Australian Occupational Therapy Journal

(2002)

49

, 48–52

Blackwell Science, Ltd

I n P r a c t i c e

Reflections on clinical practice by occupational therapists working in multidisciplinary pain management programmes in the UK and the USA

Edwina

Shannon

Pain Management Unit, North Adelaide, South Australia, Australia

K E Y W O R D S

chronic pain,

cognitive-behavioural therapy,

fellowship,

functional restoration.

INTRODUCTION

Pain management services for people with chronic pain isa relatively new, rapidly expanding area in health services.Multidisciplinary pain management treatment serviceshave been shown in numerous research programmes tobe the most effective method for helping people managetheir ongoing pain more effectively (Flor, Fydrich & Turk,1992). They specialise in the treatment of people withchronic pain syndrome, which is characterised by:• persistent pain (greater than 3– 6 months duration);• numerous previous unsuccessful medical or alternate

interventions;• pain has become the central focus of life;• pain behaviour, such as moaning, wincing, moving in a

guarded fashion;• associated psychosocial dysfunction, such as depres-

sion and anxiety;• excessive or inappropriate drug intake (prescribed and

non-prescribed);• widespread reduction in a variety of activities, includ-

ing work.An appraisal of outcomes of multidisciplinary pain

management treatment by Large & Peters (1991) indicated

increasing consensus that pain management programmesare effective in not only increasing activity level and returningpeople to work, but reducing use of medication and medicalservices. The International Association for the Study ofPain has developed desirable qualities for pain treatmentfacilities, including the staffing of multidisciplinary paincentres and clinics (Loesler, 1991). It recommends theinclusion of occupational therapists for both assessmentand treatment services. There is considerable scope in theoccupational therapist role to facilitate improvement infunctional activity status through graded activity prescrip-tion, task adaptation and work simplification, training incorrect body mechanics, and work-site modification (Giles& Allen, 1986; McCormack, 1988; Strong, 1987). However,there is little documentation of the efficacy of occupationaltherapy treatment. It is unclear if this is due to their limitedrole in the treatment regime, or a lack of involvement inevaluation and research (Strong, 1996).

As an occupational therapist I have been working inthis field for almost 12 years, initially in London for18months, and then at the Pain Management Unit inNorth Adelaide, South Australia. In this latter position, Iinitially worked as a sole part-time occupational therapistin a treatment team with an occupational physician,

Edwina Shannon

BAppSc(OT), MHlthSc(OT); Occupational Therapist.Correspondence: Ms Edwina Shannon, Pain Management Unit, 201 Melbourne Street, North Adelaide, SA 5006, Australia. Email:shanrix@senet.com.au

Accepted for publication July 2001.

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psychologist and physiotherapist. Two years ago, as myworkload expanded, I was joined by another part-timeoccupational therapist.

In 1998 I completed a masters degree in Health Science(Occupational Therapy). My research thesis focused onassessment of functional activity levels by occupationaltherapists in the area of pain management. My researchaimed to evaluate change in functional capacity for par-ticipants in a pain management treatment programme. Iconducted an extensive literature review of pain-relatedjournals to explore the range of standardised assessmentswith reported acceptable levels of validity and reliability,that were cost and time-effective for the clinician toadminister. I concluded that to gain a true perspective ofchange to functional capacity of the chronic pain patient,both self-report and direct observation scales are desirable.Furthermore, although many standardised self-reportassessments are available, I concluded that there are alack of standardised, practical, cost-effective direct-observation assessments that can be readily used in theclinical area.

It was during this period of research that my interest intravelling overseas to observe the work of other therapistsworking in the same area was ignited. I wished to furtherexplore some of the areas of assessment and treatment thatI had read about in my literature review of professionaljournals. Discussion with occupational therapists at INPUT,St Thomas’ Hospital, London, convinced me that someimportant two-way learning could occur with furthercollaboration on both assessment and treatment protocol.Furthermore, attendance at various national pain manage-ment conferences and workshops reinforced my conclusionthat although there was an increasing number of cliniciansinvolved in this area in Australia, their work was not wellrecognised or represented in the relevant literature.

