Multidisciplinary care for a multifaceted phenomenon
By Helen Roome BSc(OT), MAVP, Prac. Dip. Labour Law, PG Dip. Int. Pain Mgmnt.
Scientific progress over recent decades has revealed pain to be more complex, and its impact on people more comprehensive, than previously thought. Moving away from the overly simplistic, biomedical model (in which pain is viewed merely as a sensory symptom of tissue damage or body state); the International Association for the Study of Pain has instead affirmed that pain is a whole-person, whole-life experience with multiple contributors and consequences - better described using the biopsychosocial model of George Engel. (1)
According to the biopsychosocial model, biological (including genetics and lifestyle influences), psychological (such as beliefs and mood), and social or contextual (for example, support and physical environment) factors converge to create a person’s pain experience. This pain experience in turn impacts on all these aspects of their health and life. (2)
Such a multifaceted phenomenon necessitates multimodal care by multiple healthcare professionals. Working together as a multidisciplinary pain team, practitioners from across the fields of medicine, surgery, mental health and rehabilitation, need to use their diverse knowledge, skills and modalities to address these many biopsychosocial treatment targets. (2)
Occupational therapists (OTs) are rehabilitation healthcare professionals whose role in pain management remains mostly under-recognized and under-utilized. (3) This is despite OT being recommended in respected clinical guidelines about chronic pain, such as the National Institute for Health and Care Excellence (NICE) guidelines for chronic pain in adults (2021) and the British Pain Society’s “Guidelines for Pain Management Programmes for Adults” (2021).
This article aims to unpack what most people don’t know about OT’s contribution to multidisciplinary pain management and offer compelling reasons for their inclusion in pain teams.
Enter Occupational therapists – the ‘expert generalists’
OT emerged as a distinct profession during World War I, when engaging wounded soldiers in creative and vocational activities proved to be an effective part of their rehabilitation. The central idea that people participating in meaningful activities (or ‘occupations’) is an effective means to rehabilitation, and its goal, is what gives the profession the name “Occupational” therapy. (3) To clarify, in this professional context, the term ‘occupation’ does not refer only to vocational or work-related activities, but also to the many and varied activities people perform every day to care for themselves and others, socialise, and relax through recreation. (4)
As the profession has evolved, OTs have developed core models, like the “Person–Environment–Occupation” model of Mary Law, Gary Kielhofner’s Model of Human Occupation, and the Canadian Model of Occupational Performance, to understand people and their participation in these occupations better. (4)
According to these models, occupational performance involves a dynamic interaction between the person, the environment (or context), and the occupation they engage in - such that changes in any one of them influence the others. OTs view the person holistically as having physical, cognitive, psychological and spiritual capacities to engage, and recognise that the person is central in this interaction. Lastly, these models propose that optimal occupational performance takes place when there is a good ‘fit’ between these three elements. OTs have, therefore, multiple ways to improve this fit by facilitating change in any or all of these elements. For example, the performance of a person with an impairment can be optimised by teaching them new skills, removing environmental barriers to their participation, and/or simplifying the occupation they want to engage in, into smaller steps.
Engel’s biopsychosocial model is the bedrock of these models and is fundamentally integrated into OT education and practice. Beyond just learning about this model at an undergraduate level, it is fleshed out in the curriculum through the inclusion of subjects across the life-, health- and social sciences (from physiology to psychology) and the broad clinical experience students gain in both physical and mental health rehabilitation settings.
This deeply embedded biopsychosocial approach, holistic view of the person in their unique context, and practical focus on occupational performance, is what sets OTs apart from other healthcare professions. (3) Whereas physiotherapists focus on optimising physical function for movement; and psychologists on understanding and treating mental processes; OTs bridge both professions by working at the intersection of these capacities and their impact on what people want and need to do in their daily lives. In this regard, OTs could be called the ‘expert generalists’ of the multidisciplinary team.
Occupational therapists in the multidisciplinary pain management team
It is not difficult to see how a profession so grounded in the biopsychosocial model could play a role in treating the phenomenon of pain as it is now understood. When we consider that it is the suffering (in other words, the psychological and functional impact) of pain, rather than the pain itself, that drives people to seek help from healthcare services (5), we might go further than that to conclude that the inclusion of OTs in the multidisciplinary pain team is essential.
As members of the team, OTs’ role, first and foremost, is to facilitate the person’s active engagement in occupations within the socio-cultural and physical contexts where their daily life is lived out (3). This function-first lens enables participation in meaningful occupations, irrespective of the presence of pain and symptoms; with pain reduction often an indirect outcome of that participation.
