PAIN
The role of occupational
therapy in pain
management
Wendy Hill
Abstract
Occupation is central to human behaviour. Occupational therapy is
based on the premise that there is an intrinsic relationship between oc-
cupations, health and wellbeing. Chronic pain restricts the perfor-
mance of activities that individuals need to, want to and are
expected to perform. As activity performance is central to an individ-
ual’s identity, these restrictions can further impact the person’s psy-
chological health and wellbeing. Occupation is not performed in
isolation and the inability to fulfil valued family and social roles has a
further impact on the person’s social environment. The focus of occu-
pational therapists working in pain management is therefore to enable
individuals with chronic pain to participate in the activities that have
value and meaning to them, despite their pain. The occupational ther-
apy intervention will include the use of strategies such as activity man-
agement, activity adaptation, the development of coping strategies
and vocational rehabilitation and may involve working with patients
at home, school or workplace in addition to clinical settings. The aim
of this article is to explain the role and value of occupational therapy
within the pain management team.
Keywords Chronic pain; occupational therapy
Royal College of Anaesthetists CPD Matrix: 1D00, 2E03
Occupation, the focus for therapy
‘Occupation’ refers to any purposeful activity and includes the
areas of self-care, productivity and leisure. The inability to
perform activities which hold meaning and purpose for the in-
dividual and enable involvement in valued roles, can cause sig-
nificant psychological distress and result in deterioration in
physical and mental health, as well as impacting their social
environment. The aim of occupational therapy is to enable in-
dividuals to achieve satisfying performance in these areas to
support recovery, health, wellbeing and social participation. The
barriers to occupation for someone in pain are not solely due to
the limitations on movement, but the psychological and social
impact of those limitations. The emotional issues associated with
living with chronic pain can then further limit the person’s ability
to engage in occupations.1
Occupational therapy not only recognizes the importance in
sustaining activities in order to prevent deterioration, but the
value of activity in improving health and functioning. Fisher et al
found that as meaningful and enjoyable occupational involve-
ment increased, pain often decreased.1
Wendy Hill DipCOT is a Specialist Occupational Therapist at the Pain
Clinic, Queen Elizabeth Hospital King’s Lynn, Norfolk, UK. Conflicts
of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:9
The focus of occupational therapy within the pain team,
therefore, is to enable individuals to achieve satisfying perfor-
mance in activities, despite pain and fatigue. The core interven-
tion is activity management, which includes activity analysis,
skill development, activity adaptation, problem-solving, priori-
tizing, planning and pacing of activities to resolve an imbalance
of under-/overactivity. In addition, occupational therapists will
use ergonomics, communication skills training, coping skills
training, relaxation training, stress management and environ-
mental modification. They will enable the development of skills
to set and achieve goals through graded activity, provide adap-
tive equipment if required and facilitate return to work.2
Occupational therapy may be provided individually and
within groups, including pain management programmes.
Assessment
Accurate assessment forms the basis for any treatment plan.
Although a good understanding of the nature of the patient’s pain is
required, occupational therapists will focus primarily on the impact
of the individual’s pain on their occupational performance. They will
assess the impact of reduced performance on their routines, role
fulfilment and relationships as well as the person’s physical and
psychological wellbeing. They will consider the individual’s abili-
ties, strengths, coping strategies, past patterns of occupational
functioning and future goals. Occupational therapists also need to
understand the occupational identity of the patient as this constitutes
the values, beliefs, roles and interests which drive them to perform.
These motivations will then form the basis for the formulation of
patient-led treatment goals.
Occupational therapists will use their core skill of activity
analysis to identify the barriers to participation. Their under-
standing of the physical, emotional, cognitive and social demands
of activities enables them to assess the specific deficits of the indi-
vidual and obstacles within the environment. The identification of
physical and social environmental barriers may include assessment
within the patient’s home, workplace or educational site.
The assessment will form the basis of treatment and occurs in
collaboration with the patient. It is essential for effective therapy
that the patient has accepted their personal responsibility in self-
managing their condition and is willing to work collaboratively
with the therapist. The therapeutic relationship is key to ensuring
patient engagement with therapy.
Activity management
Having identified the barriers to performance through assess-
ment of the patient and their environment, occupational thera-
pists identify the techniques required to enable patients to
successfully engage in occupation. These techniques will include
problem-solving, grading of activity, education regarding pacing,
goal-setting, ergonomics and energy conservation.