FELLOWSHIP PROGRAMME

I applied for a Churchill Fellowship in 1998 with the ideaof visiting pain management programmes that fulfilled thefollowing criteria. First, the programme needed to bemultidisciplinary in nature, with an active occupationaltherapy role in treatment. Second, it needed to beacknowledged as a model of excellence within its owncountry; have an active evaluation process; and have pub-lished findings from their programmes in journals related

to pain and injury management. Third, the programmeneeded to be willing to accommodate visitors to activelyobserve and participate in its programme structure.

I relied on advice from acknowledged experts in painmanagement both nationally and internationally toprovide recommendations of ‘leading edge’ programmes.Unfortunately, due to time constraints, I could not visit allprogrammes recommended that fell within my selectioncriteria. But in the interest of maximising the usefulness ofmy experience, I chose programmes that would give arange in diversity of model of practice, treatment approachand available facilities.

In June and July of 1999, having secured a ChurchillFellowship, I visited the following programmes:• INPUT Pain Management Unit, St Thomas’ Hospital,

London, UK;• Pain Management Unit, The Royal National Hospital

for Rheumatic Diseases, Bath, UK;• University of Miami Comprehensive Pain and

Rehabilitation Centre, South Shore Hospital, Miami,USA.Both INPUT and the Pain Management Unit in Bath

work in a cognitive-behavioural framework. This approachwas first developed by Fordyce (1976) and is based on theassumption that although pain may initially result fromunderlying pathology, environmental factors can influenceongoing pain behaviour and emotional suffering. Laterdevelopments emphasised the role of the patient’s beliefsand cognitions in pain perception, affective distress andpain behaviours (Turk, Meichenbaum & Genest, 1983). Acognitive behavioural approach focuses on reinforcing wellbehaviours such as goal-directed activities and exercise,and extinguishing pain behaviours such as lying down anddiscussing pain. The therapist role is that of a facilitator ofchange, and aims to shift the patient’s view of themselvesfrom being passive and pain-focused, to being resourcefuland pro-active. The emphasis is on assisting people withchronic pain improve their quality of life, rather thanreduce their pain experience per se. They aim to teachstrategies to increase activity tolerance and occupationalrole performance and reduce the psychosocial dysfunc-tion associated with chronic pain (Wittink & HoskinsMichel, 1997). Although this approach was developed inthe USA, pain management services have proliferatedin the United Kingdom in the last decade, with muchpublished research being generated from a variety of painmanagement centres. INPUT, in particular, has provided

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E. Shannon

extensive literature on the assessment and cognitive-behavioural treatment of chronic pain.

The Comprehensive Pain and RehabilitationCenter (CPRC) in Miami follows a functional restora-tion model, where the emphasis is on identifying andeliminating the cause of ongoing pain, combined withvigorous physical reconditioning and graded activityprogrammes (Rosomoff & Rosomoff, 1991). The func-tional restoration process was developed by Mayer

et al.

(1987), and although it incorporates a cognitive-behavioural approach, aspects of a ‘sports medicine’ modelof rehabilitation are incorporated. ‘Hands on’ therapiessuch as ice, heat, passive mobilisation and massage maybe utilised to allow reduction in pain symptoms andrapid improvement in range of movement and activitytolerance. This model was influenced by work-orientatedrehabilitation services, known as work hardening, in the1980s (Matheson, 1984), with return to work a primaryfocus of treatment. Functional restoration models oftreatment are well represented in the USA and Canada,and there have been similar programmes established inAustralia over the last decade. These programmes gener-ally, but not exclusively, serve the workers’ compensationpopulation. The CPRC was established in 1974, and has along history of excellence of treatment and publications inthis area.

In each centre, I liaised predominantly with occupa-tional therapists, observing their interaction with patientsfor both assessment and treatment. Occupational therapytreatment services were predominantly in a group formatat both INPUT and the Pain Management Unit, Bath.Within this context, patients were instructed in goalsetting for activity, and methods of establishing baselinesand grading activity to allow goal achievement. In bothprogrammes they were instructed in body mechanics,energy conservation and work simplification. A wider rangeof activities of daily living facilities such as kitchens andgarden area at INPUT allowed greater direct observationand feedback in skill acquisition, whereas at Bath, limitedfacilities led to more patient feedback and discussion.Both programmes covered self-management of ‘flare-ups’of pain, with a range of strategies such as relaxation andcognitive restructuring. The Pain Management Unit atBath was trialing a pain management programme foradolescents during my visit. They reported that althoughthis approach has been used successfully in the USA, thiswas the first time it had been used in the UK.

