AOTA Role of OT in - Pain-Management-2021

Position Statement
Role of Occupational Therapy in Pain Management

The American Occupational Therapy Association (AOTA) asserts that occupational therapists
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and occupational therapy assistants, collectively referred to as occupational therapy practitioners
(AOTA, 2020b), are distinctly prepared to work independently and to contribute to
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interprofessional teams in the treatment of pain. Occupational therapy practitioners work to
ensure active engagement in meaningful occupations for “persons, groups, or populations (i.e.,
the client)” (AOTA, 2020b, p. 1) at risk for and affected by pain.
The U.S. Department of Health and Human Services (HHS; 2019) has recognized pain as a
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public health problem that has significant physical, emotional, and societal costs, estimated at
$560 billion to $635 billion annually in the United States. An estimated 50 million U.S. adults
and 5% to 38% of children and adolescents are affected by chronic pain (Dahlhamer et al., 2018;
HHS, 2019). According to the Institute of Medicine (IOM; 2011), “pain is one of the most
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common reasons people seek treatment” (p. 155). Pain has been found to affect a person’s ability
to exercise, enjoy normal sleep, perform household chores, attend social activities, drive a car,
walk, have sexual relations, maintain relationships, and find enjoyment in life (Dorfman, 2018;
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World Health Organization [WHO], 2004). Efforts to improve care for people affected by pain
have been influenced and, at times, complicated by initiatives to combat the opioid crisis (HHS,
2019). HHS has described the opioid crisis as lying at the intersection of two public health
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challenges: reducing the burden of suffering from pain and containing the harms resulting from
prescription opioid medications. Unfortunately, initiatives to address the potential harms of
opioid medications have had unintended consequences for some people with chronic pain, such
as limited access to treatment for pain, stigma, and rising suicide rates (HHS, 2019).
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Overview: Understanding Pain

In 2020, the International Association for the Study of Pain (IASP) provided a revised definition
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of pain: “an unpleasant sensory and emotional experience associated with, or resembling that
associated with, actual or potential tissue damage” (Raja et al., 2020, p. 1976). Pain is a
subjective experience unique to the person, one that is influenced by biological, psychological,
and social factors. The purpose of pain is to protect the person from actual, potential, or
perceived harm. Nociceptive pain results from actual or threatened damage to non-neural tissue
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and is caused by activation of nociceptors. Nociceptors are sensory receptors in the peripheral
somatosensory nervous system that are able to transduce and encode noxious stimuli (IASP,
2017). When noxious stimuli are encoded, nociception occurs (IASP, 2017). Neuropathic pain is
caused by lesions or diseases occurring in the central or peripheral nervous system (IASP, 2017).
Nociplastic pain can occur as a result of altered nociception, without evidence of threatened or
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actual tissue damage or disruption to the somatosensory nervous system. Inadequately treated
pain can result in adverse effects such as “delays in healing, changes in the central nervous
system (neuroplasticity), suicidal ideation and behavior,” and aberrant opioid medication
behaviors (Cheatle, 2016, p. 44).
PREPUBLICATION DRAFT; TO BE PUBLISHED IN THE AMERICAN JOURNAL OF OCCUPATIONAL THERAPY, 75(SUPPL. 3).
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Acute pain typically occurs suddenly; is usually associated with a specific event, injury, or
illness; and is expected to last a short duration (IOM, 2011). Acute pain that is not effectively
managed may increase recovery time and contribute to hospital readmissions (Baratta et al.,
2014). Chronic pain has been defined as “pain that persists or recurs for more than 3 months”
and requires special treatment and care (Treede et al., 2019, p. 19). Categories of chronic pain
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proposed by the IASP for the International Classification of Diseases (11th ed.; WHO, 2021)
include chronic primary pain syndromes and chronic secondary pain syndromes (Treede et al.,
2019; see examples in Table [ID]TBL1[/ID]1). In chronic primary pain, pain can be a disease in
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itself; in chronic secondary pain, pain is a symptom of an underlying condition.
Social and economic determinants of health have been found to correlate with chronic
conditions, including pain (Goldberg & McGee, 2011). HHS (2019) noted that “various
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populations have unique issues that affect acute and chronic pain,” including “children, older
adults, women, pregnant women, individuals with SCD [sickle cell disease], individuals with
other chronic relapsing pain conditions, racial and ethnic minority populations, active duty
service members and veterans, and patients with cancer and those in palliative care” (p. 44).
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The evidence supports occupational therapy’s belief that occupational engagement promotes
health and well-being (Stav et al., 2012). Participation in the meaningful occupations of activities
of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest
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and sleep, education, work, play, leisure, and social participation can be significantly limited for
people with pain. It is estimated that of the 50 million U.S. adults with chronic pain, 19.6 million
experience high-impact pain, which is pain that interferes with daily life or work activities
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(Dahlhamer et al., 2018).
People with chronic pain report significant changes in psychological state, occupational
performance, relationships, and life satisfaction (Fisher et al., 2007). The long-term
consequences of chronic pain include risk for developing additional physical dysfunctions,
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psychological disorders such as depression, impaired memory and attention, impaired sleep,
impaired sexual function, impaired quality of life, increased economic burden, and interference
with work performance (Fine, 2011). Stigma, especially for those receiving opioid therapy, can
originate at the patient, provider, and societal levels and can create a significant barrier to
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treatment of people with chronic pain (HHS, 2019). Stigma of people with chronic pain not
associated with opioid treatment has also been identified. People with chronic pain report that
they often do not feel believed by romantic partners, family, friends, and their health care
providers (Cosio & Demyan, 2021).
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Model for Care

Before the 1960s, pain was treated predominantly under the biomedical model, which viewed
pain as a primarily medical issue requiring a physical treatment (Jensen & Turk, 2014). As
Jensen and Turk (2014) noted, studies have demonstrated that chronic pain may worsen when
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treated according to the biomedical model (e.g., Chan & Peng, 2011; Deyo & Mirza, 2009).
Since the recognition that pain is influenced by more than biological factors and can present as a
chronic condition, the biopsychosocial model of pain has become the most widely used approach
to the treatment of pain and is thought to be more effective than biomedical approaches.
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The biopsychosocial model of pain “evaluates the integrated ‘whole person,’ with both the
mind and the body together as interconnected entities, recognizing biological, psychological, and
social components of pain and illness” (Bevers et al., 2016, p. 99). The biopsychosocial model of
pain emphasizes that with chronic pain, as with other chronic illnesses, the emphasis in treatment
is on not a cure but the reduction and management of symptoms and their impact on health and
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well-being (Gachtel & Howard, 2018). The approach to reducing pain’s impact on health and
well-being includes self-management, which relates to the activities a person carries out to
increase skills and confidence in managing their health problems (IOM, 2003). The Pain
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Management Best Practices Inter-Agency Task Force recognized the importance of “patient self-
management support as part of patient-centered care and as a mechanism for improving pain
outcomes” (HHS, 2019, p. 61).
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Occupational Therapy’s Role in Pain Management
Occupational therapy practitioners work to increase clients’ engagement in meaningful and
enjoyable occupations, which has been shown to result in reported reductions in pain (Fisher et
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al., 2007). The Occupational Therapy Practice Framework: Domain and Process (4th ed.;
OTPF–4; AOTA, 2020b) provides guidance for practitioners on the process of delivering
occupational therapy services. Occupational therapy practitioners apply their expertise in the
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evaluation process by creating the occupational profile to determine the client’s “occupational
history and experiences, patterns of daily living, interests, values, needs, and relevant contexts”
(AOTA, 2020b, p. 21) and then synthesize that information to determine how each affects the
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client’s pain experience and occupational engagement.
Occupational therapy’s role in pain management is supported by the clear compatibility of
occupational therapy’s foundational principles, philosophies, models, frameworks, interventions,
and training with recommendations for the treatment of pain. Consistent with the
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biopsychosocial model, “occupational therapy practitioners recognize the importance and impact
of the mind–body–spirit connection on engagement and participation in daily life” (AOTA,
2020b, pp. 6–7). The OTPF–4 states that occupational therapy’s focus on “the whole is
considered stronger than a focus on the isolated aspects of human functioning” (AOTA, 2020b,
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p. 7) and “that active engagement in occupation promotes, facilitates, supports, and maintains
health and participation” (p. 5), reflecting the WHO’s (2006) view that “health is a state of
complete physical, mental and social well-being and not merely the absence of disease or
infirmity” (p. 1). This understanding distinctly prepares occupational therapy practitioners to
work within the biopsychosocial model to assess and address “physical, cognitive, psychosocial,
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sensory–perceptual, and other aspects of performance in a variety of contexts and environments

