Occupational therapy and pain management. (Pain).

She will always remain vividly etched in my memory as an enthusiastic, active eight-year-old girl who desperately wanted to participate in all the home, school and recreational activities of her family and peers. However, the pain and swelling of juvenile rheumatoid arthritis (JRA) cruelly prevented that participation. Facial grimaces, posture realignment and guarded movements evidenced her suffering as she valiantly attempted the activities presented in evaluation sessions. The top priority of this child's occupational therapy program needed to be effective pain management with an outlook toward active participation in daily activities.

Pain management is an integral part of occupational therapy intervention. Although not all conditions seen by therapists present a pain component, those that do require knowledgeable attention. Pediatric evaluation and treatment methods assess the location and intensity of pain, ease discomfort by reducing pain and guide participation in meaningful, purposeful activities. An occupational therapist's primary interest lies in selecting and grading activities that develop skills and tolerance, the necessary aptitudes for occupational performance in daily routines. For children, these routines may include self-care, household chores, transportation, school activities, recreation and participating in family and social relationships.

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage." The Classification of Chronic Pain, edited by H. Merskey and N. Bogduk, continues the definition by stating, "pain is a multidimensional experience--physical, psychological and social, always subjective and always an unpleasant emotional experience."

Authorities on pain agree that the distinction between chronic and acute pain must be determined and accurately assessed before effective treatment begins. Most often, those children referred for occupational therapy experience chronic pain rather than acute pain.

Combined authoritative sources describe chronic pain as pain experienced for long periods of time, often endured by those children with disease processes and injuries and known to affect personality, routine and performance in daily activities. Conditions such as juvenile rheumatoid arthritis, scoliosis, musculoskeletal disorders, cerebral palsy, burns, hand injuries, migraines and cancer can be responsible for this persistent pain which hampers full participation in daily child centered activities.

Referral and Evaluation

When chronic pain, such as that experienced in JRA, affects a child's mood or interferes with activity, referral to OT is warranted. Typically, a child is referred for evaluation and treatment of a condition that may also include pain; however a child may be referred for the symptom of pain alone.

After the referral is made and initial information about the child is gathered, the evaluation phase begins. Therapy practitioners first assess the factors contributing to reported pain. Psychological and environmental factors as well as age and development are pivotal in determining the impact pain is having on the child's occupational performance. Culture, family and religious values and attitudes toward pain are considered as well. Complete and accurate assessment lays the foundation for a treatment plan that promotes health and prevents further hindrance.

Standardized tools for assessing pain have been developed specifically for children. These evaluations include one or more methods used to identify the location, intensity, frequency and environmental factors that spark behaviors associated with pain. Joyce Engel, PhD, OT, a leading researcher in occupational therapy's role in pain management, lists these "overt" or "observable behaviors" as "guarded movement, bracing, posturing, limping, rubbing and facial grimacing, all of which suggest discomfort" (Willard and Spackman's Occupational Therapy, 10th edition). Movement responses, appearance, vocalizations and the quality of activity engagement are also assessed. Taken as a whole, these evaluative methods gather vital information from both the verbal and non-verbal child in need of pain relief.

Specific pain scales are selected based on age and developmental level of the child. Infants, for instance may be evaluated using the Riley Infant Pain Scale Assessment Tool. The FLACC Scale (Face, Legs, Activity, Cry and Consolability) is a behavioral scale for scoring post-op pain in young children, while the Faces Pain Rating Scale may be used for children as young as three years. This scale consists of six cartoon faces ranging from a smiling face for no pain to a tearful face for the worst pain. Results from these assessment tools are analyzed before, during and after intervention. The valuable information gathered adds to the pain management team's integrative and collaborative plan.

Complete pain evaluations do not focus solely on "observable" behaviors. Information is also gathered from the child's own verbal description of their pain. Since pain is so subjective, self reporting has proven to be a powerful source of information. Dr. Engel describes this assessment as "covert." She maintains that interviews with the child gather pain information such as identification, onset, location, intensity, frequency, duration, exacerbility and relieving factors. Hester's Poker Chip Tool and the 0-10 Numeric Pain Intensity scale are often used in assessing these self-reports.

Since occupational performance is the primary goal of occupational therapy, the therapist takes evaluation one step further. Observation of activity performance in therapy settings (clinic, home or school) completes the information necessary to develop the occupational therapy treatment plan and contribute to the team's overall intervention.

On a scale of 0-10, the Brief Pain inventory measures the extent to which pain interferes with an older child's or adolescent's general activity range. Results engage the older child in the goal setting process, perhaps motivating them to work diligently toward those goals.