At CPRC in Miami, the treatment focus was more onan individual basis, where the treatment was a mixture of‘hands on’ therapy for mobilisation and heat/ice modalitiesand one-to-one coaching in correct posture and bodymechanics, combined with a graded exercise and activityprogramme. Biofeedback was used extensively in occupa-tional therapy sessions to facilitate learning on adjustmentof posture and movement patterns while performing workand home related activities.

Although patients were involved in some groupeducation for topics such as body mechanics and energyconservation, most therapist–patient interaction was inindividual sessions, reflecting a more traditional approachto rehabilitation. This programme had a strong focuson return to work, with graded activity programmesfrequently matched to job demands. However, vocationalcounsellors and ergonomists on the team appeared tohave the predominant role in facilitating the return towork process.

In each programme I also spent time with othermembers of the teams, including physiotherapists,nurses, psychologists, doctors, ergonomists and massagetherapists.

REFLECTIONS

My study was an extremely valuable experience in manydifferent ways. It was a great privilege to have the oppor-tunity to observe and interact with such a variety of skilledtherapists in my own area of interest and knowledge. Ineach of the programmes visited, I was able to liaise withpeople who could not only provide me with helpfulinformation in their approach to the assessment andtreatment of people with chronic pain, but I could alsodiscuss my own pain management work in Australia. Thisprovided the opportunity for meaningful discourse, notonly for the duration of my visit, but also in developinglinks for ongoing information sharing and collaborationon research.

The programmes I visited in the United Kingdomprovided affirmation for the approach of the Pain Man-agement Unit where I currently work. Not only did weshare the same theoretical model of cognitive-behaviouraltherapy, but our working models of practice were verysimilar. It was reassuring to observe sessions that hadsimilar structure and outcome to my own practice. This

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not only confirmed that I was ‘on the right track’, it alsoallowed me to look at variations of the same theme. Inparticular, at INPUT, I found that their excellent organ-isational skills meant that there was a clear structure foreach session with patients, with learning goals and strat-egies clearly outlined.

At the programme in Bath, I focused less on thestructure of the programme due to the unit’s reticencefor me to take notes while observing. However, extensivediscussion with treating therapists, both before and aftereach observed session, allowed me to focus on the thera-peutic interaction between the therapist and the patientgroup. Their aim was to help people break free of thedependent-helpless role commonly found in the chronicpain syndrome: to ‘normalise’, not ‘medicalise’ theirproblems. I was impressed by their ability to hold backfrom the ‘expert’ role and provide the answers to pain-related problems, particularly as it sometimes led tofrustration from the patient group. Practising problem-solving strategies allowed the group to take a muchgreater responsibility for themselves and their pain. Iwas grateful for the opportunity to observe skilfulpractice in this type of therapy. In my own work, I rarelyhave the opportunity to observe other therapists, andconsequently have had limited opportunity to observeand reflect on the benefits and outcomes of differentstyles of interaction.

The programme at CPRC in Miami was also stimulat-ing in many different ways. It was energetic and enjoyable,and the skill of the various therapists was apparent, parti-cularly in physical modalities, such as the use of mobilisa-tion and heat/ice for pain relief. It was also interesting(and personally challenging) that the programme operatedon a different model from that in which I work. Therapistsdoing ‘hands on’ treatment is generally considered incom-patible with a cognitive-behavioural model of treatment,but here in a functional restoration model, it was regularpractice. Also, the focus of pain reduction and eliminationrequired discussion regarding pain levels and pain experi-ence to a much greater extent than was found in thecognitive-behavioural programmes. This was thoughtprovoking, especially in the light of the apparent rapidgains that patients made in this programme.