 Problem-solving
Many activities can be made accessible through simple ad-
justments in method or the environment. By using a problem-
solving approach, individual barriers to participation can be
addressed and overcome.
 Grading activities and pacing
Pacing is a well-recognized approach for managing pain and
involves doing activities in manageable chunks with small rests
451 Ó 2016 Elsevier Ltd. All rights reserved.
 PAIN

between. It involves the patient understanding the amount and Work

type of activities that they can manage without exacerbating their
A reported 41% of people who attend pain management clinics
pain. The aim, is to rest or change activity before experiencing
state that their pain has prevented them from working.2 The
high levels of pain or fatigue and so avoid a long period of re-
National Pain Audit found that the most significant impact of
covery. Activities can be graded with regard to their specific
pain on people’s lives was on their ability to work.4
cognitive, physical, social and emotional demands. Understand-
Employment is a key part of normal life for the majority of
ing these demands then allows variation in order to pace effec-
adults and good meaningful work has been identified to have a
tively and also enables the gradual development of tolerance to
positive effect on physical and mental health. It is widely
increase participation. Pacing also includes prioritization and
recognized that where their health condition permits, sick and
planning to ensure that valued activities can be managed within
disabled people should be supported to remain in, or re-enter
the demands of daily life.
work as soon as possible. This is because work itself has been
 Goal-setting
found to be therapeutic and helps promote recovery and reha-
Many people with pain often struggle to adjust to the re-
bilitation. It also minimizes the risks of the physical, psycho-
strictions imposed by their pain and continue to try to achieve
logical and social effects of long-term absence from work.5 From
unrealistic goals. Others give up on being able to achieve any-
an occupational identity perspective, work is central to individ-
thing. Enabling individuals to set achievable short- and long-term
ual identity and roles and so vocational rehabilitation is a key
goals provides the basis for treatment and a focus which aids
focus for occupational therapists working in chronic pain.
motivation for further therapy.
Vocational rehabilitation has been defined as whatever helps
 Ergonomics
someone with a health problem to stay at, return to and remain
Ergonomics is the fit between man and his environment and is
in work and is the responsibility of all healthcare professionals.6
often applied within the workplace but has application in every
It has been noted that the longer a person with pain is absent
area of activity. Occupational therapists will help patients iden-
from work, the less likely they are to ever work again. Early
tify ways of performing activities that minimize the impact on
intervention when patients are on sickness absence is therefore
their pain. This may involve teaching specific techniques
vital. Within pain management teams, occupational therapists
including postures and movement and will include identification
are often ideally placed to support individuals with chronic pain
of changes within the environment to facilitate engagement.
to remain in or return to work. They will apply their activity
These changes may include the use of adaptive equipment.
management skills in relation to work roles to enable patients
 Energy conservation
develop the skills required to manage the physical, psychological
Patients with chronic pain frequently experience fatigue and
and social demands of returning to work. With the patient’s
in certain conditions such as fibromyalgia, fatigue can be as
consent, occupational therapists can liaise with employers to
disabling as pain. Occupational therapists will use energy con-
identify potential obstacles or hazards and to adapt the work-
servation techniques with patients to help them manage their
place and/or the role. Assessment within the work environment
activities efficiently in order to reduce fatigue and enhance
can be invaluable in identifying adjustments which will facilitate
performance.
return to work or support patients struggling within work.
Observation of the patient working helps with the therapist’s
Coping strategies
activity analysis by allowing accurate assessment of the physical,
Chronic pain is frequently associated with low mood, disturbed cognitive and social demands of the role.
sleep and a strain on relationships. Occupational therapists will There are a range of obstacles which prevent people from
work with patients to develop strategies to help them manage returning to work. The biological obstacles may be most obvious e
their sleep, mood and stress. They may also help them develop pain, skills, medication, sleep and activity levels. The psychological
assertiveness and communication skills. Occupational therapists’ barriers include depression, dysfunctional attitudes and beliefs
training in mental health enables them to support patients with about pain and disability, catastrophizing, lack of motivation, low
psychological difficulties but interventions will be guided by the expectations about returning to work and low self-efficacy. The so-
individual therapist’s training and expertise. Therapists will often cial barriers include work-place demands, family roles, transport,
undertake additional training in cognitive behavioural therapy, employer attitudes, benefit system, child care, work relationships
motivational interviewing and acceptance and commitment and employers’ poor understanding. Effective rehabilitation must
therapy. consider the range of biopsychosocial obstacles to recovery/return
to work (clinical, personal and occupational).7
Group work  Biological
Following assessment of the work role, either through dis-
The value of group work for people with chronic pain is well
cussion with the patient or a workplace assessment, the
recognized and there is high-level evidence for the efficacy of
occupational therapist will provide advice regarding specific
pain management programmes (PMPs) with guidance for best
postures and movements and the application of pacing and
practice from the British Pain Society.3 Occupational therapists
energy conservation within the workplace. They may also
are often involved with PMPs but may also run groups for spe-
involve other members of the team in enabling the patient
cific occupational or functional needs, for example groups for
prepare for returning to work. For example, specific physical
people with fibromyalgia, or for those wishing to return to work.