Intervention

Pediatric occupational therapists are vital members of the interdisciplinary pain management team. Other members usually include physicians, nurses, psychologists, physical and occupational therapy practitioners and sometimes speech pathologists. All are dedicated to relieving pain in the child. Each clinician contributes an expertise that is interlaced with others' to develop a strong web of intervention for pain relief and activity engagement.

To reflect that relief and engagement, occupational therapy goals are established. They focus on improving skills and tolerance necessary for involvement in meaningful activities. Naturally, age and developmental levels are of primary importance in activity selection. Therapeutic activities are carefully selected, prioritized and graded to provide success at each attempt. Each success builds upon another until the child is ready to apply these skills and tolerance levels to their normal routine.

Therapeutic modalities such as TENS (skin stimulation pain relief), heat, cold, therapeutic massage, splinting and adaptive equipment are used in conjunction with proper use of body mechanics, joint protection, task simplification and energy conservation. Therapists may also employ the combined approach of modalities and relaxation training, distraction and social support. Most treatment plans include a combination of these strategies.

Family participation, education and counseling powerfully support the therapeutic process and provide treatment at home and in the community. Britain's National Occupational Therapy Pain Association recommends education on pain reduction to include goal setting, monitoring activity levels, grading tolerance levels and activity pacing. Occupational therapy practitioners work in full cooperation with the pain management team in providing these services as reinforcement to both the child and the family.

OT intervention for the little girl with JRA included the use of heat, massage and gentle range of motion as preliminary modalities to reduce discomfort. Distraction from pain is accomplished through activities such as reading, puzzles, story telling or board games. Resting splints or adaptive devices may be introduced to diminish stress to her joints and to stabilize her wrist and hand. Once swelling, heat and pain are reduced through these preliminary modalities, activities are selected to increase range of motion and muscle strength. Adaptive equipment for play may be introduced to promote active participation while also reducing the stress on swollen, painful joints. These adapted activities and equipment are then introduced to home, school and community environments.

Occupational therapy extends the web of interdisciplinary therapeutic pain management by enabling children to participate in their daily activities. Expressions of pride and joy replace grimaces of pain as children once again engage in meaningful activity in their homes, at school and during play.

Resources

American Pain Society 4700W. Lake Ave., Glenview, IL 60025 Website: http://[e-mail]

Childbrain Resources: National Foundation for Treatment of Pain American Chronic Pain Association, Inc. Website: http://www.childbrain.com/resources.shtm

Child Neurology and Development Center 6 Tuxedo Ave., New Hyde Park, NY 11040 Website: http://www.healthcommunities.com

International Association for the Study of Pain Website: http://www.halcyon.com

National Occupational Therapy Pain Association Supported by British Association of Occupational Therapists. Website: http://www.notpa.org.uk/home.shtml

Parent Resources Website: http://www.lex2.k12.sc.us?cong/2002/parent.htm

Pediatric Pain Links, Science Helping Children IWK Health Care G.A. Finley and P.J. McGrath Website: http://www.dal.ca/~pedpain/links.html

World Health Organization Resources About Cancer Pain Relief in Children. Website: http://www.whocancerpain.wisc.edu/ eng/12_1/resources.html "Cancer Pain Release," Editor Sophie Colleau, PhD Website: http://www.whocancerpain.wisc.edu/index.html

Engel, Joyce M., PhD, OTR/L, (Dec/Jan 1996) Pediatric pain management, REHAB Management, Vol. 9, 43-46.

Engel, Joyce M., PhD, OTR/L, (2003) Pain management, Willard and Spackman's occupational therapy. (10th ed., pp. 634-637) Philadelphia, Lippincott, Williams and Wilkins.

Doctors' Guide Global Edition. [c] Doctors' Guide Publishing Limited 1995 Available through: http://www.pslgroup.com/dg/1ff02.htm

Mersky, H., & Bogduk, N. (Eds.). (2nd ed.). (1994). The classification of chronic pain. IASP Press[R] Available through: http://www.iasp_pain.org or http://www.painbooks.org

Reducing Pain from Surgery What Every Parent Should Know. Yale-New Haven Hospital [c] 1999-2003 Available through: http://www.ynhh.org/choice/reducingpain.html

Carolyn O. Cantu, MS, OTR, is a licensed pediatric occupational therapist and educator who has practiced and taught all over the world for 32 years. Most recently, she was a pediatric therapist and clinical educator for the Infant Parent Program, Austin, TX. She has now returned to Austin Community College this Spring as curriculum writer and instructor.