Then, apart from supporting the person with chronic pain using their own scope-specific pain management interventions, what OTs do well is fulfill the role of ‘knowledge translators’. (3) Similarly to assembling a puzzle from a pile of separate puzzle pieces, OTs help the person with chronic pain to integrate the diverse modalities, skills and strategies provided by other members of the multidisciplinary pain team, into their daily occupations and routines. In this way, OTs complement the work of other members of the multidisciplinary pain team. In practice this may look like:
· Improving post-surgical pain-related outcomes through pre-surgery pain education (6) or facilitating prompt return to activities and work after medical interventions and procedures.
· Translating movement and physical activity gains achieved by physiotherapists in the clinical setting into participation in daily activities (like domestic chores, manual work or recreation) through graded exposure, training in pacing, or the application of ergonomic principles.
· Applying the Cognitive Behavioural Therapy principles used in psychotherapy bypsychologists to daily activities and real-life contexts, so that this experiential learning supports behavioural changes, role re-engagement and habit restructuring.
Since chronic pain can persist over a long time, this knowledge translation usually requires OTs to teach the person additional self-management skills, like pacing, problem-solving, mental flexibility, stress management and action planning, that will help them practice pain management and live life well over time. (3)
With multiple targets and modalities involved, coordinated care and goal alignment are important across the disciplines that form part of the multidisciplinary pain team caring for the person with chronic pain.
Although the term “multidisciplinary” remains most familiar in healthcare; there has been another important shift in pain management - towards what is called “interdisciplinary” teamwork. Despite some commonalities in the definitions, like the provision of multimodal treatment by multiple different disciplines, this term is not interchangeable with “multidisciplinary” because of its greater emphasis on collaboration and coordination. (7)
Whilst a multidisciplinary team may be said to be client-centred, in that the person with chronic pain is the focus of the team, practitioners may have different management goals for the person - some of which may have even been identified without the person’s involvement. (7) In this team model, the person with chronic pain is more likely to remain a passive consumer of healthcare - and that passivity perpetuates pain. (8)
In contrast, in an interdisciplinary team model, the person with chronic pain is an active member of the team engaged in goalsetting and decision making throughout care. Their team of practitioners collaborate from the start and set management goals by team consensus. They then continue to work together in a complimentary and collaborative way with regular communication. (7) This model of care is both ethical and effective.
The added value of Occupational Therapy in pain management
Work rehabilitation
Keeping or returning people with chronic pain to their optimal work capacity is a priority of interdisciplinary pain management teams because of the significant individual and societal impact of reduced productivity and unemployment. (4) It is particularly in advancing this goal, that OTs play a unique role on the team and can add significant value to pain management.
OTs can perform work capacity evaluations and, as necessary, work-site visits, to assess the barriers and enablers to the person’s optimal work performance. (4) This enables them to determine their need for work/vocational rehabilitation and their likelihood of returning to work. (9)
Vocational rehabilitation may include liaising with employers, recommending reasonable accommodations (like adapted equipment, assistive technology, and workspace redesign) and creating and supervising conditioning (called “work hardening”) and Return-to-Work programs. (9)
Long-term self-management
People with chronic pain spend most of their lives outside the clinical setting and health-care system, at work or home. In this everyday context, they continually manage the impact of their pain on their daily lives. For this reason, self-management is widely accepted as the “first rung of the ladder in pain care” (10) and integral to ongoing pain management. (3)
Successful pain self-management requires gaining self-efficacy and learning certain knowledge and skills to perform key tasks, such as partnering effectively with healthcare providers, modifying participation in meaningful life roles, managing the psychological distress of chronic pain, and maintaining a healthy lifestyle in terms of nutrition, sleep and physical activity. (10) All tasks that OTs are well-suited to teach and support.
The self-management strategies (the ‘what’) that OTs teach people are not unique to the profession, but their focus on the ‘how’ of using them in daily life is. OTs consider self-management strategies in terms of their meaning to the person, contextual fit, interplay with self-concept, and changing nature of the person’s participation over time and lifespan. These considerations enable them to be effectively translated into daily practices and habits. (3)
For example, the typically-prescribed exercise programs for chronic pain can be translated into an occupation, such as a sport or hobby, that matches the person’s interests, values and context. Likewise, sleep hygiene can be matched to the person’s own rhythm and daily routine. Personalising and contextualising self-management strategies like this facilitates better adherence over time. (3)
Through this self-management knowledge translation, OTs support self-efficacy and resilience-building beyond clinical encounters and treatment courses. (3)
Group interventions
Teaching self-management has sustained benefits, regardless of the format of its delivery – from in-person to virtual individual sessions and self-directed study. It is, however, most often taught in group programs. Amongst other benefits, groups allow for the modelling of positive health behaviors by peers and social persuasion in the form of peer support and encouragement. (11)
Unsurprisingly, much of the evidence for the efficacy of self-management comes from research on group-based programmes. This reveals that more beneficial effects were experienced when group programs were delivered by healthcare practitioners. OTs often facilitate or co-facilitate groups with other members of the multidisciplinary team.