to support engagement in occupations” that may be affected by pain (AOTA, in press, p. 1).
HHS (2019) has recognized occupational therapy as a provider of restorative therapies that
“play a significant role in acute and chronic pain management” (p. 31). Occupational therapy
practitioners have further been recognized as “the ideal therapeutic leaders” for functional
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restoration, an approach carried out by an interdisciplinary team that focuses on functional

outcomes as a primary focus instead of reduction of pain (Harden et al., 2013, p. 12). HHS
(2019) has also recommended that people with pain receive a comprehensive assessment paired
with a multidisciplinary treatment plan targeting “measurable outcomes that focus on
improvements, including quality of life . . . , improved functionality, and activities of daily
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living” (p. 1). HHS recommendations for people with pain also focus on improving self-
management, which occupational therapy practitioners recognize as a component of managing
health. Within occupational therapy practice, health management is more than just knowledge
acquisition; it also includes “activities related to developing, managing, and maintaining health
and wellness routines, including self-management, with the goal of improving or maintaining
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health to support participation in other occupations” (AOTA, 2020b, p. 32). Occupational
therapy’s distinct value in addressing self-management and guiding clients to integrate new skills
and routines within the context of their lived experience is not found in other health care
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professions.
Guidance for Occupational Therapy Practitioners
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Because of the prevalence of acute and chronic pain, occupational therapy practitioners
encounter individuals, groups, and populations affected by or at risk for pain across all practice
settings. Practitioners are prepared to address the impact of acute and chronic primary and
secondary pain on occupational engagement. The unique skill set of occupational therapy
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practitioners and application of the OTPF–4 facilitate successful evaluation and treatment of pain
in individuals, groups, and populations.
Evaluation and Assessment

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The occupational therapy process begins with evaluation, which includes the development of the
occupational profile and the analysis of occupational performance, taking into account the
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impact of pain (AOTA, 2020b). In addition to physical, cognitive, psychosocial, and sensory–
perceptual factors related to occupational engagement, the practitioner identifies the presence,
intensity, location, type, and frequency of pain and assesses the client’s
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● pain coping skills (HHS, 2019),

● pain perceptions (HHS, 2019),
● cognitive and emotional responses to pain (HHS, 2019), and
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● pain self-efficacy (Simon & Collins, 2017).

The administration of specific pain assessments (see Table [ID]TBL2[/ID]2 for examples)
provides data to document the client’s subjective experience of pain. The practitioner synthesizes
this information and develops an intervention plan to address the client’s engagement in
meaningful occupations.
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The occupational therapy process is guided not only by the biopsychosocial model of pain
but also by occupational therapy–based models and frames of reference. Commonly used
occupational therapy models and frames of reference that align with the biopsychosocial model
of pain include the Person–Environment–Occupational Performance (PEOP) Model and the
Model of Human Occupation (MOHO). In the PEOP Model, biological and psychological
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factors are considered intrinsic (person) factors, and social factors are considered extrinsic
(environment) factors (Christiansen et al., 2005). The MOHO also recognizes the dynamic
interaction between person characteristics, including volition, habituation, and performance
skills, and the environment (Park et al., 2019). Many other occupational therapy models and
frames of reference are consistent with the biopsychosocial model, including the Canadian
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Model of Occupational Performance and Engagement, Occupational Adaptation Model, Theory
of Occupational Adaptation, and Cognitive–Behavioral Frame of Reference.
Interventions
The OTPF–4 directs occupational therapy practitioners through the intervention process and
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targeting of outcomes. The occupational therapy process focuses on using occupations
therapeutically to achieve an outcome of greater participation. For individual clients with pain,
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this process may focus on implementing nonpharmacological interventions for improving pain
self-management that allow the client to increase participation in occupation. For a group client,
the practitioner may provide education to the multidisciplinary team regarding the
biopsychosocial model of pain. Population-based interventions may include providing back
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injury prevention training or ergonomics training in employment settings.
Clients with chronic pain who have had frequent encounters with the health care system may
be frustrated by the persistence of their pain despite receiving services and by their experiences
with stigma (Dow et al., 2012). Occupational therapy practitioners should be intentional in
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building the therapeutic alliance through a focus on client-centered care and respect for the
client’s lived experience of pain, a process often referred to as therapeutic use of self. Studies
have indicated that a strong therapeutic alliance can improve the outcomes of people with pain
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(Kinney et al., 2018; Lewis et al., 2010).
Because self-management is an important aspect of managing pain, occupational therapy
practitioners should consider the client’s readiness for change; occupational therapy
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interventions typically ask the client to alter or develop new habits and routines related to
managing their pain (HHS, 2019). Most important, the practitioner should work to identify the
client’s goals for occupational performance and pain management. It is important for clients to
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understand that eliminating their pain may not be realistic and that becoming an active
participant in their own pain management may be the most beneficial strategy for achieving their
personal goals, which may include increasing participation in occupation (IOM, 2011).
Occupational therapy for the management of pain is considered a nonpharmacological
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treatment and is recommended regardless of whether the client is receiving an opioid

prescription (Dowell et al., 2016; HHS, 2019; IOM, 2011). Occupational therapy interventions
provide distinct value in the treatment of pain by placing the focus of intervention on improving
participation in valued occupations and by using occupation itself as a medium for therapy (Hill,
2016; Lagueux et al., 2018). The occupational therapy practitioner uses a top-down approach to
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determine appropriate interventions that address the occupational deficits caused by pain, taking
into account the biological, psychological, and social factors that influence pain and the
interactions among the person, environment, and occupational engagement, which can be
complex (Lagueux et al., 2018). The occupational therapy practitioner also considers the
identified needs of the individual, group, or population, including barriers to occupational
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performance (Hesselstrand et al., 2015; Hill & Macartney, 2019). Interventions should focus on
occupations, with activities used as needed but only to support occupational participation. In
addition, occupational therapy practitioners may consider the use of complementary health
approaches and integrative health to support occupational participation, following established
guidance related to scope of practice (AOTA, 2017b). The following paragraphs provide
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examples of types of interventions that would be appropriate for treating pain, using OTPF–4
Table 12 as a guide (AOTA, 2020b, p. 59).
Occupations
The occupational therapy practitioner uses occupation and activities, the components of
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occupation, as the primary intervention to support achievement of client and therapeutic goals
(AOTA, 2020b). The therapeutic use of occupation involves the occupational therapy
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practitioner ensuring that the activity addresses the mental, physical, and spiritual needs of the
client (AOTA, 2020b). For a client with pain, the practitioner would consider the client’s
biopsychosocial factors when determining appropriate occupations and activities for treatment.
As the client works to improve their ability to self-manage their pain, the occupational therapy
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practitioner may facilitate the client’s incorporating self-management strategies, also considered
an occupation, into daily routine. Occupation, including ADLs and IADLs, may be used in
training the client in concepts such as pacing; energy conservation; health management routines,
such as exercise and sleep; body mechanics; and posture. An example would be the occupational
therapy practitioner using the occupation of dancing when training the client in appropriate
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frequency, duration, and intensity of physical activity for chronic pain, because this has been
shown to significantly reduce pain (Ambrose & Golightly, 2015). The types of interventions that
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are discussed in this document often use occupation or components of occupation as a
therapeutic medium.
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Physical Agent Modalities and Mechanical Modalities
Occupational therapy practitioners may use physical agent and mechanical modalities (PAMs)
and provide training to the client in the safe self-application of PAMs as a coping strategy to
address client factors that increase pain or stiffness and to promote occupational engagement
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(AOTA, 2018b; Dehghan & Farahbod, 2014; Honda et al., 2018). These interventions should be
used only in preparation for occupation and should focus on self-management (AOTA, 2018b,
2020b).
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Assistive Technology and Environmental and Activity Modifications

