Introduction
Many people suffer from chronic pain. In these patients, the most common ‘ wish’ is to be pain free. One of the most important features of chronic pain is its influence on the quality of life. When pain is chronic and poorly controlled, it creates anxiety, and affects the personal and professional life (Menzel, 2006). This is reflected in the case of Susan, who suffers from lower back pain and has been referred to a pain management programme. This essay involves the health problems of Susan, a 47-year-old catering manager. It is proposed that she seek an occupational therapist (OT) that will use treatment modes to help her develop, recover and maintain day-to-day living (Kielhofner, 2004). It is always possible for Susan to take up further pain management strategies to control and manage her pain. Pain management programmes aim to return people affected by chronic pain to a life that is as normal as possible (Ducharme, 2000). In order, to provide comprehensive treatment, OT can use a bio-psychosocial approach to care for Susan (Ducharme, 2000). Susan has recently separated from her husband on a trial basis and is experiencing distress over her husband moving back to her house to look after her daughter. She rarely goes out due to her lower back pain, which is incessant, despite prolonged medication that interferes with her sleep and rest. Therefore, by validating pain and taking a bio-psychosocial approach, and considering psychological as well as social factors to care and strategies, OT can eliminate the contributing factors (Strong, 1996). The Gate Control Theory can explain pain in physical and psychological terms, as proposed by Melzack and Wall (1965). The theory states that the information is transmitted from sensory receptors to ‘ gates’ in the spine and information is then transmitted to the brain (Menzel, 2006). Concurrently, connected emotions such as depression are felt, which stimulate nerve fibres to transfer information from the brain. Physical and psychological information open the gates where the pain signals can enter the spinal column (McCormack, 2007). This does not make the pain any less real, and it does not imply that it is ‘ all in the patient’s head’. It commonly dictates that the physiological and psychological causes of chronic pain are complicated to treat (Adam, 2006). Conversely, relaxation and pacing can close the gate by reducing the feeling of pain and by constraining the nerve impulses (Adam, 2006). For that reason, this essay will focus on outlining the potential contribution OT could utilise for pain management. The goal of this possible intervention with Susan is to increase functional independence, increase self-esteem and enhance psychosocial functioning. The treatment includes setting goals, pacing and yoga.
Setting Goals and Pacing
As Susan’s husband now moves back into the house, so the author assumes that Susan may not engage in activity such as housework and taking care of her daughter; she also has decreasing activity tolerance due to her chronic pain. Thus, the author believes that by setting goals and pacing, OT can suggest specific goals that can reflect specific activities that Susan can engage in; OT needs to focus on client-centred outcomes (Park, 2011). OT must work closely and collaboratively to help Susan realise her measurable, achievable goals and prevent her from losing commitment in the face of her affliction (Strong, 1996). It is important that Susan sets goals that are meaningful to her as this motivates her to continue with long-term goals (Nicholas, 2005). To set goals, OT may use the Canadian Occupation Performances Model (COPM), which is applicable for use with chronic pain management (Rochman, 2007). Carpenter (2001) states that COPM enhances the therapeutic relationship between patient and therapist, providing the opportunity to share problems and fears, allowing resolutions to be found. Using COPM standardised assessment helps Susan to understand the importance of activity. The OT can also recommend for Susan to use a stepladder as a visual reminder (Millar, 2003). The author utilised the stepladder to set goals with patients who attended an anxiety management programme during a placement. The stepladder received positive feedback from the patients. People with decreased volition, like Susan, benefit from focusing on incremental steps; it can be very helpful to use a worksheet that has a goal placed at the top and a ladder that lists the steps to the goal (Millar, 2003). OT needs to advise Susan to keep working through the steps on her list as often as possible. Alongside goal-setting, activity pacing is also considered a potential intervention, an essential component of occupational therapy in pain management (Birkholtz, 2004). Pacing is useful in helping Susan to carry out tasks and take part in the activities to fulfil her goal. Birkholtz (2004) states that pacing teaches patients to break tasks into smaller, manageable sets of activity. Pacing also involves introducing tasks by grading them, in order for the patient to build up skills, tolerance and confidence for doing the activity, so that the activity level may be increased. Harding (1995) indicates that gradual increases in activity are to be expected. Huet (2013) suggests that short rests should be taken often, rather than fewer long rests. Nielson (2013) stresses the importance of explaining to patients that they should learn to pace themselves by ‘ not overdoing but gradually increasing the tolerance’ so pain reduction can be accomplished. However, the patient still learns to make satisfying progress toward goals in the areas of work, play and social relations. There are three P’s to pacing, these being: prioritise, plan and practice (Birkholtz, 2004). Prioritising is important as it is impossible to pace everything at once; Susan may have some activities that have to be done in a certain time. As with setting goals, OT needs to clarify with Susan about activity that is realistic and achievable. Pacing exercise has to come in manageable amounts (Nicholas, 2005). As Susan rarely goes out, the author will use this as an example, because walking is particularly helpful for pacing, starting with short distances and building up (Nicholas, 2005). OT looks at Susan’s mobility as she walks to a local shop from her house; OT can then assist her mobility by providing a linden stick seat, which has a sturdy seat when she needs to rest. Planning is also important, as conducting activity in a paced manner can take longer, needs to be done in a different way, or may require assistance (Birkholtz, 2004). If the local shop is a 10 minute walk from her home, but her pain level usually increases before she gets there, then she needs to work out what her current baseline is. Therefore, instead of pushing through to the full 10 minutes, the OT can teach her to time herself and stop at 5 minutes intervals, taking a short rest using the linden stick seat (Birkholtz, 2004). She can then continue the walk to the shop, do her shopping and perhaps have another short rest, and repeat the steps for her walk home. By using this method, she is stopping the pain from accumulating too much, so that it can calm down during the rest before she walks again. During that time OT can monitor Susan’s progress, provide her with regular feedback and work with her to review and develop the pain management as she progresses (Donaghy, 2008). We recommend this daily for a week; practice can turn into action, as it can be fascinating to do more than the 10 minutes. At this point the OT can advise Susan to gradually increase the time that she spends walking between stops to six minutes, then seven minutes the following week (Birkholtz, 2004). By using this method, Susan can achieve her goals and be active.