OTs are particularly well-suited to facilitate pain self-management group programs because of their comprehensive formal training in group dynamics, psychosocial interventions, and facilitation skills; as well as the practical experience they gain facilitating groups in diverse settings during their clinical placements.
The evidence shows that self-management programmes lead to lasting reductions in pain intensity and pain-related distress, as well as improved role function and overall health-related quality of life. (12) (13)
Promoting resource-efficient delivery and solutions for systematic challenges
Research evidence also reveals that self-management group programmes are resource- and cost-efficient. They can be offered in any setting and utilise very little resources. Since more beneficial effects are experienced when group programs are shorter (less than 10 weeks) and since the fees charged per group participant are lower, the costs of participating in a group programme are considerably less for the person with chronic pain than engaging in numerous sessions of individual pain management.
In addition, research findings suggest that successful self-management leads to individual and societal economic benefits over time due to decreased use of analgesics, reduced visits to emergency rooms and other healthcare consultations, fewer hospitalisations (with shorter hospital stays also translating into fewer days off work), and reductions in long-term complications that would utilise more healthcare resources. (12) (13)
Apart from their involvement in facilitating cost-efficient pain self-management groups, growing research demonstrates that OT offers other economically valuable solutions in healthcare. For example, by integrating OTs into interdisciplinary primary care teams, community-based and home care services become more effective at delivering proactive, preventive care that helps people manage complex conditions, like chronic pain, at home and avoid costly hospitalizations. (14)
As an aging population drives healthcare cost concerns, home care services present opportunities for effective intervention. They, however, remain underfunded, and OTs underutilized, despite older adults increasingly facing conditions like pain and experiencing needs directly aligned with this profession’s expertise. As this demographic shift intensifies healthcare demands, team-based care models that incorporate OT will become essential for delivering cost-efficient care. (14)
OTs also provide evidence-informed, non-pharmacological alternatives for treating chronic pain, thereby helping to mitigate rising medication expenses. For example, OTs can design personalised exercise programs and suggest activity and other modifications for people living with Rheumatoid Arthritis that reduce joint stress, improve mobility, and enable participation in meaningful daily activities. These interventions consequently decrease dependence on expensive pain-relieving medications. (14)
Moving beyond misconceptions about Occupational therapy
Including and utilising OTs more in the interdisciplinary pain management team will also require addressing misconceptions held by other members of the team, the public and OTs themselves.
It seems that, as OTs qualify and begin working in clinical settings, they can tend to lose their unique ‘expert generalist’ role and become super-specialised in fields of practice, like hand therapy, neurotherapy, mental health or paediatrics. Then, when working closely with other rehabilitation professionals, like physiotherapists, they might even ‘divide’ the care of the person between them with OTs focussing on some anatomical areas and functional capacities only. This can lead to other practitioners and the public developing a one-dimensional view of what OTs treat, for example “only hands” or “only workplace injuries” or “only mental health problems”.
OTs themselves, misguided by outdated pain science and practices, have generally shied away from pain management and referred conditions like chronic low back pain and sciatica on to their physiotherapy colleagues instead.
Including updated pain education in undergraduate OT training, educating other practitioners and the public on the breadth of OT practice, and advocating for the role of OT in pain management directly (e.g. by hosting educational events, participating in team discussions) and indirectly (e.g. visibility on teams, report-writing) are all needed. Referral to OTs should be done early enough for them to help prevent functional impairment and the chronification of pain. (15) Discussions around these referrals can also be used as opportunities to increase the expectations of the person with pain for positive outcomes from OT intervention. (15)
This article set out to unpack what is often unknown or overlooked about OTs’ contribution to multidisciplinary pain management and to provide compelling reasons for their inclusion in pain teams. In doing so, it has highlighted how they bring a distinctive whole-person, function-first perspective to pain management.
As the importance of integrated, person-centred pain care is increasingly recognised, it is imperative that the role of OT be acknowledged and embedded at a systemic level. Only through such recognition can interdisciplinary teams fully harness the expertise of OTs to advance comprehensive, sustainable, and person-focused approaches to pain care.
References
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