O T I N R E H A B I L I TAT I O N

TOPIC: OT MANAGEMENT
FOR PAIN

-AARTHI A

BOT(FINAL YEAR)

SRIHER
 INTRODUCTION

• Pain is defined as an unpleasant sensory and emotional experience associated with actual or
potential tissue damage

• The perception of pain may depend on the situation or the mental state
 PA I N T E R M I N O L O G Y
• Acute pain: Pain associated with tissue damage and typically resolves once the tissue heals.

• Chronic pain: Pain that persists past the healing phase following an injury; impairment is greater than anticipated based on the physical
findings or injury and it occurs in the absence of observed tissue injury or damage.

• Allodynia: Pain due to a stimulus that does not normally provoke pain.

• Analgesia: Absence of pain

• Causalgia: A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with
vasomotor and sudomotor dysfunction (such as diabetic autonomic neuropathy) and later trophic changes.

• Central pain: Pain initiated or caused by a primary lesion or dysfunction in the central nervous system.

• Chronic pain syndrome: Pain that exists when individuals have developed extensive pain behaviours such as preoccupation with pain,
passive approach to health care, significant life disruption, feelings of isolation, demanding, angry, or doctor-shopping.

• Dysesthesia: An unpleasant abnormal sensation, whether spontaneous or evoked.

• Hyperalgesia: An increased response to a stimulus that is normally painful.

• Hyperesthesia: Increased sensitivity to stimulation, excluding the special senses. Hyperesthesia includes both allodynia and
hyperalgesia
• Hyperpathia: A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive
stimulus, as well as an increased threshold.
• Malignant pain: Pain associated with cancer.
• Nociceptive pain: Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of
pain receptors, (nociceptors)
• Paresthesia: An abnormal sensation, whether spontaneous or evoked.
• Persistent pain: Pain related to tissue damage or the threat of such damage that persists because the causative factors
persist.
• Psychogenic pain: An older term for pain believed to be caused by psychological factors when organic factors were
absent or not severe enough to explain the pain complaint.
• Recurrent pain: Repeated episodes of acute pain.
B I O P S YC H O S O C I A L M O D E L O F PA I N

Loeser and Fordyce

NOCICEPTION
BODY

PAIN

MIND ENV SUFFERING

PAIN
BEHAVIORS
PA I N S Y N D RO M E S
• Headache Pain
• Low Back Pain
• Arthritis (OA and RA)
• Complex Regional Pain Syndrome
• Myofascial Pain Syndrome
• Phantom Pain
• Chronic Pain and Depression
• Fibromyalgia
• Cancer Pain
• Central Pain Syndrome
E X A M I N AT I O N O F PA I N

Pain is a purely subjective phenomenon. Unlike range of motion (ROM), strength, or tissue extensibility, pain
has no objective or specific measurement tool.

Effective examination of chronic pain is more complex than the visual analogue or numeric rating scales
typically used for acute pain. The psychosocial aspects of chronic pain should be examined and evaluated to
better identify psychosocial factors and guide intervention within a biopsychosocial model of care.

Pain should be examined both at rest and with movement.

M N E M O N I C S F O R PA I N A S S E S S M E N T
• Site: Where is the pain?
S

• Onset: When and how did it start? Sudden or gradual? Trauma, illness, or
O other possible cause?

• Character: How does the pain feel? Sharp? Stabbing? Burning? Aching?
C Other?

• Radiation: Does the pain radiate? Where? What causes radiation?

R

• Associations: Other symptoms, such as numbness, paresthesia, heaviness,

A other?

• Time course: How does the pain vary over the day?
T

• Exacerbating/relieving: What aggravates or relieves the pain?

E

• Severity: Intensity rating

S
ASSESSMENT TOOLS
• A referral for an occupational therapy (OT) evaluation is made when pain interferes with the client’s
occupational performance.

• Factors that may contribute to pain perception, occupational role disruption, decreased occupational
performance, and diminished quality of life should be identified.