demands in relation to movement may require targeted
The value of these groups is not only economical but the op-
intervention from physiotherapists and cognitive demands
portunity for shared experiences and learning.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:9 452 Ó 2016 Elsevier Ltd. All rights reserved.

requiring levels of attention and concentration may affect the
medication regime prescribed by the consultants.
 Psychological
Occupational therapists will help patients identify realistic
goals in relation to work and build confidence and self-
efficacy through the use of graded activity and work-related
tasks. They will support the development of coping strate-
gies, such as stress management and assertiveness, specif-
ically related to the work environment. Liaison with the
employer may enable the grading of psychological demands to
reduce stress.
 Social
Occupational therapists can also signpost the patient to
agencies who can help with social obstacles such as benefits,
transport and child-care. They may refer to access to work for
the provision of equipment or other support within the
workplace. They may also liaise with disability employment
advisers based in Job Centres to identify further support and
training available.
For patients who have been out of work for some time but
wish to return, occupational therapists will assist in realistic goal
setting and identifying suitable roles. They will identify the steps
required to achieve the long-term goal of work and this will often
include voluntary work. The author has developed a vocational
rehabilitation programme within the hospital to provide graded
work experience for patients who are unsure of their fitness for
work. This 3-month programme enables patients to gradually
achieve a consistent work pattern and provide evidence of
employability to prospective employers.
A unique contribution
The impact of pain on the ability to engage in meaningful oc-
cupations, and the resulting impact on physical, psychological
and social wellbeing, ensures that occupational therapists are
increasingly being recognized as invaluable members of the
multidisciplinary pain management team. The general aim of
pain management, including PMPs is to improve participation in
daily activities, reduce distress, and enhance quality of life. This
ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:9
PAIN
includes focus on increasing mobility, self-care, work, leisure
and social activities2 which are the core areas of concern for
occupational therapists. ‘Through their overarching focus on
occupational engagement, occupational therapists make a
unique contribution to pain prevention and management
programs.’8 A
REFERENCES
1 Fisher GS, Emerson L, Firpo C, Ptak J, Wonn J, Bartolacci G, et al.
Chronic pain and occupation: an exploration of the lived experi-
ence. Am J Occup Ther 2007; 3: 290e302.
2 Core Standards for Pain management Services in the UK. Faculty
of Pain Medicine. 2015, http://www.rcoa.ac.uk/node/21140
(accessed 1 Dec 2015).
3 British Pain Society. Guidelines for pain management programmes
for adults. 2013, www.britishpainsociety.org/book_pmp2013_
main.pdf (accessed 1 Dec 2015).
4 National Pain Audit Final Report 2010e2012. Dr Foster intelligence,
British Pain Society, healthcare quality improvement partnership
2012.
5 Waddell G, Burton AK. Is work good for your health and well-
being? 2006. London: The Stationery Office. Also available at:
https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/214326/hwwb-is-work-good-for-you.pdf
(accessed 28 Jan 2016).
6 Waddell G, Burton K, Kendall N. Vocational rehabilitation e
what works, for whom and when? 2008. London: The Statio-
nery Office. Also available at: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/209474/hwwb-
vocational-rehabilitation.pdf (accessed 28 Jan 2016).
7 Waddell G, Burton AK. Concepts of rehabilitation for the man-
agement of common health problems. 2004. London: The Statio-
nery Office. Also available at: https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/208968/hwwb-
concepts-of-rehabilitation.pdf (accessed 28 Jan 2016).
8 Canadian Association of Occupational Therapists. CAOT position
statement: pain management and occupational therapy. 2012,
www.caot.ca (accessed 10 Dec 2015).
453 Ó 2016 Elsevier Ltd. All rights reserved.