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Our Focus

To enable individual with chronic pain to participate in the activities that have value and meaning to them, despite their pain.

In primary healthcare setting, we focus on community participation, group intervention, domiciliary and out-reach programs as well as daily out-patients encounter.
Examples:
Multidisciplinary team approach in rural area to promote pain awareness in senior citizens.
Pain free approach in out-patient encounter.

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Impact of Pain

Pain can have a significant impact on both the physical and emotional well-being of the individuals, their family members and the society they lived in.

It may lead to:

Increased dependency on others
Reduced productivity and employment issues
Issues on relationships and social life
Difficulties participating in daily activities (ADL/Work/Leisure)
Sleep disturbances
Emotional and Psychological effects
Social isolation
Reduced quality of life.

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Objectives

To perform a comprehensive assessment and use non-pharmacological approach to treat acute and chronic pain pertaining to psychosocial and environmental factors.

The core intervention is activity management to resolve an imbalance of under activity or over activity. This includes activity analysis, skill development and activity adaptation, problem-solving, prioritizing, planning and pacing of activities.

The outcome of our service is to enable individuals to achieve satisfying occupational balance to support recovery, improve their functions in everyday activities and achieve optimum quality of life.

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OT Process

The occupational therapy process includes evaluation, intervention, and outcomes; occurs within the purview of the occupational therapy domain; and involves collaboration among the occupational therapist and client.

“Evaluation requires synthesis of all data obtained, analytic interpretation of that data, reflective clinical reasoning, and consideration of occupational performance and contextual factors”. �(Hinojosa et al., 2014)

“Process and skilled actions taken by occupational therapy practitioners in collaboration with the client to facilitate engagement in occupation related to health and participation. The intervention process includes the plan, implementation, and review” (AOTA, 2015).

Outcomes are the end result of the occupational therapy process; they describe what clients can achieve through occupational therapy intervention. Some outcomes are measurable and are used for intervention planning, review and discharge planning.

Evaluation

Intervention

Outcome

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To initiate the evaluation process, both occupational therapists and occupational therapy assistants may contribute to the evaluation, following which the occupational therapist completes the analysis and synthesis of information for the development of the intervention plan (AOTA, 2020)

EVALUATION

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What do OT assess?

Occupation identity which drives them to perform

Values/ Beliefs/ Roles/ Interests

Barriers in participation

Physical/ Emotional/ Cognitive/ Social demands.

Physical & social environmental barriers

Home/ Workplace/ Educational site

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What do OT assess?

Impact of reduced performance

on their routines, role fulfillments & relationship

Client's abilities, strengths & coping strategies

in relation to person's physical and psychological well-being

Past patterns of occupational functioning & future goals

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List of Suggested Assessments

Activity of Daily Living and Instrumental Activity of Daily Living (ADL AND IADL)

Brief Pain Inventory (BPI)

To assess the

severity of pain and the impact of pain on daily functions.

The Canadian Occupational Performance Measure (COPM)

Measures performance and satisfaction in self- care, productivity and leisure from the client’s perspective.

The Functional Assessment of Cancer Therapy - General (FACT-G)

Measure four domains of HRQOL in cancer

patients: Physical,

social, emotional, and functional well-being.

The Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F)

Assesses self-reported fatigue and its impact upon daily activities and function.

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List of Suggested Assessments

Activity of Daily Living and Instrumental Activity of Daily Living (ADL AND IADL)

Katz Index of Independence in Activities of Daily Living

To assess functional

status as a measurement of the client’s ability to

perform activities of daily living independently.

Occupational Identity Questionnaire (OIQ-P V.1.0)

A self-report

assessment of the occupational identity of older adults.

Lawton - Brody Instrumental Activities of Daily Living Scale (IADL)

Most useful for identifying how a person is functioning at the present time, and to identify improvement or deterioration over time.

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List of Suggested Assessments

Personal and Environmental Factors

Depression Anxiety Stress Scale (DASS)

To assess the fundamental symptoms of

depression, anxiety and stress/tension.