I found the biofeedback sessions of particular interest.Although I currently use biofeedback for muscular re-education in my own pain management practice, thesophistication of the technology and expertise in their

application used in the Miami programme was well inadvance of my current skill level. Portable, lightweightunits, with multiple channels to explore the work of dif-ferent muscle groups, makes this an ideal assessment andtreatment tool for occupational therapists working in painmanagement.

On a personal level, I found the experience of myChurchill Fellowship very thought provoking. Apart frombeing a student, I have found it rare in my adult life to beallowed the luxury of being an observer. Indeed, at thebeginning of my tour, I found this experience distinctlyuncomfortable, and felt the desire to demonstrate my ownknowledge base and skill level. However, I endeavouredto resist this urge, as I could sense the enormous value ofobservation in learning. Similarly, I initially found myselfwanting to make judgements on what I was observing, interms of its merit, and whether I could use/adapt whatI had seen. But I found it to be much more helpful to‘suspend judgement’. This allowed me to stay focused forlonger, and helped me avoid making snap judgements onthe value of any one intervention. Later reflection on whatI had observed seemed to give a much more balancedevaluation, recognising that all programmes had interesting,helpful and different approaches, none that were necessarily‘right’ or ‘wrong’. I find myself continually reflecting onmy travels and what I observed and learnt, and applying itto my clinical practice.

I found my discussion with both patients and therapistsin each programme particularly interesting and worthwhile.My role as a Churchill Fellow from another country gaveme a unique position of being the impartial bystander whounderstood the pain management paradigm. Hearing thepatients’ stories and their reflections on the programmesgave me insights that could not be learnt otherwise. Myinteraction with occupational therapists reminded me thatthe occupational therapy world is a small and welcomingone, and sharing the same beliefs, approaches and problemsrapidly leads to building rapport and friendship.

In both countries I visited, it was apparent that thespecialised treatment of chronic pain is well accepted.Occupational therapists in the UK currently have almost200members in their pain special interest group, whichwas founded in 1993. In the USA, effective pain manage-ment appeared to be seen as good practice in return towork for injured workers, not just the last resort for thosein the ‘too hard’ basket. I was impressed that research andeducation were key components in all programmes that I

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visited. Australia would appear to have a long way to goto develop the same level of expertise and awareness.

Despite regular discussion, development of a nationalpain management strategy for occupational therapists andphysiotherapists has yet to happen. Interest groups fortherapists working in the area of pain management seemto come and go, but fail to maintain a cohesive force. Wehave yet to develop a national register of therapistsworking in the area of pain management, and provide anetwork of information dissemination and mentoring.Development of cohesive undergraduate and postgraduateeducation for occupational therapists in pain managementalso needs to be explored.

I would like to conclude by adding that the process ofapplication for the fellowship was almost painless, andthe rewards were great. For anyone who has consideredthe possibility of developing their knowledge base andskills with overseas experiences, it is well worth exploringthe range of travelling fellowships and scholarshipsavailable, such as the Churchill Fellowship, to make yourdream a reality!

ACKNOWLEDGEMENTS

I would like to acknowledge the support and encourage-ment of the staff team of the Pain Management Unit,North Adelaide, in particular Dr Graham Wright andSharon Haarsma. Their continual support in both theapplication for my fellowship and the discussion andimplementation of my findings has been unwavering. Iwould like to thank all the occupational therapists andother staff at the pain management programmes that Ivisited for the generosity in their time and commitmentto sharing of information. In particular to Jackie Adamsand Louise Stewart-Corry of INPUT, London; MargaretWheeler of the Pain Management Unit, Bath; and RonaldFrench of the Comprehensive Pain and RehabilitationCenter, Miami.

My thanks to Professor Jenny Strong for her supportfor my work in the area of pain management, and adviceon resources. Her leadership in the area of pain manage-ment continues to make important inroads for the worldof occupational therapy, both nationally and internation-ally. I would also like to thank the Winston ChurchillMemorial Trust for making this opportunity possible.

REFERENCES

Flor, H., Fydrich, Y. & Turk, T. C. (1992). Efficacy ofmultidisciplinary pain treatment centres: A meta-analytic review.

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