• Verbal Rating Scale (VRS)

• Numeric Rating Scale (NRS)

• Visual Analog Scale (VAS)

• Facial Pain Scale (FPS)

ASSESSMENT TOOLS
• Brief Pain Inventory(long and short forms)
• Geriatric Pain Measure
• Global Pain Scale
• Pain Disability Index
• Pain Disability Questionnaire
• Graded Chronic Pain Scale
• CRIES - Crying, Requires increased oxygen administration, Increased vital signs, Expression, Sleeplessness Pain Scale
for infants 0 to 6 months
• FLACC - Face, Legs, Activity, Cry, Consolability Scale for infants and children 2 months to 7 years
• COMFORT Pain Scale for unconscious or ventilated infants, children, or adolescents
• Pain Thermometer - for elderly individuals with dementia
• COPM
MEDICAL MANAGEMENT
Medication
• Aspirin and acetaminophen are frequently used in the treatment of mild pain (e.g., backache) because of their high level
of effective ness, low level of toxicity, and limited abuse potential.

• Non steroidal anti-inflammatory agents have been used in the treatment of arthritis and inflammation of a musculo-
skeletal origin.

• Codeine is often used for moderate intensity pain that has not responded adequately to aspirin or acetaminophen.

• Morphine is the standard medication used in the relief of severe pain.

O C C U PAT I O N A L T H E R A P Y M A N AG E M E N T

• Occupational therapy interventions focus on increasing physical capacities, productive and satisfying
performance of life tasks and roles, mastery of self and the environment through activities, and education
ACTIVITY TOLERANCE-GRADING

• Activity levels are increased on a gradual basis, with the client working to “tolerance” (i.e., gradual increase in
task demands such as mobility, strength, and endurance), as opposed to “pain,” before a scheduled rest period.

• The client should not initiate rest at the time of the pain onset or exacerbation because this may reinforce pain
behaviour's.

• A gradual increase in activity also lessens the likelihood of an exacerbation of pain.

• Task selection based on occupational roles, interests, and abilities is a unique contribution of occupational
therapy in pain management.
BODY MECHANICS AND POSTURE TRAINING

• Instruction in and rehearsal of proper body mechanics and postures that will not increase the risk of low back injury
or strain are essential for clients experiencing both acute and chronic LBP.

• Practice in using the body safely and to maximum performance during routine tasks in natural (i.e., home, work, or
leisure) environments is particularly important

• The client should be taught to avoid tasks or positions that do not allow balanced posture.
 The patient is taught to do the following:

PRINCIPLES OF ● Incorporate a pelvic tilt during static sitting or standing to unload the facet joints, aid in
pelvic awareness, and decrease muscular tension in the low back.
BODY ● Position the body close to and facing the task. This aids in balance by getting the objects
MECHANICS as close to the centre of gravity as possible.

● Avoid twisting. Twisting causes stress on the ligaments and small muscles of the spine.
Instead, turn the body by stepping with both legs to face the activity.

● Use the hip flexors and extensors to lower and raise the body. These are large muscles
with leverage and power to handle heavy loads.

● Avoid prolonged repetitive activity or static positions. Take microbreaks and walk briefly
or stretch every hour.

● Balance activity with rest to facilitate endurance and safety.

● Use a wide base of support. Stability while lifting is increased when the feet are at least
hip distance apart. One foot slightly in front of the other provides additional support.

● Keep the back in proper alignment, ear over shoulder, shoulder over hips, and hips over
knees and feet to maintain the natural curves of the back. Practice in front of a mirror.

● Test a load before lifting to decide whether the lift should be modified. Describe how to
modify the lift: get help, split the load into more than one lift, or put the object on wheels.

● Stay physically fit. Strong muscles and flexible joints are the best defence against injury
or recurrence of an injury.
 PRIORITIZE

PLAN

ENERGY
C O N S E RVAT I O N PACE
TECHNIQUES

POSITION

POSITIVE ATTITUDE
 JOINT PROTECTION PRINCIPLES
● Respect Pain
● Distribute load over several joints
● Reduce the force and effort required in activities
● Use correct patterns of movement
● Use good body positioning, posture and moving and handling techniques
● Use the strongest, largest joint available for the job
● Avoid staying in one position for too long
● Use ergonomic equipment, assistive devices, and labour-saving gadgets
● Pace activities: balance rest and activity, alternate heavy and light tasks, take microbreaks
● Use work simplification: plan, prioritise, and problem solve
● Modify the environment and equipment location to be ergonomically efficient
● Maintain muscle strength and range of movement
 SPLINTING

(1) prevention of contractures

(2) maintenance of ROM achieved during an exercise session or surgical release,
(3) reduction of developing contractures

(4) protection of a joint or tendon and

(5) to reduce the overall pain experience
A DA P T I V E E Q U I P M E N T

• Patients with persistent activity limitations due to defined physical impairments may benefit from
assistive devices to improve function.

