowing that the odds of success are getting ever smaller. Clinicians fear raising the topic, often worrying they’ll “take away hope” and lots continue looking for pain reduction for their patients, and feel frustrated because they are aware of the tiny chance of being successful.
Together we end up with people on an endless cycle of seeking pain reduction and not helping people to live well in the interim.
I don’t think it’s impossible to both look at pain reduction AND begin moving towards a life that includes pain, but it’s a difficult process that requires more research to guide us.