Occupational Therapy Chronic Pain Management Techniques: Evidence-Informed Guide

My Pain Story

After two years since my lower back injury involving 2 slipped discs in my lower back, I continued to feel the pain. Despite being an occupational therapist myself, I didn’t think to try “OT’ing myself”. I tried medications, antidepressants that helped some with nerve pain, CBD, physical therapy, chiropractic, rest, walking, not walking, and so on. Everything conservative except surgery. And I am still glad that I avoided surgery as I have heard some horror podcasts involving some people in a similar situation ending up worse off with an even lower quality of life. All the while, people around me like friends and family asked if surgery was a candidate. First, I would recommend that if you could, avoid surgery yourself or advise your patients to avoid it unless it is absolutely unbearable. Try conservative approaches first. It’s certainly less expensive and carries much lower risks – which I am all for.

In the first 2 years, I would say my pain “improved”, but the pain was still there – enough to limit me and my activities as well as my personal and professional life, physically or psychosocially. Afraid to do another patient transfer and risk re-injury or aggravating my condition, I quit my job and whenever I felt pain-free and was motivated, I created content for OT Dude.

After one day of just being tired of feeling hopeless and self-pity, I became obsessed with researching and treating my chronic pain, particularly evidence-based interventions and philosophies to integrate into a more personalized evidence-informed practice for my personal pain management. I found the book Explain Pain and went down a rabbit hole of pain treatment for myself and to potentially help others.

I am still on this journey, but what little I have done in a few months has drastically improved my pain compared to the first 2 years of these other less successful approaches. It’s really incredible. Here’s what I found. I hope it helps you as a practitioner, you as a patient, your family members, or your friends. Good luck!

Pain Education

There are two major schools of thought when it comes to pain education with patients. One is they cannot learn the ins and outs of how pain works like the anatomy and physiology of it. I’m talking about things and terms like nociceptors, gate control theory, and the CNS. Some very influential researchers like Moseley and Butler (authors of Explain Pain) believe that pain education can actually help patients to experience reduced pain.

The other school of thought is that explaining to this degree of technicality and detail is too complex for the patient and not worth the effort. They’ll just fall asleep!

As you can guess, I believe that the right answer and approach are somewhere in the middle. Patients should have a basic level of understanding of what causes pain. If they are interested in the minutiae of pain, then I would go into more about it. Otherwise, I think because of our limited time for interventions with patients, it could be better spent on the actual education and interventions for pain management and treatment. Pain education should also teach about how psychology plays a role in pain. Education can be very empowering, and the more you know about pain, the better.

Studies show that those who have lower education levels also have higher levels of pain.

If you or your patient enjoys the material and want to nerd out about pain, then go for it – the research shows that pain education helps to lower their actual pain. Pain education can be simple and does not have to be technical. A good approach is to use metaphors. Overall, I am currently in the camp of providing pain neuroscience education (PNE) to all — sprinkled throughout the therapy session.

Pain is Unique

Pain is subjective. Pain is personal. At the same time, pain is universal to us as humans. We all experience some degree of pain. So a common trap for those who experience pain is self-pity. “I have the worse pain out of anybody.”

However, all of us experienced pain at one time in our life. It just may not be chronic. Helping and allowing patients to understand this concept (“we all experience pain and yeah, it can really really hurt!”) can be freeing and therapeutic. I am not saying to diminish one’s complaints of pain. Not one bit. But instead for the patient to gain insight into the fact that others have experienced a similar pain as them, and they are okay. They can even live happy and fulfilling lives with a high quality of life. It gives people hope, kind of like a support group.

Pain Definition

For the first time since 1979, the IASP, which is the International Association for the Study of Pain, introduced a revised definition of pain. Pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Notice the keywords here: resembling, associated with, actual or potential. This means that the pain that one experiences are NOT necessarily due to potential tissue damage. This hints at the psychosocial don’t it? To me, this was a relief because since it has been two years since my injury (which should have resolved at the tissue level based on the research), it assured me that my body was okay. What was more likely was that I just had something else going on that kept triggering the pain.

Chronic pain is often defined as pain that persists for more than 3 months.

The IASP also states that:

  1. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
  2. Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
  3. Through their life experiences, individuals learn the concept of pain.
  4. A person’s report of an experience as pain should be respected.
  5. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
  6. Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Did you know this? Have you read something similar to this before regarding pain? I certainly didn’t.

For me, these 6 points alone provide a good guide for how to perceive and approach the treatment of their chronic pain. Unfortunately, I think my medical providers and pain treatment team have failed me.

If I read this and known this from the beginning, my path for my pain recovery could have been made much shorter, with less suffering, less financial loss, and less psychosocial stress. 100%!

So share this with your patients. It could help alleviate their suffering and help them to live functional lives – and that’s SO OT.

Categories/Types of Pain

Keep in mind that patients can have a combination of the following categories of pain.

  1. Nociceptive – non-neural tissue damage and/or inflammation, e.g., musculoskeletal and visceral
  2. Neuropathic – nerve damage; lesion or disease in the CNS
  3. Nociplastic – “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain”.
  4. Nonspecific – cannot be explained by tissue damage, pathology or local dysfunctions.

Nociplastic Pain Criteria

Examples: fibromyalgia, complex regional pain syndrome, chronic low back pain, visceral pain disorders such as irritable bowel syndrome and bladder pain syndrome

  1. report pain of at least 3 months duration;
  2. report a regional rather than discrete pain distribution;
  3. report pain that cannot entirely be explained by nociceptive or neuropathic mechanisms;
  4. show clinical signs of pain hypersensitivity (i.e., evoked pain hypersensitivity phenomena such as static or dynamic mechanical allodynia, heat or cold allodynia, and/or painful after-sensations after any of the mentioned evoked pain hypersensitivity assessments) that are at least present in the region of pain

Pain is Complex

One way to think about this is why people experience chronic pain in the first place. If their tissue damage is resolved (they are healed) and they continue to experience pain, then pain must be much more complex than just physical tissue damage or nerve damage. We all know that the body is incredible at healing itself such as our bones. The same goes for the healing and resolution of the tissue damage that causes the pain. So a physical cause is not always the cause of the pain.

Aha moment: Pain is much more complex than what we learned in OT school – see IASP point #1.

What Doesn’t Always Work

My analogy for conventional and commonly prescribed pain interventions is to that of diet pills. It’s popular. But it doesn’t always work. Yet many people believe in them or try them. But it’s likely not going to work. For pain interventions, if they worked, then one would experience chronic pain based on these common interventions, right?

I am not blaming medical providers, other medical professionals, or the Rx industry – it’s just that what we thought worked for pain does not. We were wrong about pain. And a lot of practitioners aren’t up to speed on pain and it’s kind of a specialty in itself.

So if you have a lot of anger towards others, I recommend that you soften up and avoid the blame game. Sure, it sucks that you may have been misled or given false hope, but it’s up to you to encourage your patients to take an active approach – as opposed to passive pain management like surgery or medication or going to get this done or “fixed”.

Medications and Recreational Drugs

They may help, sure. But they come with side effects and they can be addictive. You may become dependent on them. If you stop taking a certain combination of medications to control your pain, e.g., financial, suddenly made illegal, you forgot to take them, then you’re going to be in a world of hurt. My guess is that even the latest and most promising medications aimed at controlling pain will not work – our bodies are just too complex. Our body like our brain will find a way to warn us (invoke pain) because something else is not managed, e.g., our stress, our depression, our emotions, our health. I’m not 100% opposed to this intervention. I just don’t think it’s as effective and practical as we are all made to believe.

Wouldn’t you rather have your patients live medication and drug-free instead or on a decreased dosage instead at least?

Surgery

In the research that I looked at for pain, surgery is not going to always fix one’s pain. You probably already know that. Some high-level RCTs for pain such as low back pain surgeries have helped with short-term relief with pain, but in the long-term, conservative approaches could have been just as good. That is why the ED doctor who saw me first, my PCP, and other professionals I have talked to all have advised against surgery for me. The same probably goes for other conditions.

With that said, your patient’s condition may be more severe and literally intolerable and all they can do is lay there, every moment in pain. Overall, patients should be really educated about the risks of surgery, e.g., paralysis and numbness, and encouraged to try other alternatives first. Occupational therapists should not be afraid of overstepping the physician and can help the treatment team with this process by providing education and insight into what to expect after surgery. At the end of the day, we want to help patients to make educated and informed decisions based on their lifestyles, needs, means, expectations, and support systems.

Chiropractic

I did chiropractic pretty early on and was a little inconsistent in the beginning due to COVID-19 first arriving in the US. What ultimately made me stop was that I was not noticing any change in my pain but also, I experienced some twinges of sharp pains during my adjustments that just freaked me out. And it was in a different part of my body that never hurt before. So weird. If this was supposed to help me, why was I hurting from time to time?

But everyone is different. My wife loves getting regular adjustments and gets a lot of relief from it. I just don’t think it was for me and it could have made my condition worse this whole time. I’ll never know. But my gut feeling now is “hey, it hurts, I should stop.”

What also made me stop was this kind of passive approach to my treatment. Like I saw other clients in pain and they kind of came in with the expectation of going in to have their pain fixed. I was guilty of the same expectation. But we now know that pain is much more complex and trying to fix one thing when many other things are also needing attention won’t work. I also wasn’t excited about regularly having to see a chiropractor for the maintenance and prevention of my chronic pain. It was not cheap!

Some people have found relief from massage and other similar therapies. I never really tried it due to it being more cost-prohibitive than chiropractic in my area. Again, you may get some relief from massage, but keep in mind the long-term cost versus other more financially friendly interventions that will be mentioned below. If your spouse happens to be a massage therapist, then consider yourself very lucky!

Just Resting and Doing Nothing

This doesn’t work (and many can agree) and can lead to a decreased quality of life, occupational deprivation, depression, isolation, and so on. I’ve been there. Sure, sometimes you think resting and letting things heal is going to work, but soon or later, you are going to have to get your life back and resume your activities. And the moment you try something a little too much, you may experience pain and be even more down about yourself.

This is similar to the boom-bust cycle. Boom = being gung ho about doing things and then Bust = pain and doing nothing to avoid further pain. The cycle repeats over and over unless we break out of it and become smarter about our pain treatment.

Although I don’t regret it, it does suck to have lost 2 years of my life when I could have done so much more for my personal, professional, and spiritual life if I had taken a middle-of-the-road approach: don’t go too hard like a cheetah, but also don’t be too conservative and careful either by becoming a sloth. Instead, your patient should be an actively compassionate critically thinking, and problem-solving human who runs when appropriate and also lays down when needed at other times.

Similar Stories from Peers and EBP

An OT friend of mine (hey Shubhi!) shared a bunch of resources for pain management and treatment. One of these was an OT Potential podcast episode (hey Sarah!) featuring Linda Crawford titled, “Acceptance and Commitment Therapy, Pain, and OT with Linda Crawford“. Linda had a similar story. She tried everything but still continued to experience chronic pain. She then decided to OT herself and has been pain-free ever since.

4 Pain Pillars to Lower Pain

According to Adriaan Louw, a pain educator and researcher, there are four pillars for the management and treatment chronic pain.

  1. Pain education – as mentioned above
  2. Exercise – that gets your heart rate over 100 beats per minute for 20-30 minutes, 5x a week. If exercise is not your thing, I recommend engaging in activities that are aerobic that just get you moving!
  3. Sleep and sleep hygiene – 8 hours a night and limiting naps to no more than 20 minutes.
  4. Meaningful goal-oriented activities – this is so OT!

Occupational Therapy for Chronic Pain


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Sources

  1. Moseley, G. L., & Butler, D. S. (2015). Fifteen years of explaining pain: the past, present, and future. The Journal of Pain, 16(9), 807-813.
  2. Poleshuck, E. L., & Green, C. R. (2008). Socioeconomic disadvantage and pain. Pain136(3), 235.
  3. https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
  4. International Association for the Study of Pain (IASP). IASP Terminology. [(accessed on 28 March 2019)]; Available online: https://www.iasp-pain.org/terminology?navItemNumber=576#Centralsensitization
  5. https://www.painresearchforum.org/news/92059-whats-name-chronic-pain
  6. Kosek E., Clauw D., Nijs J., Baron R., Gilron I., Harris R.E., Mico J.A., Rice A.S., Sterling M. Chronic nociplastic pain affecting the musculoskeletal system: Clinical criteria and grading system. Pain. 2021 doi: 10.1097/j.pain.0000000000002324.
  7. Louw, Adriaan. 2013. Why Do I Hurt?: A Patient Book about the Neuroscience of Pain.