• Improves ADL and Leisure

RELAXATION TRAINING
• Relaxation training is well recognized as a viable intervention for the alleviation of skeletal
muscle tension, distraction from pain, reduction of fatigue, enhancement of additional pain
relief measures, relief of anxiety, and elimination of in-somnia

• Many techniques are available for inducing relaxation. Abdominal breathing is the simplest
way to encourage relaxation. The learning sequence involves (1) awareness of breathing
pattern, (2) inhalation, and (3) slow exhalation

• Abdominal breathing is incorporated into the following relaxation techniques.

• Progressive muscle relaxation (PMR) is used to relieve excess tension that can result in
muscle spasms, pain, and fatigue. PMR involves
(1) focusing attention on a muscle group

(2) systematic tensing and relaxing of major musculoskeletal groups for several seconds

(3) passive focusing of attention on how the tensed muscle feels

(4) release of the muscles

(5) passive focusing on the sensations of relaxation
• Autogenic training (AT) involves the silent repetition of phrases about homeostasis.

• AT includes

(1) scanning the mind and body for tension

(2) passively concentrating on physical and mental states

(3) concentrating on cues for relaxation

• AT has proven effective in treating persons with tension headaches, substance abuse, and musculoskeletal
disorders, in addition to promoting wellness

• Guided imagery is the purposeful use of images to reduce stress and distract attention away from intrusive
thoughts. In this technique, the participant focuses on a relaxing environment (e.g., a peaceful garden) of his or
her choice. Meditation, massage, yoga and physical exercise may also be used as relaxation approaches.

• Visualization – Imagining a safe and relaxing environment, including sounds, smell and eel
NEUROMUSCULAR RE-
E D U C AT I O N

• Neuromuscular re-education can be useful for re-training muscles

for proprioception, motor control, or relaxation.
• Neuromuscular re-education using EMG biofeedback can teach
patients to relax overactive muscles and isolate functional muscles
• Biofeedback, which uses feedback to the patient to teach modified
neural control, can also stimulate a relaxation response and
decrease autonomic function associated with stress
• A variety of biofeedback devices can be used with chronic pain
o Electromyogram
o Galvanic skin response (GSR)
o Temperature biofeedback
 Physical agent modalities (PAM) may be used by
occupational therapists as adjuncts to or in preparation
for purposeful activities.

PHYSICAL AGENT Both heat and ice are useful in reducing pain and
M O DA L I T I E S muscle spasm of musculoskeletal and neurologic
pathologies.

Superficial heat includes hot packs, heating pads,

paraffin wax, fluidotherapy, hydrotherapy, and heat
lamps.

The application of heat increases local metabolism and

circulation. Vasoconstriction occurs initially, followed by
vasodilatation resulting in muscle relaxation.
PAM:

INDICATION CONTRA-INDICATION

• Subacute and chronic traumatic and inflammatory • Acute inflammatory conditions, cardiac
conditions such as muscle spasms, arthritis of the insufficiency, malignancies, or peripheral vascular
small joints of the hands and feet, tendonitis, and disease.
bursitis. • Pre-existing oedema
• Insensate clients
Cold Therapy
• Cold can improve pain control by elevating the pain threshold. Local
vasoconstriction occurs in direct response to cold therapy (cryotherapy).
• When the area is subsequently exposed to air, vasodilatation occurs.
• Cold applications also result in decreased local metabolism, slowing of nerve
conduction velocity, diminished muscle spasm and spasticity, decreased edema, and
lessened tissue damage.
• Cold can be applied via commercial packs, sprays, ice cups, or a massage stick.
• There are several contraindications in the use of cryotherapy.

ü Peripheral vascular disease or any circulatory compromised area

ü Cold sensitivity or Raynaud’s phenomenon

ü Multiple myeloma, leukemia, or systemic lupus

ü Cold urticaria/intolerance; can occur with rheumatic diseases, or following crush
injuries or amputations
T R A N S C U TA N E O U S E L E C T R I C A L
NERVE STIMULATION

• Transcutaneous electrical nerve stimulation (TENS) is a

non-invasive pain relief measure that uses cutaneous
stimulation.

• TENS should be used for intervention periods not to

exceed 60 minutes at a time to achieve pain control.

