CHRONIC PAIN:
The Power of Lifestyle Redesign® Informed
programs to turn the tide
Michal Atkins, MA, OTR/L
April 19, 2018
Objectives:
1. Define chronic pain and pain typologies
2. Describe the impact of pain on people’s lives
3. Identify the key elements of providing an OT Lifestyle
Redesign® Informed program for individuals with
chronic pain.
4. List Pain assessments most relevant to Lifestyle
Redesign® Informed programs
5. Value the important contribution of OT Lifestyle
Redesign® Informed program for the person with
chronic pain.
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Stroke pain
• Central post-stroke pain • Other post stroke pain:
(SPSP)- Neuropathic • Shoulder pain
pain syndrome
30-40%
Characterized by:
Motor and sensory
• Pain deficits
• Sensory abnormalities • Painful spasticity.
• Tension-type headache.
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Impact on Occupational
Performance
• Performance components
• Sensorymotor
• Cognition
• Psychological
• Social
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Impact on Occupational
Performance
Performance areas:
• ADL
•Work
•Leisure
•Rest and sleep
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SCI pain
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Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain
. Pain. 2011;152(3 Suppl):S2-15. doi:10.1016/j.pain.2010.09.030.
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Pain amplification
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Definitions:
• Allodynia- Pain evoked by stimuli that is usually not
painful (touch or brush).
• Hyperalgesia-An increased response to a stimulus
that is normally painful.
• Paraesthesia-An abnormal but non-painful (and
not unpleasant) sensation, either spontaneous or
evoked.
• Dysaesthesia- An abnormal unpleasant sensation,
either spontaneous or evoked.
(Klit, H.,Pinnerup, NB, Jensen, TS, 2009).
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MultiModal Pain
Management
Over the Counter
-acetaminophen, NSAIDs, topicals
Antidepressants
-Tricyclic (TCAs)-amitriptyline, nortriptyline, desipramine
-Serotonin and Norepinephrine reuptake inhibitors (SNRIs)-
duloxetine, venlafaxine
Anticonvulsants
-carbamazepine-trigeminal neuralgia
-gabapentin-postherpetic neuralgia, neuropathic pain
-pregabalin-postherpetic neuralgia, neuropathic pain d/t
diabetes and spinal cord injury
Non-pharmacological
-weight loss, massage,
acupuncture, TENS,CBT,
Lifestyle design® Manworren R., Multimodal Pain Management and the
Future of a Personalized Medicine Approach to Pain, http://www.aorn.org/CE, March 2015.
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Pharmacology Cont’d
Opioids (i.e., morphine, Tramdol, Codeine,
Hydrocodone).
Know as much as you can
Facilitate correct and optimal adherence through:
• Double check with the client, go to clinic
with them, help them come up with the
right questions
• Incorporate into daily habits
• Help find solutions for correct dispensing and
administering of meds.
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100
25.8
16.3
11.9
7
http://www.painmed.org/patientcenter/facts_on_pain.aspx#incidence
The American Academy of Pain Medicine
Incidence
(AAPM, 2013)
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Common Comorbidities:
• Overweight or obesity
• Diabetes
• Psychiatric conditions: Depression
and anxiety
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Lifestyle Redesign ®
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• Diverting occupations
• Exercise and physical activity
• Meditation
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Hypotheses:
• 1. Pain intensity will be significantly lower while
people with chronic pain are in flow compared to
other states.
• Flow is an optimal experience for people with chronic
pain.
• Frequency of flow experiences will differ across the
contexts of “at home” and “somewhere other than
home”.
• Frequency of flow experienced will differ across “self
care”, “work”, and “leisure”.
Robinson, K., Kennedy, N., & Harman, D. (summer, 2012). The flow experiences of people with chronic pain. The
occupational Therapy Journal of Research. 104-112.
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Findings:
• 1. Pain intensity was not significantly lower while
people with chronic pain were in flow compared to
other states.
• Yes. Flow is an optimal experience for people with
chronic pain.
• Frequency of flow experiences were greater at
“somewhere other than home” and not at “home”.
• Flow was most experienced during “work”, and not
during “self care” or “leisure”.
Robinson, K., Kennedy, N., & Harman, D. (summer, 2012). The flow experiences of people with chronic pain. The
occupational Therapy Journal of Research. 104-112.
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Assessments
• Medical Hx.
• Physical exam. varies
by Dx.
• Numeric Pain Scale
• COPM
• Typical day
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Assessments Cont’d
• Observation
• Function
• Pain inventory
• What makes it better
• What makes it worse
• Self-management skills
• Self efficacy
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“I don’t”
“I do nothing”
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Goal setting:
• Allows us to
understand the
person and “meet”
where he/she is.
• Keeps us grounded
• Key to success
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M.
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Care Processes
Support Self-Esteem
System Rapport Context &
Environment
Peer Agenda
Check-In Setting
Mentoring Occupational
Occupational Self-Analysis
Group Engagement:
Goals Activity
Dynamics Habits, Roles
& Routines Occupational
Problem Profile &
Motivational Education Experience
solving
Interviewing
Self-
Patient
Advocacy
Activation
Legend
Sequence of a Care Session
Leland, N. & Gillies, H., 2015
Core Therapeutic Processes
Care Processes
Support Self-Esteem
System Rapport Context &
Environment
Peer Agenda
Check-In Setting
Mentoring Occupational
Occupational Self-Analysis
Group Engagement:
Goals Activity
Dynamics Habits, Roles
& Routines Occupational
Problem Profile &
Motivational Education Experience
solving
Interviewing
Self-
Patient
Advocacy
Activation
Legend
Sequence of a Care Session
Leland, N. & Gillies, H., 2015
Core Therapeutic Processes
Motivation
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Sleep Hygiene:
• Maintain a regular sleep routine
• Avoid naps if possible
• Don’t stay in bed awake for more than 5-10
minutes
• Don’t watch TV or read in bed
• Watch your caffeine intake. Remember that soda
and tea contain caffeine.
• Exercise regularly
• Have a quiet comfortable bed
• Develop sleep ritual
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Resting/Sleeping
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Activity Cycle:
Over-activity
Underactivity
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Important points to
remember:
Ground goals in OT and in Occupations!
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The challenge:
Decrease Occupations
“can do
attitude”
Hopelessness MOTIVATION
Venting Increase
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Mr. A.
• Med history: 25 y/o Latino male with a Dx. Of
Peripheral Sensory Neuropathy and LBP
Ambulatory
• OT referral for Lifestyle Redesign for Chronic Pain
• Occupational Hx.:
• Began college but stopped 2nd to pain
• Lives with grandparents, father and a younger brother
• Works part time in a PT clinic
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Mr. D.
• Med history: 53 y/o AA male SCI (T5 AIS B) 2nd to
GSW when he was 14. R shoulder rotator cuff Sx.
2007; Pressure ulcer flap Sx. 2014; Carpal tunnel
Sx. 2016
• OT referral for Lifestyle Redesign for Chronic Pain
• Occupational Hx.:
Pt. lives alone
His girlfriend is also his caregiver
He has not worked but has gone to school and “likes
to hang out”.
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Challenges and
opportunities:
• Marketing the
program
• Explaining what we
do
• Role in Primary
Care
• Individual vs. Group
therapy
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Our education,
skills, ability to
solve problems,
goal oriented hands
on activity based
approach, enables
us to empower
individuals with
chronic pain to
greatly improve
their health and
quality of life.
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E
• Dr. