Physical Management of Pain

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Approaches for the physical management of pain include client education and training in methods to protect joints, prevention of pain and inflammation, work simplification, proper body mechanics, therapeutic exercise, work hardening programs, and physical agent modalities. The goal is to control pain and educate the client on strategies that can be used to more effectively manage the pain and allow engagement in enjoyable and meaningful occupations. Joint protection, work simplification, proper body mechanics, and positioning are used in both acute and chronic pain management intervention programs. The intent is to provide education and resources to minimize pain levels and prevent further complication or exacerbation of symptoms.

Joint protection principles include respecting pain by not overdoing activity, maintenance of range of motion and muscle strength, stabilization of joints to reduce the force and effort required to complete an activity, and use of correct patterns of movement (Deshaies 2006). In addition, individuals are encouraged to use the strongest joints available. For example, carrying a purse on the shoulder rather than on the wrist, using a rolling cart to transport home or work items, using the palm of the hand to open jars (Yasuda 2008).

Work simplification and energy conservation strategies focus on promoting independence and safety and preventing additional stress or trauma to the individual while engaging in purposeful activity/occupations. Key principles include using both hands to complete a task whenever possible, working within normal reach (not over extending or reaching), gathering supplies needed for the task prior to beginning, sliding heavy objects rather than carrying, and using gravity to decrease energy expenditure. Work simplification also addresses the storage and organization of work spaces, placing commonly used items in a place where they are easy to reach and use, sitting whenever possible, and determining the appropriate height of the work surface for the individual and the actual tasks being performed (Grangaard 2006, Sabata et al. 2008).

Proper body mechanics principles include maintaining a straight back, maintaining a good posture bending from the hip, avoiding positions in which twisting might be required to lift and hold objects, carrying objects close to the body, and lifting with one's legs using a wide base of support (Grangaard 2006). The goal is to reduce back stress and prevent any additional trauma that might result in increased pain levels. In addition to body mechanics, occupational therapists also work with clients in the area of proper positioning for activities of daily living including intimacy and sexual activity.

Therapeutic exercise and neuromuscular interventions are other important occupational therapy interventions for persons experiencing acute or chronic pain. Reasons for these interventions include reduction of edema and prevention of joint stiffness, restoration or maintenance of joint motion and muscle strength, effective muscle use patterns, as well as improvement in task participation without discomfort (Rochman and Kennedy-Spaien 2007, Fedorczyk and Barbe 2002, Hand Rehabilitation Center of Indiana 2001). Common techniques taught to clients include gentle stretch and individualized strengthening programs involving combinations of passive, active-assisted, to active or resistive exercises. Gentle stretch programs often involve client education to perform self-stretches. Clients who exhibit low neurogenetic pain irritability can participate in "nerve gliding" or gentle neural tension exercises as a method of pain modulation (Fedorczyk and Barbe 2002). Joint weight-bearing exercise, often referred to as "stress loading," facilitates graded sensory stimuli to the extremity and is recommended for such painful conditions as complex regional pain syndrome (Li et al. 2005, Walsh and Muntzer 2002). Although therapeutic exercise is a recommended intervention, occupational therapists help clients learn a healthy balance of active participation with stress-free, pain-limited motion.

Work hardening and work conditioning are interventions often implemented with injured workers who are preparing to return to work. While often used interchangeably, there are significant differences. Work hardening is interdisciplinary and composed of a combination of job tasks the client would perform within his/her job capacity with consideration for strength, endurance, pacing, range of motion, and differential movements specific to the client's job (Keegan and Kahlert 2006, King and Olson 2009). Ideally, a job analysis (during which the occupational therapist evaluates physical, mental, and psychological demands of the job) would be completed prior to the development of the client's work conditioning treatment plan. This would allow the occupational therapist to tailor the work hardening treatment plan to the client's work-related needs. Additionally, work hardening is unique as it includes intervention targeting the client's psychosocial factors such as self-esteem, confidence, and anxiety related to his/her job performance (King and Olson 2009); a critical component as psychological adjustment has been found vital to successfully returning injured workers to employment (Adams and de C Williams 2003). Conversely, work conditioning is less intensive than work hardening, involves fewer disciplines, and has a primary focus on physical functioning (King and Olson 2009). Additionally, injured employees may benefit from the inclusion of self-directed, occupational therapist-facilitated wellness program in which the client engages outside of the occupational therapy clinic. Occupational therapists are qualified to develop wellness programs to promote health and prevent disease with consideration for the individual client's lifestyle, exercise regimen, nutrition, and psychosocial and mental well-being (Jaegers 2008).