Occupational therapy practitioners assist with selecting assistive technology and training the
client in its use and with adapting or modifying the environment or activity to support
participation in occupation despite pain. For example, in the intervention of pacing, the
practitioner assists the client in preplanning to ensure a balance between rest and activity (Guy et
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al., 2019; Jamieson-Lega et al., 2013). Occupational therapy practitioners also instruct clients in
the use of body mechanics, ergonomics, and joint protection techniques during performance of
daily tasks to promote postures that minimize or manage pain during occupation (AOTA, 2016;
Hill & Macartney, 2019; Lieber et al., 2000; Siegel et al., 2017). To address socialization, clients
may benefit from trialing and problem-solving modifications to social activities (Benjamin et al.,
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2012; Wolf & Davis, 2014). Assistive technology such as virtual reality simulation may be used
during occupational therapy treatment to promote relaxation or increase movement (Alemanno et
al., 2019; Spiegel et al., 2019; Won et al., 2017).
Self-Regulation
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Self-regulation interventions include sensory reeducation, desensitization training, and graded
exposure. Pain can be a disease in itself when certain client factors are present (e.g., sensitization
of the nervous system), and self-regulation treatments based on sensory processing principles
may benefit the client. Intervention may include activities to address client factors, such as
mindfulness (Dorado et al., 2018; Goodman et al., 2019; Zeidan et al., 2019) and biofeedback
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(Sielski et al., 2017). Graded exposure may also be beneficial; in this intervention, the
practitioner provides guidance as the client participates in occupations the client usually avoids
or fears. The practitioner educates the client to recognize catastrophizing thoughts during
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performance and guides a gradual increase in activity demands to manage pain and achieve
maximum participation (Dekker et al., 2020; López-de-Uralde-Villanueva et al., 2016; Malfliet
et al., 2019). In addition, this can include exposure interventions to specifically target
neuroplasticity, such as graded motor imagery (Anderson & Meyster, 2018; Limakatso et al.,
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2016) and mirror therapy (Goswami et al., 2016; Wittkopf & Johnson, 2017).
Practitioners may provide pain neuroscience education to help clients understand the
underlying client factors influencing their pain and the ways self-management activities can help
them manage the pain (Louw et al., 2016; Van Oosterwijck et al., 2013). Occupational therapy
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interventions that address attention, memory, and executive function may be indicated because
studies have shown that adults with chronic pain may be more likely to demonstrate deficits in
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attention, spatial and working memory, and executive function that may be obstacles to
completing everyday tasks. It is not yet understood if the relationship between chronic pain and
cognition is causal or just an association. The occupational therapy practitioner may consider the
potential for cognitive impairment and provide training, resources, and environmental
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modifications on the basis of the client’s cognitive abilities (Ferreira et al., 2016; Moriarty et al.,
2011; Scemes et al., 2017).
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Self-Management Training
On the basis of evidence strongly supporting the benefit of self-management in addressing pain,
many occupational therapy interventions promote the client’s ability to incorporate self-
management into daily habits and routines. Such interventions include coping skills training and
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training with practice to incorporate self-regulation strategies for pain. Examples of self-
management training include the following:
● Training to facilitate the development of skills to meet goals such as pacing and body mechanics. Goal-
directed treatment is part of current recommendations for treating pain (Dowell et al., 2016; HHS, 2019).
● Training for pain flare management, also referred to as relapse prevention, including skills for identifying
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symptoms of increasing pain and implementing strategies to address the pain flare (Simon & Collins, 2017).
● Training to address the psychosocial components of pain to promote adaptive belief patterns regarding
participation in occupations. Examples of this training include both cognitive–behavioral therapy and
acceptance and commitment therapy, which are widely recognized as treatments for pain (Boschen et al.,
2016; Hann & McCracken, 2014; Hughes et al., 2017; Knoerl et al., 2016; Law, Fisher, et al., 2019).
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● Training in the use of expressive activities such as art or writing to increase client self-efficacy, a skill
required for self-management (Lynch et al., 2013; Ziemer et al., 2015).
Self-management training should always work toward skill acquisition for direct application to
the client’s daily life (AOTA, 2020b).
Medication Management
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Assessment of medication management strategies is important when treating a client with pain.
Cognitive deficits, which are often correlated with pain, may diminish the client’s performance
of this task. Medication nonadherence can lead to adverse health outcomes, including death
(IOM, 2010). Current recommendations and guidelines regarding opioid prescribing may add
greater complexity to medication management tasks because of expectations such as secure
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medication storage, regular urine drug testing, random or routine pill counts, more frequent visits
to the provider for prescriptions, and accurate reporting of all prescriptions to the prescribing
provider. Occupational therapy practitioners can be guided in addressing medication
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management, including considerations such the impact of medication side effects that may
include fatigue on daily occupations, by the document “Occupational Therapy’s Role in
Medication Management” (AOTA, 2017c).
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Advocacy
HHS (2019) has identified stigma as a major concern for people with pain because stigma can act
as a barrier to care and can have far-reaching effects on both people with pain and those who
care for them. Occupational therapy practitioners advocate to reduce stigma for people with pain,
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especially for those being treated with a prescription opioid (HHS, 2019). Current
recommendations to reduce stigma include educating interdisciplinary team members, the public,
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and appropriate groups about disease processes and interventions for acute and chronic pain
(Breeden & Rowe, 2017; Rowe & Breeden, 2018).
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Self-Advocacy
One determinant of effective pain self-management is self-efficacy, or clients’ confidence in their
ability to cope and carry out the tasks required to adequately function while experiencing pain.
Occupational therapy practitioners work to improve client self-efficacy through training to
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increase assertiveness in self-advocacy. For example, clients need to self-advocate in

preplanning social activities and altering components to ensure they can best manage their pain
(Benjamin et al., 2012). Improving self-efficacy and self-advocacy skills also empowers clients
to more confidently direct the care they receive from health professionals.
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Group Interventions
Many pain management interventions can be delivered in a group format. Education groups can
be used before surgery to provide training in expectations of pain after surgery and appropriate
nonpharmacological treatments (Kennedy et al., 2017). Chronic pain support groups may
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facilitate clients’ desire for socialization and reinforce self-management concepts (Finlay &
Elander, 2016). HHS (2019) noted that support groups can increase access to care for people
with pain. Occupational therapy practitioners understand group dynamics and are prepared to
facilitate these groups.
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Virtual Interventions
When barriers to access to care are a concern for clients with pain, occupational therapy
practitioners can deliver evaluation and treatment of pain through virtual interventions to help
increase access to care (AOTA, 2018c, 2020b; HHS, 2019). Telehealth provides a way to support
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clients in the self-management of their pain in their own context (HHS, 2019). Virtual
interventions can address care at the person, group, and population levels.
Ethical Considerations
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Occupational therapy practitioners have a professional and ethical responsibility to provide
services only within each practitioner’s level of competence and scope of practice. The AOTA
2020 Occupational Therapy Code of Ethics (AOTA, 2020a) establishes principles that guide safe
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and competent occupational therapy practice and that must be applied when addressing pain.
Practitioners should ensure that they obtain an understanding of pain physiology, pain
processing, pain-related disability, and pain-related interventions. Additional educational and
certification opportunities for health care professionals in pain management are available through
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various organizations. Practitioners should refer to relevant principles in the Code of Ethics and
comply with state and federal regulatory requirements.
Conclusion
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Occupational therapy practitioners are prepared to address the needs of people with pain within
the biopsychosocial model through their training in biological, psychological, and social sciences
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and their ability to focus on the mind–body–spirit connection. Because of the prevalence of pain,
occupational therapy practitioners are likely to encounter clients with pain in most treatment
settings. Occupational therapy practitioners are encouraged to follow HHS’s (2019)
recommendations for health care professionals to pursue continuing education and training in
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pain management to improve outcomes for those with pain. Occupational therapy practitioners
must also work to promote their distinct role in treating pain within a biopsychosocial model to
all stakeholders to ensure that occupational therapy’s value of improving occupational
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engagement for those with pain is recognized.
References
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Authors
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Kimberly Lowe Breeden, MS, OTR/L

Niccole Rowe, BA, COTA/L
Contributing Authors
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Talitha Black, MA, OTR/L, SWC, PAM, HTC

Linda Crawford, OTR/L, CDWF
Meadow Deason, OTD, OTR/L, CEES
Megan O. Doyle, MS, OTR/L, FPS, Cert-APHPT
Michael A. Pizzi, PhD, OTR/L, FA
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For
The Commission on Practice