The Home Falls and Accidents Screening Tool (HOME FAST)

To identify older people at risk of falling because of hazards within their home environment.

Rosenberg Self- Esteem Scale (RSE)

To measure

self-esteem

Pain Self Efficacy Questionnaire (PSEQ)

To assess how confident you are in doing the things at present, despite the pain.

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List of Suggested Assessments

Pain Assessment

The Pediatric Pain Profile (PPP)

Non- communicating Children’s Pain Checklist – Revised (NCCPC-R)

Designed to be used for children aged 3 to 18 years, who are unable to speak because of cognitive (mental/intellectual) impairments or disabilities.

Is used to measure pain in adults.
It stands for Face, Legs, Activity, Crying, and Consolability.
This scale can be used to help health professionals determine the best way to treat a patient who is in pain.

Wong-Baker FACES® Pain Rating Scale

Widely used with people ages three and older, not limited to children.

This self-assessment tool must be understood by the patient, so they are able to choose the face that best illustrates the physical pain they are experiencing.

The FLACC scale

Developed specially to help in assessing and monitoring pain in children with severe neurological impairments and unable to communicate pain through speech.

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List of Suggested Assessments

Work, Rest and Sleep

Pittsburgh Sleep Quality Index (PSQI)

A measure of self- reported sleep quality and sleep disturbance.

Other assessments based on client's needs

Multidimensional Scale of Perceived Social Support (MSPSS)

A short instrument

designed to measure an individual’s perception of support from 3 sources: family, friends and a significant other.

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INTERVENTION

i. Intervention Plan

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PEO Model

A model that emphasizes occupational performance shaped by the interaction between person, environment, and occupation.

Person

Occupation

Environment

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PEO Model

Person

Body Mechanics and Posture Training
Energy Conservation and Work Simplification
Splinting
Adaptive Equipment
Relaxation Therapy
Cognitive Behavioral Approaches
Desensitization/ Sensory Re-education
Mirror Therapy

Environment

Ergonomics
Environmental Modifications

Occupation

Activity Management (Occupational Balance/ Lifestyle Modifications)
Vocational Rehabilitation
Sleep Hygiene

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INTERVENTION

ii. Intervention Implementation

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Adaptive Equipment

Adaptive equipment is any device, tool, or machine that is used to assist with any

daily task.

Case example

Client with finger deformity due to Rheumatoid Arthritis.

Aims

To assist performance of daily activities by reducing joint stress and muscle strains.

Intervention

Use of long handled and enlarged handle tools can reduce strain to the joints.

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Adaptive Equipment

Examples of different types of adaptive equipment which can be suggested to clients based on individual's needs in relation to pain or fatigue.

Long-handled sponge/brush

Helps to reduce strain to the joints during bathing/showering.

Long-handled tap faucet

Helps to reduce effort in twisting tap faucet to open/close.

Walking aids

(Walking frame/sticks/rollators)

Helps to re-distribute body weight to favor a weakened or injured joint.

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Relaxation Therapy

Relaxation therapy has been shown to provide pain relief by decreasing anxiety, lowering muscle tension and distracting attention

(Good M, 1999).

Case example

Client with severe fatigue due to underlying disease.

Aims

To help a person to relax; to attain a state of calmness in order to cope with fatigue, anxiety, stress or anger in relation to pain.

Intervention

- Deep breathing relaxation technique

- Imagery relaxation technique

- Progressive muscle relaxation technique

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Body Mechanics and Posture Training

Case example

Client with chronic low back pain who works in an office with computer

Aims

To prevent/ correct improper body mechanics to reduce musculoskeletal pain during occupational performance

Intervention

- Adjust work desk height

- Raise monitor level

- Proper/ ergonomic chair suggestions

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Energy Conservation & Work Simplification

Case example

Client with recurrent trigger finger.

Aims

To reduce the amount of effort needed to perform daily tasks and building more rest.

