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.