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Julie Dorsey, OTD, OTR/L, CEAS, FAOTA, Chairperson
Adopted by the AOTA Representative Assembly, May 2021.
Citation. American Occupational Therapy Association. (2021). Position Statement—Role of occupational therapy in
pain management. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410020.
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Exhibit 1. Anna, Age 12: Juvenile Idiopathic Arthritis and Fibromyalgia
Occupational Clinician’s Findings
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Therapy
Process
Client and Anna, a girl age 12, had been diagnosed with JIA and fibromyalgia. After 2 years of
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background medication changes without improvement in disease activity, she started a new medication 4
months before OT treatment and had begun to see a little improvement. Both wrists and hands
had moderate swelling. She reported hip and ankle pain as well as pain in her right wrist
during and after using a cane for walking. Anna used the cane frequently after having several
falls, but she reported a desire to avoid using a wheelchair. She reported active fibromyalgia
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symptoms of skin sensitivity on her arms, neck, back, shoulders, and legs and widespread pain
not associated with joint symptoms.
Anna had a prior medical history of severe depression, including inpatient psychiatric care
3 months ago. She was receiving weekly psychotherapy and was taking antidepressant
medication. As a result of pain and depression, she was attending partial school days but just
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before seeking OT treatment had not been attending. Anna reported impaired sleep hygiene,
including sleep latency and maintenance. Anna reported benefits from acupuncture and
aquatic therapy, but the 1-hour drive is a barrier to consistent attendance. She lives in a small
Evaluation and
findings io
rural town with her mother and a new dog.
OT evaluation included an occupational profile using interview and the COPM, FDI, CHAQ,
physical exam, and an observational assessment of ADLs (Kashikar-Zuck et al., 2011; Law,
Baptiste, et al., 2019; Singh et al., 1994).
Anna reported spending most of her days at home in bed or sitting on the couch while her
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mother worked. She reported engaging in minimal physical activity as a result of increased
pain for several hours or days after participation. Anna’s typical day consisted of dressing,
which required more than 1–2 hours to complete; eating meals; doing some schoolwork as
able; letting the dog out throughout the day; feeding the dog; watching television; and reading.
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Anna reported that on days when her pain is less that she “feels good” and is able to play with
her dog, attempt some basic dog training, and work on art projects. Her grandparents often
come over and spend part of the day with her. She also reported visits from a friend a couple
of times a week. Anna reported that because of pain she left the house only for medical and
therapy appointments. Anna expressed that she missed seeing people at school and that she
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really wanted to do more with her new dog.

Average COPM Performance and Satisfaction scores were low, at 2.4 and 1.2, respectively,
on a 10-point scale. Her most important occupations identified were showering, dog care and
training, attending school, walking without a cane, and doing art. On physical exam, she had
decreased ROM in her shoulders, wrists, and fingers. She was sensitive to touch over most of
her body. For basic ADLs, she reported that she needed help on bad days but that she could
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often manage on her own. She showered about once a week because it hurt her sensitive skin,
and she was exhausted for several hours after showering. Anna reported that just thinking
about showering was stressful.
On ADL assessment, Anna was noted to take several rest breaks and use numerous
adaptive strategies, including sitting most of the time. Anna and her mother completed the
FDI separately, with both scoring her in the severe disability range. Her CHAQ disability
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index was also in the severe disability range. Both Anna and her parents wanted to try the
inpatient program at the children’s hospital rehabilitation unit, hoping that it might help her
get better.
Intervention Schedule: The program provided a structured schedule. In OT, Anna developed her own
schedule for carryover at home. Using principles of occupational balance, graded exposure,
and pacing, she planned and refined her schedule as she improved during her program. She
established routines for ADLs, productive occupations, therapy homework, exercise,
Page 24 of 36
restorative occupations, and recreation and play. Her main goals were to shower every other
day, attend school for 1 hour a day, spend time playing with her dog every day, and daily
physical activity. She paced her activities out over the day with built-in breaks.
Pain education: Pain education was completed early in Anna’s stay using an established
education program with review during therapy sessions (Louw et al., 2020). Anna was also
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provided information about the benefits of physical activity for people with fibromyalgia and
JIA. Her mother also completed the education program.
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Stress management: Anna learned to turn her stress and pain down through breathing and
guided meditation. In OT sessions, she practiced using strategies while engaging in
occupations to improve pain management and performance. She attended daily wellness group
sessions for patients on the inpatient rehabilitation unit with pain, run by a rotating group of
OTs, PTs, and psychologists. In the group, she learned and tried out a variety of strategies to
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stay healthy, reduce stress, improve sleep, and care for her mind and body. During the group,
she made plans for how to use what she learned, and group leaders followed up every few
days to see how the plans were going.
Graded exposure and desensitization: Anna learned and integrated a graded self-
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desensitization program into her ADL routine that addressed areas of skin sensitivity with two
goals: tolerating showers every other day and reduced skin sensitivity. Before a shower, she
used stress management strategies to calm her body and mind. Anna chose to start with
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rinsing off for a couple of minutes at the end of each day, incrementally working up to longer
showers and washing her body and hair every other day. Anna set daily and weekly goals for
this, which were written on a whiteboard in her room.
Anna worked on balance and walking without a cane in PT. As she improved, she
performed simulated dog care in OT sessions. She engaged in activities to prepare her for
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taking care of her dog, such as walking, picking things up from the floor, and throwing a ball.
The time and physical demands of these activities were increased slowly each day within
Anna’s tolerance. Once Anna could reliably carry out some of these activities, she worked
with the dog therapy program so she could practice with a dog, which was very enjoyable and
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built her confidence that she could do more with her dog at home.
Family involvement: Anna’s mother attended weekly virtual family therapy sessions because
she lived too far away to visit daily. During phone calls, Anna shared her own progress and
her plans for once she returned home with her mother. Anna’s choices and plans guided the
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way for recovery. Anna’s mother was educated on how to support Anna in reaching her goals.
Anna’s mother was encouraged to listen and acknowledge when Anna spoke of pain and
challenges but to ask about, praise, and give more attention to progress and positive steps
(Sieberg & Manganella, 2015).
Outcomes By the end of her 2-wk stay in the inpatient rehabilitation program, Anna could shower every
other day if she showered at the end of the day when she could go to bed afterward. She
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walked safely without a cane and performed dog training activities for 30 minutes with two
seated rest breaks. Anna was able to participate in 2 solid hours of therapy if she could
periodically sit to rest. This indicated that Anna could likely attend school for a similar
amount of time. COPM scores were 8.4 for Performance and 9 for Satisfaction, which showed
significant improvement in her most important occupations. FDI and CHAQ scores were in
minimal disability ranges. Anna reported at the beginning of the program that she did not feel
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that she could be more active. She was pleased to report that she could participate in more
occupations by alternating activity and rest. She reported more energy and having a plan for
managing pain while doing what she wanted to do. She continued to attend outpatient
therapies after going home from the program.
3-month follow-up: Although her pain did not go away completely, Anna was able to do much
more on most days with less pain. Her skin was less sensitive, and she was showering every
Page 25 of 36
other day as planned. She returned to school for part of the day on most days. With help from
a family friend, Anna was training her dog a couple of times a week. Anna shared several
photos of her dog and described how well she was doing with training. Overall, her mood and
daily function were better.
Note. ADLs = activities of daily living; CHAQ = Childhood Health Assessment Questionnaire; COPM = Canadian
Occupational Performance Measure; FDI = Functional Disability Inventory; JIA = juvenile idiopathic arthritis; OT =
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occupational therapy/occupational therapist; PT = physical therapy/physical therapist; ROM = range of motion.
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Exhibit 2. Gary, Age 69: L2–S1 Fusion Revision With L4–L5 Laminectomy and
Discectomy
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Therapy
Process
Client and Gary, a man age 69, was admitted to subacute rehabilitation after an L2–S1 fusion (history of
background L4–L5 fusion in 1998) with L4–L5 laminectomy and discectomy for bilateral chronic low back
pain, sciatica, and right foot drop. His acute care stay was complicated by a bacterial abscess at
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L4–L5, for which he received IV antibiotics. Gary had a prior medical history of C3–C7 spinal
fusion in 2004, myocardial infarct in 2007, hypertension, PTSD, and depression.
Gary was a Navy SEAL for 12 years, followed by 25 years as a firefighter and fire chief.
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Retired at the time of admission, Gary lived in a one-level home with a ramped entry with his
wife, who provided assistance for lower body ADLs and IADLs. Gary used a cane or
wheelchair for mobility depending on his pain. Gary’s son assisted with house and yard
maintenance. Gary reported an average of 4 hours of sleep nightly. He reported past opioid
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addiction for which he had sought treatment. Gary was proficient in using his smartphone and
the internet. Before surgery, Gary scored 35 on the Oswestry Low Back Pain Disability
Questionnaire (Fairbank & Pynsent, 2000), indicating crippled disability. Gary scored 52/60 on
the Pain Self-Efficacy Questionnaire (Nicholas, 2007), indicating good potential for self-
management of pain.
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Gary was issued an off-the-shelf TLSO to wear when out of bed after surgery. Gary wore a
custom right AFO. He reported good social and family support and exhibited high motivation
for rehabilitation.
Evaluation The OT evaluation included completion of an occupational profile (AOTA, 2017a), the COPM
and findings (Law, Baptiste, et al., 2019; Nieuwenhuizen et al., 2014), and the pain VAS (Gift, 1989) during
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the patient interview and the IRF–PAI (CMS, 2017) during direct observation. The occupational
profile identified deficits in ADL and IADL function that diminished Gary’s roles as husband,
father, grandfather, volunteer at the Veterans Affairs center and his local church, and sponsor
with NA. Gary identified his leisure activities as spending time with family, cooking, and
fishing.
The COPM revealed the following meaningful occupations:
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• lower body bathing and dressing