Intervention

- Prioritize and plan out work

- Pacing (Work and rest intervals)

- Educate joint protection techniques.

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Splinting

Case example

Client presented with hand numbness due to Carpal Tunnel Syndrome.

Aims

- To immobilize affected limb in order to support healing, and to prevent further damage.

- To promote optimum hand function.

Intervention

- Provide cock-up splint �(hard/soft material)

A splint is defined as being a removable device designed for the support of weak or ineffective joints or muscles.

(Fess, 2002)

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Cognitive Behavioral Approach

Case example

Client who is diagnosed with cancer and undergoing chemotherapy.

Aims

To change the way client perceives pain so that the body and mind can respond better when episodes of pain occur in everyday situations.

Intervention

- Individual or group session

- Coping skills technique

- Problem-solving training

- Journal/ homework to keep track of the thoughts and feeling associated with pain

- Behavior Modification Technique

Cognitive behavioral therapy (CBT) is a form of talk therapy that helps people identify and develop skills to change negative thoughts and behaviors.

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Desensitization Technique/ Sensory Re-education

Case example

Client with finger amputation presented with tactile hypersensitivity.

Aims

To reduce hypersensitivity of the pain in the affected area to return patient to work or daily functioning.

Intervention

Use a stimuli that causes the least painful response, and gradually transition to stimuli that cause the most painful response (Light or deep pressure, vibration, tapping, desensitization kit)

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Mirror Therapy

Case example

Client with complex regional pain syndrome (CRPS) which causes burning pain on hand.

Aims

To reduce symptoms of CRPS and manage pain effectively for daily functional activities.

Intervention

- The affected hand is placed behind the mirror.

- The non-affected hand is then moved and the image is viewed as the affected hand moving.

- The brain is now receiving visual feedback that the hand is moving normally without pain which corrects the mismatch that has been occurring.

A technique which uses visual feedback to take advantage of brain’s neuroplasticity to reduce chronic pain.

(Rothgangel et.al,2011)

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Mirror therapy (also called mirror box therapy) is a form of neuromuscular treatment used to help people who have suffered a stroke to reduce pain and regain function in the affected upper extremity. The technique is also used to reduce phantom limb pain for amputees and to reduce chronic pain for people with complex regional pain syndrome and other painful conditions.

Mirror therapy uses visual feedback to take advantage of the brain’s neuroplasticity.

The theory behind mirror therapy hypothesizes that the visual feedback from the mirror stimulates the mirror neuron system to reroute motor signals away from the damaged motor neurons and on to the motor cortex. This rerouting “tricks” the brain into characterizing the affected arm as “okay.”

Another theory as to why mirror box therapy is effective in treating CRPS is cortical reorganisation. In CRPS the affected limb is not used, or is used less, due to pain. This lack of use leads to altered or absent sensory feedback from the limb and results in cortical reorganisation of body’s representation in the brain. The amount of reorganisation has been shown to correlated with the severity of pain. This reorganization may be changed by providing alternative sensory input using a visual illusion, thereby reducing pain.

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Activity Management

Case example

Client with Fibromyalgia and underlying Rheumatoid Arthritis.

Aims

To optimize participation in daily occupation by altering lifestyle habits and routine.

Intervention

Elaboration in the next few slides.

(Occupational Balance/ Lifestyle Modification)

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Occupational Balance & Lifestyle Modifications

Client with chronic pain such as fibromyalgia often experience fatigue which can be disabling, therefore these are a few strategies to suggest.

1. Problem Solving

May require simple adjustments in method or environment.

2. Grading Activities

Aim to change the activity before client experience high levels of pain/fatigue which may slow down recovery process.

3. Pacing

This enables gradual development of tolerance to increase participation.
Involves prioritizing and planning.

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Occupational Balance & Lifestyle Modifications

Client with chronic pain such as fibromyalgia often experience fatigue which can be disabling, therefore these are a few strategies to suggest.

4. Goal setting

Set achievable short term and long term goals, which helps in motivation for further therapy.