• TENS diary should be used to record the level of pain on

a scale of 1 to 10 before and after intervention
 RELAPSE MANAGEMENT
• Clients with chronic pain frequently experience a flareup.
• During the flareup the client is typically encouraged to reduce aerobic conditioning exercises (e.g.,
walking, stationary biking, swimming). As pain subsides, an incremental, gradual increase in activity
should be implemented.
• The client should be encouraged to increase his or her use of pain-coping and self-management
strategies throughout the flare-up
C O M P L E M E N TA RY A N D
A L T E R N AT I V E A P P ROAC H E S

• Movement therapies such as yoga, tai chi, and qigong will improve flexibility, strength, balance, proprioception
and decreasing kinesiophobia

• Mental therapies such as hypnosis and meditation

A P P ROAC H E S

• REHABILITATIVE FOR
• COGNITIVE BEHAVIORAL THERAPY
• BIOMECHANICAL FOR
• MOHO
COMMONLY ASKED MGR UNIVERSITY QUESTIONS

I. OT management for pain

II. Principles of biofeedback

III. Electromyography on muscle-reeducation

IV. Management for LBP

V. Joint protection techniques

VI. Energy conservation

VII. Any 2 indications of biofeedback

VIII. Biofeedback
BIOFEEDBACK
• Biofeedback—which means biological feedback—refers to the process of using instrumentation to feed back to the patient
immediate sensory information about what the body is doing.
• This allows the patient to make small alterations in body functions during performance in order to improve the actual
functional outcome.
• Types of biofeedback
EMG biofeedback - This type of biofeedback helps make the patient more aware of muscle activation
Electro goniometric biofeedback - It allows the patient to learn the correct movement patterns
• And is used for muscle re-education and training.
HOW DOES IT WORKS?
• In biofeedback, small electrodes are attached to the patient’s skin to detect the tiny electrical signals that are generated
when skeletal muscle contracts. When the onset of a muscle contraction is detected, the biofeedback unit will alert the patient
with, typically, an auditory or visual stimulus.
• As the muscle contraction progresses and strengthens, the auditory tone will become louder, and the visual display will
become larger.
INDICATIONS
o Urinary incontinence
o Motor dysfunction and spasticity following stroke
o Muscle dysfunction and myoclonus following spinal cord injury
o Focal hand dystonia
o Cerebral palsy
BIOFEEDBACK EQUIPMENT

• Biofeedback units have three major components to detect, measure, and report activity in the body:
o Transducer - detects the target activity in the body
o Processing unit – It contains electrical circuits that amplify, integrate, or prepare the messages from
the electrodes for an output signal
o The output mechanism - Provide visual and auditory feedback
Electromyography Biofeedback Session for Muscle Re-education

• Begin with large, widely spaced electrodes over the muscle belly.
• Initially set the threshold at an attainable level.

• During a 10- to 15-minute treatment session, the patient voluntarily contracts the muscle to reach
the threshold level.
• When possible, incorporate purposeful activities to facilitate the muscle activity desired.

• Gradually raise the threshold during the treatment session to challenge the patient to contract the
muscle more strongly.
T R E AT M E N T O F T H E PAT I E N T W I T H LOW BAC K
PA I N

• The occupational therapist facilitates the patient’s active participation in tasks and activities by teaching body
mechanics and how to perform activities safely.
• PAM such as hot packs
• Transcutaneous electrical nerve stimulation (TENS)
• Stretching exercises
• Relaxation techniques for stress reduction
• Biofeedback for muscle control
• Group educational sessions
• Therapeutic activity, including games, crafts, ADL, and work tasks
Application of principles of body mechanics in various postures are as follows:
• While standing, the patient places one foot on the shelf under the sink or on a low stool to achieve posterior pelvic tilt.

• To sit, the patient lowers the body by flexing the knees and hips without bending the spine by placing the hands on the
chair’s armrest

• A slightly reclined sitting posture is preferred for prolonged sitting.

• When lying in bed, the ideal posture to decrease pressure on the spine is supine with the knees flexed. A pillow should
be placed under the knees to maintain the flexed posture.

• Log roll to come to a seated position.

• To pick up a lightweight object - lowers both knees in a semi squat position

• To pick up a large or heavy object - the patient adds more central support by lowering one knee to the floor (half-
kneeling) so that the body is close to and facing the object.
REFERENCE

- PEDRETTI’S Occupational Therapy practice skills for physical dysfunction

- Physical Rehabilitation SUSAN B. O’SULLIVAN

- Occupational Therapy for Physical Dysfunction 7th Edition

THANK YOU