• cooking
• mentoring others in NA
• spending time with family.
His average scores were 3.25 for Performance and 2.00 for Satisfaction.
Gary reported a baseline pain level of 5 on the VAS, increasing with movement. The IRF–
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PAI assistance levels at admission were as follows: modified independent in all areas except
lower body dressing and donning and doffing of footwear, requiring maximal assistance;
bathing and toilet hygiene, requiring moderate assistance; and toilet transfers, requiring contact
guard assistance. He was able to don and doff the TLSO independently while seated at the edge
of the bed and required maximal assistance to don his AFO.
Page 26 of 36
Intervention The OT practitioner coordinated with Gary, his family, and the treatment team to implement the
following interventions in conjunction with the interventions of other disciplines to provide
continuity of care:
• Therapeutic use of self and motivational interviewing strategies, including open-ended
questions, affirmation, reflective listening, and summarizing to establish rapport with Gary
(Alperstein & Sharpe, 2016; Rollnick et al., 2008).
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• Pain education curriculum with an emphasis on identifying Gary’s individual pain
contributors (Rufa et al., 2017)
• Education for back stabilization, neutral spine, compensatory strategies, use of adaptive
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technology, and optimal body mechanics for ADLs and IADLs (Malfliet et al., 2019).
• Timed medication administration and physical agent modalities, including cryotherapy
and TENS for chronic low back pain (Jauregui et al., 2016; Lagueux et al., 2018), along
with training in self-application to optimize graded exposure and activity tolerance during
therapy sessions.
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• Short-term goal setting using the SMART goals format on the basis of COPM scores to
promote meaningful occupational engagement:
◦ Complete lower body dressing and bathing independently using adaptive equipment
and compensatory strategies within 1 week
◦ Prepare his “famous” chili with activity modification within 2 week
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◦ Sit for a 45-minute online meeting with a mentee within 2 week
◦ Attend a family wedding in 4 weeks.
• Engagement in meaningful occupations while implementing pacing and graded exposure
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(Lagueux et al., 2018; López-de-Uralde-Villanueva et al., 2016; Malfliet et al., 2019).
• Cognitive–behavioral therapy thought restructuring activities to address thought patterns
contributing to pain, PTSD symptoms, and depression (Cuijpers et al., 2013; Malfliet et
al., 2019; Strong, 1998); for example, Gary reframed “I am worthless because of my pain”
to “Not doing everything I used to is OK. I can love and support others in new ways.”
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• Home evaluation, including assessment of the physical environment and activity analysis
of his daily occupations. The OT practitioner provided recommendations for home
modifications, optimal body mechanics, activity modification, and adaptive technology
(Stark et al., 2017).
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• Implementation of strategies to address sleep hygiene (Nijs et al., 2018). Specifically,

Gary established a bedtime routine with his wife and refrained from drinking liquids after
dinner.
• Relaxation strategies to increase parasympathetic activity addressing pain, sleep, and
PTSD symptoms (Anderson & Bliven, 2017; Lagueux et al., 2018). Gary began with
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paced diaphragmatic breathing exercises and then integrated guided mindfulness activities,
including a body scan and mindful breathing activities during therapy sessions. Gary
downloaded a smartphone application with guided mindfulness and breathing activities to
encourage self-management.
Outcomes Gary was discharged home reporting a baseline pain level of 3 on the VAS and with IRF–PAI
assistance levels at independent or modified independent. Gary’s average COPM scores
ep
increased to 6.78 for Performance and 6.00 for Satisfaction. Gary cooked his famous chili with
activity adaptations and rest breaks. Gary completed a 1-hour mentoring session via phone and
was able to remain seated the entire session.
Note. ADLs = activities of daily living; AFO = ankle-foot orthosis; AOTA = American Occupational Therapy
Association; CMS = Centers for Medicare & Medicaid Services; COPM = Canadian Occupational Performance
Measure; IADLs = instrumental activities of daily living; IRF–PAI = Inpatient Rehabilitation Facility Patient
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Assessment Instrument; IV = intravenous; NA = Narcotics Anonymous; OT = occupational therapy; PTSD =

posttraumatic stress disorder; SMART = Specific, Measurable, Achievable, Relevant, and Time-bound; TENS =
transcutaneous electrical nerve stimulation; TLSO = thoracic lumbar sacral orthosis; VAS = visual analog scale.
Exhibit 3. Carrie, Age 27: Polytrauma Sustained in a Motor Vehicle Accident
Page 27 of 36
Therapy Process
Client and Carrie, a woman age 27, was admitted to an IRF after a high-speed motor vehicle accident
background in which she was the sole passenger, sustaining the following polytrauma:
• left LE tibial plateau fracture ordered to be non–weight bearing with surgical fixation
• right LE femur fracture ordered to be weight bearing as tolerated with surgical fixation
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• right UE distal ulnar fracture
• left facial lacerations with plastic surgery repair.
Carrie had no prior history of fractures, surgeries, or anxiety disorders but was diagnosed
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with acute stress disorder during transportation from the hospital to the IRF. Her pain control
had been “difficult” during hospitalization, with the use of multiple medications, and she
reported poor sleep with flashbacks of the accident. Carrie lived with her boyfriend and
worked full time as a kindergarten teacher.
D
Evaluation and The OT practitioner met with Carrie in her room, where she presented with flat affect and
findings had a difficult time meeting the practitioner’s eyes. The practitioner immediately used
therapeutic use of self to facilitate therapeutic relationship building and ensure a safe,
supportive environment (AOTA, 2020b, p. 20) to assist Carrie in voicing current functional
concerns and raising questions regarding her injuries and the pain she was experiencing and
to guide her toward eventual self-management. In addition, the practitioner provided pain
n
science education (Louw et al., 2016, 2018) to help Carrie
• normalize her pain neurophysiology and fracture healing;
• understand her injuries and mobility precautions to decrease her fear; and
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• understand pain from the perspective of the biopsychosocial model, especially the
relationships among trauma, stress, sleep, and pain.
The practitioner administered the COPM (Gentry & Pearson, 2019; Law, Baptiste, et al.,
2019) as part of compiling the occupational profile (AOTA, 2020b) and helped Carrie
at
identify her five most important occupations to address:
1. tolerance of being in a car to go on outings
2. restful sleep
3. makeup application
4. return to sexual intimacy with her boyfriend
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5. LB dressing.
Her Performance and Satisfaction scores were both 1.
Carrie’s current ADL performance was assessed by means of direct observation using the
IRF–PAI (CMS, 2017). She required partial to moderate assistance with UB dressing and
substantial to maximal assistance with LB dressing, putting on and taking off footwear, and
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toilet hygiene. Carrie did not complete a shower during her initial evaluation, citing a fear of
“too much pain.”
Additional objective assessment and observation revealed the following:
• rating of 9 on a pain scale of 0–10 in her LEs by means of the NRS (Ferreira-Valente et
al., 2011) during standing and transfers
• allodynia of left facial scars
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• guarding behavior of right shoulder and elbow