Manual techniques are preparatory occupational therapy interventions and useful measures in controlling acute and chronic pain. These techniques include passive range of motion, joint mobilization, myofascial release, deep tissue massage including trigger point release, and manual edema mobilization. Passive range of motion may be used to elongate tissues. Joint mobilization is used to enhance the integrity of the joint capsule and to control pain (Lundon 2007). Myofascial release may be implemented to decrease the tension of the body's soft tissue structures and inhibit active trigger points that may be limiting range of motion and causing pain (Dávila 2002). Deep tissue massage, including trigger point release, is used to inhibit the presence of point tenderness and taut muscular bands that often cause referred and myofascial pain (Kasch 2002, Simons et al. 1999). Manual edema mobilization is used to stimulate the lymphatic system and facilitate drainage of localized and generalized edema to promote tissue health and reduce pain (Priganc 2008). There are multitudes of additional manual techniques that may be employed to reduce a client's pain. Each should be applied in conjunction with other therapeutic interventions.

Physical agent modalities (PAMS) are composed of the application of light, water, temperature, sound, and/or electricity to produce a soft tissue response (Bracciano 2008). In occupational therapy, these are most commonly used as a precursor to working with the client in purposeful or occupation-based interventions (McPhee et al. 2003) or following a client's occupational therapy session as means of controlling for a resultant inflammatory response. Common PAMS include cryotherapy such as ice massage and cold packs, thermotherapy such as hot packs, fluidotherapy and paraffin wax, thermal or non-thermal ultrasound, electrical stimulation, iontophoresis, infrared, neuromuscular stimulation (NMES), and transcuta-neous electrical nerve stimulation (TENS). An occupational therapist's selection of PAMS is dependent on the acute or chronic nature of the client's pain. Often, therapists will employ a combination of PAMS. For example, a client who is 2-month status post a distal radius open reduction internal fixation surgery may benefit from thermotherapy to increase muscular extensibility prior to occupational therapy activity and cryotherapy following therapy to control any minor edema incurred during treatment. PAMS are not intended to be the sole treatment modality and should always be applied in conjunction with other methods of therapeutic intervention (Bracciano 2008). In occupational therapy, PAMS are used to prepare the client's tissue for movement and/or provide the individual with relief of pain prior to or following the client's engagement in functional activity or occupations. Primary objectives of PAMS implementation are to provide the client with limited pain, enhance the client's willingness to engage in movement and activity, and, ultimately, decrease the fear avoidance response when the client is able to engage in activity without increasing the pain. When appropriate, and depending on the nature of the PAM, clients may be educated in self-application of PAMS to implement as preventative or post-activity pain control method (Fig. 15.3). This is applicable particularly with clients who have chronic pain conditions as a measure to build responsibility for symptom management (Rochman and Kennedy-Spaien 2007, Moscony 2002).

Splinting and bracing may be needed to provide pain relief for the client. Occupational therapists may fabricate customized dynamic or static splints for clients, or they may fit clients with prefabricated splints. The purposes of splints are to provide rest, maintain joint alignment, and support the client's anatomy in functional positions. The goals are to increase function, prevent or correct deformities, protect healing structures, and restrict painful or harmful motion (Fess 2005). Splints are provided commonly to treat acute pain, but they may also be used to provide support and proper alignment with individuals experiencing chronic pain.

Figure 15.3. Client education during thermotherapy intervention.

Another approach commonly used by occupational therapists in the treatment of clients with pain is kinesiotaping. Kinesiotaping can be used to control inflammation through the enhancement of lymphatic drainage (DeBono 2007) to reduce pressure on pain receptions. It is also used as an external support as it provides proprioceptive feedback to clients, a quality that can assist clients in remediating dysfunctional movements (DeBono 2007, Kase 2000).

Occupational therapy plays an important role in the provision of physical pain management intervention. In addition, essential to a client's return to function is the area of psychosocial management.

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