Occupational, Physical Therapy Key to Integrative Pain Management

LAS VEGAS—Patients with pain may benefit from interventions by both occupational and physical therapists, according to Susan McNulty, OTD, OTR/L, CP, and Erica L. Sigman, DPT, OCS, who explained their roles on a pain management team.

McNulty, an adjunct assistant professor of clinical occupational therapy at the University of Southern California (USC), Los Angeles, California, began by outlining what occupational therapists can do to manage patients with chronic pain. “Occupational therapists consider the impact of chronic pain on occupational performance, emphasizing pain's effects on functional ability in work, leisure, and activities of daily living,” she said.

This includes identifying specific activities or behaviors that aggravate the pain and suggesting alternatives; teaching methods for decreasing frequency and duration of painful episodes; facilitating increased functioning for daily activities at work and home; collaborating with the healthcare team; and recommending adaptive equipment.

An occupational therapy approach focuses on several tactics. For example, a patient can be helped to establish and/or restore daily structure for day and home/work activity with the creation of a daily schedule that incorporates breaks. Patients may maintain independence with the introduction of adaptive equipment, such as a button hook for dressing themselves or grab bars for safety in the bath or shower. Patients may also be instructed to modify their body position or home/ office equipment to support their posture and performance skill abilities. For example, for a patient with radiating arm pain, voice recognition software may be recommended to reduce keyboard use; ergonomics for using the computer in bed may also be explored.

An occupational therapist can help patients prevent social isolation by encouraging activities in group contexts, such as attending family events, volunteering, working, or participating in community activities. For example, a patient with intense chronic pain who had an interest in art began to go on museum tours and lectures.

Dr. Sigman, an instructor of clinical physical therapy at the USC Division of Biokinesiology and Physical Therapy, Los Angeles, California said the physical therapist educates and helps patients understand pain physiology; that is, by reducing the threat, it helps to downregulate the sympathetic, endocrine, and motor systems, restoring normal function. By combining knowledge of pain physiology with different movement strategies, patients can improve physical activity, capacity, and quality of life. The physical therapist can work with patients to eliminate aggravating and alleviating factors to set realistic goals. This includes helping them understand their baseline status and to recognize patterns in an effort to establish a plan of action and plan for progression, she said.

Activity pacing and graded exposure to movement, such as use of imagined movements, activates the same neurotags/regions of the cortex as actual movements, leading patients to begin to “re-map” the cortex without as much pain as there normally would be. Physical therapies also play a role in therapeutic and cardiovascular exercise, Dr. Sigman said. For example, patients with fibromyalgia treated with prescribed graded aerobic exercise reported improved self-assessment of disease impact, improved scores on the Fibromyalgia Impact Questionnaire, and decreased pain and tender points. Manual therapy may also modulate pain by increasing pressure and/or pain thresholds.

Occupational and physical therapy goals and treatment for three patients for whom referral was warranted were highlighted during the presentation.

  • Marcia, a 25-year-old engineering PhD student with back and neck pain for 2 years, exacerbation of symptoms secondary to benign spinal cord tumor treated by cervical laminectomy for spinal cord decompression. Her chief complaint: constant neck pain and increased pain and fatigue with prolonged sitting and standing.
  • Tony, a 43-year-old unemployed man and father of a 13-year-old son, diagnosed with complex regional pain syndrome relating to his left foot following a crush injury in a motor vehicle accident 7 years earlier. His chief complaint: pain with any weight-bearing of the left lower extremity and pain with cold temperature in the region of the left foot.
  • Cynthia, a 45-year-old woman employed in the entertainment industry, diagnosed with trigeminal neuralgia, occipital neuralgia, chronic headaches, myofascial pain, and temporomandibular disorder due to face trauma secondary to an animal attack. Her chief complaint: anxiety and depression. For each patient, the goal was to provide education and practical strategies that would reduce pain and increase functionality.

The presenters concluded with a comparison of conventional and multidisciplinary pain centers. They noted that when patients were treated in a multidisciplinary pain center, return to work was almost twice as likely; functioning better than 75% of those in a conventional treatment model; they had less pain and increased physical activity; and annual medical costs were reduced by 68%.

Recommended rehabilitation interventions within a multidisciplinary team include therapeutic exercises (stretching, range-of-motion, endurance, and strengthening); physical agent modalities (heat, TENS [transcutaneous electrical nerve stimulation]), patient education (proper body mechanics, back education), environmental modification and graded functional activity (work site visit, ergonomics), and cognitive-behavioral strategies (positive reinforcement, progressive relaxation, biofeedback).