• discomfort during AROM assessment of the right UE compared with the left UE.
The OTA discussed with Carrie’s therapy team the benefit of continuing to provide pain
science education using the same messaging from each team member during sessions to
empower her with a better understanding of her pain.
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Page 28 of 36
Intervention The OTA provided the following interventions in the inpatient rehabilitation facility:
• Graded exposure to ADLs, transfers, and mobility (Vlaeyen et al., 2018), with
incorporation of diaphragmatic breathing (Chen et al., 2016) and mindfulness strategies
(e.g., monitoring emotions and self-talk, focusing on sensations such as warmth of
water during a shower; Hardison & Roll, 2016), eventually adding in pacing strategies
(Rochman, 2014). The OT collaborated with the PT to ensure that the same strategies
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were carried over into PT sessions.
• Use of the encouraging and collaborating modes of the Intentional Relationship Model
(Taylor, 2008) with Carrie to build empathy, hope, and the therapeutic alliance, all of
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which have been shown to modulate pain perception and increase the release of
endogenous chemicals (Benedetti, 2011; Fuentes et al., 2014). Carrie routinely reported
decreased pain by the end of OT sessions.
• Completion of LB dressing first in long sitting progressing to seated, with adaptive
equipment to promote body mechanics that allow for tolerable pain levels (Rochman,
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2014).
• Education regarding return to sexual intimacy with her boyfriend, including
recommendations for gradual return (e.g., starting with touch and kissing), positioning,
and open communication (McRae, 2013).
• Series of seated yoga poses to promote decreased guarding behavior and discomfort
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with AROM of her right UE, focusing on breath control (Moonaz, 2019).
• Various relaxation techniques, including apps on her smartphone to address sleep
(Dwivedi, 2019). The OT collaborated with the licensed clinical social worker
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regarding education related to nighttime flashbacks of the accident (El-Solh, 2018) and
the use of slow breathing strategies to decrease sympathetic nervous system
hyperarousal (Busch et al., 2012; Zaccaro et al., 2018).
• Collaboration with the PT to increase independence with bed mobility so Carrie could
achieve a comfortable sleep position.
at
• Graded use of a motor imagery sequence to address allodynia of Carrie’s facial scars:
◦ laterality of faces by circling the right or left side of faces in magazines, progressing
to identifying facial expressions in others (e.g., watching television)
◦ visualization of her own facial expressions
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◦ sensory discrimination using initially tolerated textures with graded exposure to

ultimately achieve tolerance of the textures of makeup sponges and brushes
(Parkitny et al., 2016).
• Cognitive–behavioral therapy incorporated with sensory discrimination (e.g., changing
language from “this texture is gross” to “this texture feels different but is safe for my
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skin”; Duncan, 2011).

• Graded exposure to her boyfriend’s car, beginning with being near the car and using
mindfulness techniques (e.g., tolerating the sound of the engine), then gradually
progressing to sitting inside the car and driving short distances. The OT encouraged
Carrie to use her slow breathing strategies (Busch et al., 2012), with initial safety
behaviors (e.g., looking around frequently for other vehicles) decreasing with each
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exposure. Carrie learned to tolerate distress and reported decreased pain and anxiety
after treatment (AOTA, 2018a; Torchalla et al., 2019).
Outcomes Carrie scored independent with ADLs on the IRF–PAI by discharge, rated her pain as 4 at
most on the NRS, and reported COPM Performance and Satisfaction scores of 6 or higher for
the occupations selected at reassessment. In addition, she demonstrated the use of a variety
of pain self-management strategies independently and achieved tolerance of riding in her
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boyfriend’s car before successful discharge home.

Note. ADL = activity of daily living; AOTA = American Occupational Therapy Association; AROM = active range
of motion; CMS = Centers for Medicare & Medicaid Services; COPM = Canadian Occupational Performance
Measure; IRF = inpatient rehabilitation facility; IRF–PAI = Inpatient Rehabilitation Facility Patient Assessment
Instrument; LB = lower body; LE = lower extremity; NRS = Numeric Rating Scale; OT = occupational
Page 29 of 36
therapy/occupational therapist; OTA = occupational therapy assistant; PT = physical therapy/physical therapist; UB
= upper body; UE = upper extremity.
Exhibit 4. Tom, Age 43: End-Stage Lung Cancer and AIDS
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Therapy Process
Client and Tom, a man age 43, had end-stage lung cancer secondary to Kaposi’s sarcoma and end-stage
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background AIDS. Tom was experiencing increasing shortness of breath and pleuritic chest pain and had
recently lost a considerable amount of weight. After a short hospital admission, Tom and the
health care team decided that a free-standing hospice was the best setting for end-of-life care
given Tom’s unstable living environment, level of poverty, and lack of a caregiver. He had
one daughter, who was expecting his first grandchild, with whom he maintained contact.
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Tom reported no history of substance abuse.
Evaluation and The OT evaluation was conducted at bedside in Tom’s private room in hospice. Completion
findings of the occupational profile revealed the following information: Tom enjoyed woodworking
and sold crafts he made from items he found along the streets where he lived. Tom reported
that one of his goals was to provide a lasting remembrance for his future grandchildren.
The OT asked Tom to get out of bed and wash his hands in the sink across the room.
n
From this observation, the OT identified the need for moderate to maximal assistance with
bed mobility, upper body dressing, and transfer to a walker and moderate assistance with a
walker to walk to the sink. His dynamic balance was poor when engaged in the self-care
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activity of hand washing. Strength, coordination, and range of motion were functional.
Tom’s endurance was poor, and he needed two rest periods to ambulate 30 ft. He required a
5-minute rest period sitting on the edge of the bed before he requested to lie down. He
required maximal assistance to move from sitting to supine.
at
The OT administered the following assessments:
• The Brief Hospice Inventory (Guo et al., 2001) was used to assess Tom’s physical
symptoms (e.g., pain, fatigue), psychological symptoms (e.g., anxiety, depression),
perception of hospice care (e.g., sense of being cared for), and overall quality of life.
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Tom had tremendous fatigue and was anxious about his diagnosis and not seeing his
unborn grandchild.
• The Pizzi Occupational Loss Assessment (Pizzi, 2018) was administered to assess
Tom’s sense of loss in several areas of occupation and the impact it had on his quality
of life. Tom expressed a great sense of loss in the occupations of work and
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productivity, self-care, management of his own environment, and ability to engage in

craft activities.
• The Pizzi Health and Wellness Assessment (Pizzi, 2001; Pizzi & Richards, 2017;
Serwe et al., 2019) was used to assess Tom’s perceived level of health in six areas,
followed by occupation-related questions related to each area and interest in working
on each level of health. Tom’s primary interest was working on productivity
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(occupational health) and his craft items while preventing, to the extent possible,
further decline in his physical and emotional health.
• The OT used the FLACC scale (Merkel et al., 1997) to observe Tom’s pain level.
Clients are rated 0–2 for a total of 10 possible points, with higher scores indicating
more intense pain; Tom scored 7. On the NPRS (Ferreira-Valente et al., 2011), Tom
rated his overall pain at 6 when in bed and at 8–9 when up (sitting) or walking.
Pr
Because pain management is a primary concern in hospice care, the OT routinely

measured Tom’s pain during occupational task participation.
For more hospice-oriented assessments, see National Palliative Care Research Center
(2013).
Intervention In intervention in a hospice setting, it is most crucial that the meaningfulness of any activity
be explored to maximize the client’s quality of life at the end of life. Improved quality of
life, in turn, can diminish multidimensional aspects of pain. To promote maximum
Page 30 of 36
participation through adaptation of the person, occupation, and environment, the OT was
guided by the Environment–Health–Occupation–Wellness clinical model (Pizzi & Richards,
2017).
Using a client-centered, goal-directed approach, the OT identified Tom’s goal as being to
live long enough to see his grandchild. Although his short life expectancy made the goal of
living to see his grandchild unrealistic, this did not need to be acknowledged. The OT
ft
worked with Tom to develop a goal to create a way to keep Tom’s memory alive for his
unborn grandchild. Making use of crafts, an occupation that was very meaningful to Tom,
the OT worked from an occupation- and client-centered health promotion approach that
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focused on mental and emotional well-being and activities adapted to his declining physical
and cognitive ability.
Tom liked working with his hands, so for each visit the OT brought in several simple craft
items for him to construct, build, paint, or design. Each session was purposeful and
meaningful for Tom, and each craft item was developmentally reflected each year of his
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grandchild’s life until age 18. The ultimate goal was for his daughter to present each item to
the child on each birthday. Initially, Tom was able to sit with moderate assistance, and he
was able to put on a robe and transfer to a chair in his room, located right next to his bed
because of his waning strength and energy. He could tolerate 15–20 minutes out of bed while
engaged in his craft activities. However, on many days Tom came to sit independently, and
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after 2 weeks of sessions he was able to sit for up to an hour out of bed while actively
engaged in this occupation.
The staff continually asked him, “What are you doing?” They reported that Tom had been
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accepting less pain medication and that he consistently reported less pain for up to several
hours after OT sessions. The OT used this opportunity to educate the staff about the power
of occupation, including how engagement in meaningful occupation works on mind, body,
and spirit and how, with this client and many others, it assisted in managing pain.
Over time, the OT helped wrap each craft item, and together they placed them in a basket.
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Outcomes Tom presented the completed crafts to his daughter, who had not known what her father was
preparing. All staff were present for this, and many tears were shed. The power of
occupation was present and lifted the spirits of many while improving Tom’s physical,
mental, emotional, and spiritual health. Tom met his goal to complete a craft for his
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grandson to be given on each of his birthdays until he turned 18.