Yoga
Yoga is the other intervention that the author may recommend to Susan. By using a yoga DVD, it will be easy for Susan to do yoga at home. Light yoga involves relaxation, breathing and gentle physical exercise (Gupta, 2005). Yoga can be good for Susan’s back pain, helping to strengthen and stretch her back muscles. Since Susan stands and sits for prolonged periods when she works as a catering manager. She may use her back weight which uses more muscle groups. Therefore, by suggesting yoga to Susan, it may help her achieve better posture and alignment that will stay with her for the entire day. Furthermore, during physical exercise like yoga, our bodies release endorphines which interact with inceptors in our brain that reduce our perception of pain (Kevin, 1988). OT can encourage Susan to practice yoga every day for at least five minutes, to practise pacing; this can help her to break the classic over-activity and under-activity pattern which she uses to avoid most activities (Donaghy, 2008). Kabat-Zinn (1982) indicates that yoga maybe an effective intervention for patients with chronic pain. Therefore, by engaging Susan in this purposeful activity, physiological mechanisms associated with pain reduction can be stimulated (Huet, 2013). Tull (2011) conducted research in which six women were asked to practice yoga. The women’s experiences were then analysed using observation and in-depth interview. The participants stated that the pain became troublesome, but they were able to control the pain when it interfered with daily life; this notion is also agreed by Sherman (2005) who states that yoga appears to be more effective in improving function and pain in patients with chronic pain. Being anxious and depressed can caused increased muscle tension and an inefficient breathing pattern (Adam, 2006). This breathing pattern can heighted muscle tension as the sympathetic nervous system becomes more engaged (Sabel, 2007). With increased muscle tension, the patient may experience more pain and limited movement, which in turn increases levels of anxiety, thereby inhibiting the ability to focus on learning new skills (Tull, 2011 and Sherman, 2005). In this case, yoga breathing and relaxation are the aspects of yoga practice to distract the mind, reducing pain in the body and providing an opportunity to go through the pain instead of resisting it, thereby causing the pain to lose its full impact (Tull, 2011). Martin (2002) stated that yoga is mainly used as a relaxation therapy, which can eliminate tension through the body and create a peaceful state of mind. Yoga music can be therapeutic, relaxing and even hypnotic, helping to drive the person to finish the full set of yoga stretches. The music enhances complexity to the level of relaxation that is achieved while doing yoga (Peter, 2009). Menzel (2006) suggested that relaxation for patients with back pain helped in reducing the sensory and affective components of the back pain experience. Background music can be used to promote muscle relaxation (McCormark, 1988). OT can provide Susan with a relaxation tape and she can use the yoga music when she wants to go to bed. By relaxing her mind and listening to relaxation music, she may be distracted and possibly have more comfortable sleep (Collingwood, 2011). Yoga can also promote good posture and thus more effective breathing, which reduces tension throughout the body (Sabel, 2007). After tension is reduced, the patient can be taught to breathe diaphragmatically (Lecky, 1999). An improved breathing pattern can have immediate effects on pain, and can contribute to improving stamina and occupational performance (McCracken, 2007). As we focus our breathing, we concentrate on the breathing, taking our mind away from the pain (Stuckey, 2003). Therefore, Susan can apply and practice this breathing exercise technique whilst doing almost any housework. Lastly, what the OT suggests to Susan is that improving her social and interpersonal skills can increase the number of relationships that she has, as well as helping to make them deeper and more meaningful (Hagedorn, 2002). By working together with her and involving her daughter in the yoga sessions Susan can have support in order to maximise her skills and increase her volition. It may also be more fun, and she may not feel isolated (Creek, 2002). Social pain and physical pain are detected by the same pain receptors in the brain (McCracken, 2007), which may explain why she has been depressed and her physical pain has been worse (Adam, 2006). However, if her daughter works closely with Susan, she may be able to reduce her pain. Initially, OT suggests that Susan walks with a linden stick seat every time she walks outside of the house. Her husband can assist with certain elements of the task to ensure that she motivates herself to go out. It is always helpful to empower the individual with positive statements, and to reinforce her self-esteem with praise and support (Hagedorn, 2002).
Conclusion
To summarise, by analysing the variety of aspects that affect a person’s pain experience, it is easy to understand why it can prove difficult to manage. Susan has been suffering the physical pain of her illness while being emotionally depressed. Therefore, her care encompasses different issues when trying to achieve pain management. Activity helps reduce pain because the patient, when involved, is no longer concentrating on the pain. Therefore, setting goals, pacing and yoga are recommended. As Susan experiences a reduction in her perception of pain, her psychological state improves and her confidence increases. The activity that the author recommends enables Susan to learn new methods of controlling her pain symptoms. Thus she becomes more skilful at modulating her pain.