5. Stress Management

To manage mood and stress level
Deep Breathing Exercise
Guided Imagery
Progressive Muscle Relaxation

6. Good Sleep Habits

To manage fatigue and improve quality of sleep.
Practice Sleep Hygiene (Refer to Sleep Hygiene)

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Vocational Rehabilitation

Case example

Client with Fibromyalgia and underlying Rheumatoid Arthritis.

Aims

To facilitate client to maximize functional work performance even with the pain.

Intervention

- Assess workplace and suggest necessary modifications to the setting.

- Suggest tools adaptation.

is defined as whatever helps a person with health problem return to work and remain in employment.

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Sleep Hygiene

Case example

Client with Fibromyalgia and underlying Rheumatoid Arthritis.

Aims

- To improve quality of sleep

- To overcome fatigue

- To improve quality of life

Intervention

- Assist in developing sleep pattern/routine�(Regular wake and sleep time) .

- Adjust sleeping position

- Deep Breathing Exercise

- Room atmosphere (Dimmed lights, comfortable temperature, mattress/bed, de-clutter room)

involves nightly routines, modifications to the daily environment (quiet sleep space, dark room, etc.), and decisions (limiting caffeine in the hours before bedtime, being active during the day, etc.) that will optimize sleep.

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Occupational Therapy Outcomes

HOME

Client will be able to perform activities of daily living with minimal pain/has better coping skills with pain.

WORK

- Client will be able to participate in a supported work environment.

- Client is able to meet job demands.

SOCIETY

- Client will be able to cope with pain which then improves social and emotional wellbeing.

- Client is able to participate in social activities in the community.

Related to the interventions provided and to the targeted occupations, performance patterns, performance skills, client factors, and contexts.

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Conclusion

Chronic pain restricts the performance of activities that an individual need to, want to and are expected to perform.

The role of Occupational Therapist not only recognizes the importance in sustaining activities to prevent deterioration but also the value of activity in improving health and functioning.

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List of Contributors

Thillainathan A/L Krishnan

Pegawai Pemulihan Perubatan Cara Kerja U44,

Penyelaras Perkhidmatan Pemulihan Cara Kerja di Kesihatan Primer, Bahagian Pembangunan Kesihatan Keluarga (KKM)

En. Mohammad Luqman Bin Abd Rani

Pegawai Pemulihan Perubatan Cara Kerja U44, Klinik Kesihatan Wakaf Bharu, PKD Tumpat Kelantan

Khor Seng Yin

Pegawai Pemulihan Perubatan Cara Kerja U41, Klinik Kesihatan Ayer Keroh, PKD Melaka Tengah (Melaka)

Noriedayu Binti Sarim

Pegawai Pemulihan Perubatan Cara Kerja U41, Klinik Kesihatan Bandar Botanik, PKD Klang (Selangor)

Nurlhuda Binti Jamiluddin

Pegawai Pemulihan Perubatan Cara Kerja U41, Klinik Kesihatan Jinjang, PKD Kepong (WP Kuala Lumpur)

Suriati Binti Muhammad

Jurupulih Perubatan Cara Kerja U32, Klinik Kesihatan Bandar Tun Hussein Onn, PKD Hulu Langat (Selangor)

Nurasmilla binti Md.Noor

Jurupulih Perubatan Cara Kerja U29, Klinik Kesihatan Arau, PKD Kangar (Perlis)

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References

Bower,E.S (2011) Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach. Retrived from https://www.webmd.com/painmanagement/features/cognitive-behavioral
https://www.cdc.gov/arthritis/basics/fibromyalgia.htm (accessed on 22.11.22)
E. Fess, A history of splinting: To understand the present, view the past, Journal of Hand Therapy 15(2) (2002), 97–132.
Rothgangel, A. S., Braun, S. M., Beurskens, A. J., Seitz, R. J., & Wade, D. T. (2011). The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. International Journal of Rehabilitation Research, 34(1), 1-13.

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