Tom died a month after presenting the basket of gifts, and 6 months later, his daughter
came to the hospice to show off her beautiful newborn son—named Tom. She marveled at
her father’s creativity and expressed gratitude for the OT intervention that helped her dad be
remembered.
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Note. FLACC = Face, Legs, Activity, Cry, Consolability; NPRS = Numeric Pain Rating Scale; OT = occupational
therapy/occupational therapist.
Exhibit 5. Robin, Age 35: Complex Regional Pain Syndrome Type 2

ep

Therapy Process
Client and Robin, a woman age 35, noticed swelling in her nondominant left hand with weakness,
background burning, and aching that radiated to her forearm after an acupuncture needle was placed in
the area of her left dorsal proximal thumb. One month after her injury, Robin was diagnosed
with acute CRPS Type 2. She was treated with an opioid, a sympathetic nerve block, and 5
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months of PT without improvement of her symptoms. Six months after diagnosis, Robin was
referred for telehealth therapy to an occupational therapy practice in her state specializing in
pain rehabilitation.
Robin worked from home in an administrative position, had a 6-year-old son, and was an
avid exerciser. She reported high levels of anxiety and fear about her diagnosis, but she also
reported a strong social support system that included her counselor, husband, and mother.
She identified her most meaningful occupations as work, caring for her son, and exercising.
Page 31 of 36
Evaluation and OT assessments and treatment were conducted exclusively during telehealth sessions.
findings Occasional screenshots and short videos were made (with permission) to visually document
Robin’s progress. The assessments included the following:
• measures of physical symptoms and function, including left hand and arm edema, skin
changes, allodynia, range of motion, and strength
• Pain Drawing and Comparative Pain Scale (Harich, 2002) to identify pain descriptors,
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pain alleviators, and pain triggers
• a functional impact questionnaire designed by the therapist to measure performance of
ADLs, IADLs, movement, sleep, sexual function, bowel and bladder function,
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recreation, and social function
• Self-Compassion Self-Test to measure psychosocial and emotional factors including
isolation versus common humanity, self-judgement versus self-kindness, and
overidentification versus mindfulness (Costa & Pinto-Gouveia, 2013; Neff, 2003; Raes
et al., 2011; Tian et al., 2020; Wren et al., 2012)
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• Fear Avoidance Hierarchy to identify goals for engagement in meaningful activities
and measure levels of fear and avoidance of those activities at assessment and for
tracking improvements over time (Boersma & Linton, 2005; Waddell et al., 1993)
• Sensory Symptoms Checklist to investigate responses to daily sensory experiences
affecting the pain experience, identify sensory under- or overresponsiveness in sensory
n
processing, and educate Robin on integrating sensory modulation strategies into her
self-management plan (Wild, 2010)
• Occupational Experience Profile to assess Robin’s experience of daily activities,
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including information on activity meaning, environment, time of day, and self-reported
impact of pain on measures of productivity, pleasure, social connection, and restoration
(Atler, 2015; Atler et al., 2015).
The initial findings revealed physical impairments of Robin’s left hand and forearm,
including skin changes and dorsal and palmar edema consistent with the radial nerve CRPS
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Type 2 diagnosis. In addition, it was discovered that Robin was experiencing symptoms of
ulnar nerve involvement from an unknown injury.
AROM visual assessment found the following:
• wrist: ∼50% reduction in supination and pronation, flexion and extension, and ulnar
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and radial deviation

• thumb: ∼50% reduction in thumb flexion, extension, and opposition
• fingers: inability to fully extend, abduct, or flex fingers; perform functional grasp; or
form 2- and 3-point pinch.
Pain levels and descriptors were as follows:
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• current level 4–6

• worst level 8
• lowest level 1 (after a nerve block)
• “burning,” “constant,” “dull and achy,” “worse in the morning,” and “itchy”; pain with
movement felt like “bands pulling.”
Robin’s pain increased with the following activities:
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• overuse
• typing
• cold
• fatigue
• grasping and lifting.
Pain alleviators included the following:
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• hot showers
• heating pad
• keeping busy.
Robin reported being fearful of being bumped into and was sensitive to clothing textures
and tactile stimulation of her left arm and hand.
Using the Functional Impact Questionnaire and Fear Avoidance Hierarchy, Robin
identified 10 goals for therapy, including being able to type, play with her son, and swim.
Page 32 of 36
Her initial fear rating was 6–8, and her initial avoidance rating was 2–10 (on a 0–10 scale).
Robin tested low (2.5/5) on self-compassion skills; was overresponsive to light, sound, and
tactile input; and was underresponsive to vestibular input. The OEP revealed that she had a
lack of occupational balance in activities and additional factors that influenced her pain,
including isolation (negative) and walking outside (positive).
Intervention The OT practitioner used motivational interviewing (Flinn & Jones, 2011) during each
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session to provide opportunities for Robin to share her pain experiences. During early visits,
Robin often cried, and she expressed frustration with the loss of her ability to perform
meaningful activities and fear that her pain would never improve. She reported that she was
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hard on herself and felt like a failure when she could not complete activities or meet the
expectations of others or those she set for herself. The OT practitioner validated her emotions
and encouraged her to continue to practice self-compassion and celebrate steps in her
progress. The OT practitioner explained to Robin the role of OT and the importance of
developing a partnership for cocreation of an individualized care plan (Gardner et al., 2016;
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Oosterhof et al., 2014; Taylor, 2008).
The OT provided the following specialized interventions:
• graded motor imagery (Driediger et al., 2006; Moseley, 2006; Moseley et al., 2012):
◦ right–left discrimination laterality exercises for hands
◦ mirror box therapy—observation of her right hand’s reflection in the mirror, with
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graded progression toward matching active movements of the left hand in the box
◦ motor imagery practice—observing pictures and videos, progressing to mental
practice of hand movements
io
• nerve gliding and neurodynamic exercises (Butler, 2008)
• graded exposure, pacing, and self-management education for progressing activity
tolerance (Goubert & Trompetter, 2017; Hassett & Williams, 2018)
• education in pain science (Butler & Moseley, 2013; Louw, 2015), including
◦ role of the nervous, immune, and endocrine systems
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◦ biopsychosocial factors
◦ family education
◦ self-management strategies
• sleep hygiene education (Smith et al., 2000; Vitiello et al., 2013), including
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◦ circadian rhythm restoration strategies

◦ environmental and positioning modifications
◦ sleep routines and the use of meditation and calming activities
◦ blue light therapy and effect of device use on sleep quality
◦ self-management of insomnia and wakefulness
ub
• sensory modulation, including

◦ deep breathing (Anderson & Bliven, 2017)
◦ mindful interoceptive awareness (Cayoun et al., 2017; Di Lernia et al., 2016)
◦ light touch and tactile desensitization
◦ individualized sensory self-regulation strategies (Cayoun et al., 2017; Di Lernia et
al., 2016; Haase et al., 2016)
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• education and training in self-compassion skills (Cayoun et al., 2017; Costa & Pinto-
Gouveia, 2013; Dickerson et al., 2004; Di Lernia et al., 2016; Nixon, 2011), including
◦ mindfulness
◦ self-kindness
◦ common humanity
• use of the OEP (Atler, 2015; Atler et al., 2015; Fisher et al., 2007; Thompson et al.,
Pr
2020) to restore occupational balance and measure experiences of

◦ pleasure
◦ productivity
◦ restoration
◦ social connection.
Outcomes After 12 weeks of telehealth therapy, Robin reported daily pain levels of 0–1. Her sleep
quality improved to 6–8 hours of uninterrupted sleep per night, and she was able to
Page 33 of 36
discontinue the opioid medicine and transition to over-the-counter pain medications as
needed. Robin’s self-compassion skills improved from a low score to an average score of
3.5/5, and she reported that the mindfulness and self-kindness practices helped her
significantly improve her pain experience.
Robin’s fear avoidance improved to 0–2 for all 10 activities. Her edema and skin changes
resolved, and allodynia, AROM, and functional strength improved sufficiently to allow her to
ft
return to typing, parenting activities, and selected exercises.
At discharge, Robin was successfully self-managing her recovery and reported a positive
experience with the telehealth therapy delivery platform, including the benefits of being able
ra
to learn in her home environment and to be a more active participant in her therapy. She was
able to confidently grade and pace her activities and expressed gratitude for the coaching
relationship with her OT.
Note. ADLs = activities of daily living; AROM = active range of motion; CRPS = complex regional pain syndrome;
IADLs = instrumental activities of daily living; OEP = Occupational Experience Profile; OT = occupational
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therapy/occupational therapist; PT = physical therapy.
Exhibit 6. Group Intervention: Adults Scheduled for Elective Total Hip or Total Knee
Arthroplasty
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Therapy
Process
Client and
background
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The clients consisted of community-dwelling adults who were scheduled for elective total hip
or total knee arthroplasty at a local hospital. The orthopedic surgeons had ordered patients to
attend a preoperative joint replacement group education class.
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Evaluation and Postoperative pain was anticipated for all group members. Studies have found that people who
findings receive preoperative pain education report less severe pain during the first 24 hours after
surgery, experience fewer and less severe pain medication side effects, return to normal
activities sooner, and use more nonpharmacological pain management methods
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postoperatively compared with those who do not receive pain education (O’Donnell, 2015).
The group received pain education and training in pain self-management in the preoperative
joint replacement education class.
Intervention The class was instructed by multiple health care professionals, including a nurse, a PT
professional, and an OT practitioner:
ub
• The nurse provided education on postoperative pain medication and side effects to
monitor and report.
• The PT professional provided training in
◦ stretching and positioning for pain management
◦ bed mobility and transfer strategies to reduce pain and ensure joint protection.
• The OT practitioner provided the following education and training (Institute of
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Medicine, 2011):
◦ education on pain neuroscience.
◦ education on indications, contraindications, and precautions for the use of
cryotherapy (Dehghan & Farahbod, 2014). After providing this education, the OT
practitioner led a group activity to make individual ice packs and practice applying
the packs safely (AOTA, 2018b, 2020b).
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◦ education on indications, contraindications, and precautions for nonpharmacological

pain coping strategies, such as relaxation, stretch-based relaxation, mindfulness-based
relaxation, mindful performance of occupations, sensory coping strategies, imagery,
distraction, and virtual reality.
◦ an imagery activity, a diaphragmatic breathing activity, and a guided meditation.
◦ virtual reality goggles with mindfulness experiences for group members to trial.
◦ education on pacing strategies for the occupations of self-care and IADLs.
Page 34 of 36
◦ training for sleep positioning.
◦ education on the use of smartphones and tablets to download relaxation and
mindfulness apps.
◦ education on considerations for incorporating pain management strategies into daily
routines (AOTA, 2020b).
Outcomes Group members had time to prepare for and practice pain management strategies before
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surgery to facilitate increased self-efficacy for postoperative pain management.
Note. AOTA = American Occupational Therapy Association; IADLs = instrumental activities of daily living; OT =
occupational therapy; PT = physical therapy.
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at
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ep
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Page 35 of 36
Table 1. Classification and Examples of Chronic Pain Syndromes in the International
Classification of Diseases, 11th Revision
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Classification Examples
Chronic primary pain syndromes Chronic primary visceral pain
Chronic widespread pain
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Chronic primary musculoskeletal pain
Chronic primary headache or orofacial pain
Complex regional pain syndrome
Chronic secondary pain syndromes Chronic cancer-related pain
Chronic postsurgical or posttraumatic pain
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Chronic secondary musculoskeletal pain
Chronic secondary visceral pain
Chronic neuropathic pain
Chronic secondary headache or orofacial pain
Source. World Health Organization (2021).
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Table 2. Examples of Pain Assessments
Category
General pain assessments
io Examples
Brief Pain Inventory (Keller et al., 2004; MD Anderson Center, 2021)
Faces, Legs, Activity, Cry, Consolability Behavioral Pain Scale (Malviya et al.,
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2006; Merkel et al., 1997)
McGill Pain Questionnaire (Kremer & Atkinson, 1981)
Numeric Rating Scale (Ferreira-Valente et al., 2011)
Pain, Enjoyment of Life and General Activity (PEG) scale (Krebs et al., 2009)
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Visual analogue scale (Gift, 1989)

Wong–Baker FACES Pain Rating Scale (Wong & Baker, 1988; Wong-Baker Faces
Foundation, 2016)
Site-specific pain Disabilities of the Arm, Shoulder and Hand (Hudak et al., 1996)
assessments Oswestry Pain Disability Index (Fairbank & Pynsent, 2000)
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Performance skills Central Sensitization Inventory (Mayer et al., 2012)

assessments Fear-Avoidance Beliefs Questionnaire (Waddell et al., 1993)
Pain Catastrophizing Scale (Sullivan et al., 1995)
Pain Coping Questionnaire (Reid et al., 1998)
Pain Self-Efficacy Questionnaire (Nicholas, 2007)
Self-Compassion Scale (Neff, 2003; Raes et al., 2011)
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Sensory Symptoms Checklist (Wild, 2010)

Productivity and Restoration Profile; Atler, 2015; Atler et al., 2015)
Assessments validated for Canadian Occupational Performance Measure (Law, Baptiste, et al., 2019)
use with pain Functional Disability Inventory (Kashikar-Zuck et al., 2011; Walker & Greene,
1991)
Occupational Experience Profile (formerly the Daily Experiences of Pleasure,
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Patient-Specific Functional Scale (Maugham & Lewis, 2010; Stratford et al., 1995)
Page 36 of 36

AOTA Role of OT in - Pain-Management-2021

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Position Statement

Role of Occupational Therapy in Pain Management

Overview: Understanding Pain

Model for Care

sensory–perceptual, and other aspects of performance in a variety of contexts and environments

restoration, an approach carried out by an interdisciplinary team that focuses on functional

Guidance for Occupational Therapy Practitioners

Evaluation and Assessment

● pain coping skills (HHS, 2019),

● pain self-efficacy (Simon & Collins, 2017).

treatment and is recommended regardless of whether the client is receiving an opioid

Assistive Technology and Environmental and Activity Modifications

increase assertiveness in self-advocacy. For example, clients need to self-advocate in

engagement for those with pain is recognized.

American Occupational Therapy Association. (2021). The Association—Improve your

experimental study. Pain Medicine, 13, 215–228. https://doi.org/10.1111/j.1526-

El-Solh, A. A. (2018). Management of nightmares in patients with posttraumatic stress disorder:

Health, 11, 770. https://doi.org/10.1186/1471-2458-11-770PubMed

National Institutes of Health. http://grantome.com/grant/NIH/R01-NR017096-01A1

Psychologist, 69, 105–118. https://doi.org/10.1037/a0035641PubMed

of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic

performance of repetitive lifting. American Journal of Occupational Therapy, 54, 166–175.

systematic review protocol. Systematic Reviews, 5, 145. https://doi.org/10.1186/s13643-016-

trial. Neurology, 67, 2129–2134.

Occupational Therapy, 71, 7101180050. https://doi.org/10.5014/ajot.2017.023176PubMed

individuals with posttraumatic stress disorder: The role of occupational therapy.

Wild, G. (2010). Sensory Symptoms Checklist. https://sensationalbrain.com/wp-

Wong–Baker Faces Foundation. (2016). Access to scale. https://wongbakerfaces.org/licensing-

Kimberly Lowe Breeden, MS, OTR/L

Talitha Black, MA, OTR/L, SWC, PAM, HTC

The Commission on Practice

Julie Dorsey, OTD, OTR/L, CEAS, FAOTA, Chairperson

Adopted by the AOTA Representative Assembly, May 2021.

Occupational Clinician’s Findings

really wanted to do more with her new dog.

Occupational Clinician’s Findings

• lower body bathing and dressing

• Implementation of strategies to address sleep hygiene (Nijs et al., 2018). Specifically,

Assessment Instrument; IV = intravenous; NA = Narcotics Anonymous; OT = occupational therapy; PTSD =

Exhibit 3. Carrie, Age 27: Polytrauma Sustained in a Motor Vehicle Accident

• guarding behavior of right shoulder and elbow

◦ sensory discrimination using initially tolerated textures with graded exposure to

skin”; Duncan, 2011).

boyfriend’s car before successful discharge home.

Exhibit 4. Tom, Age 43: End-Stage Lung Cancer and AIDS

productivity, self-care, management of his own environment, and ability to engage in

Because pain management is a primary concern in hospice care, the OT routinely

grandson to be given on each of his birthdays until he turned 18.

Exhibit 5. Robin, Age 35: Complex Regional Pain Syndrome Type 2

Occupational Clinician’s Findings

and radial deviation

• current level 4–6

◦ circadian rhythm restoration strategies

• sensory modulation, including

2020) to restore occupational balance and measure experiences of

◦ education on indications, contraindications, and precautions for nonpharmacological

Visual analogue scale (Gift, 1989)

Performance skills Central Sensitization Inventory (Mayer et al., 2012)

Sensory Symptoms Checklist (Wild, 2010)

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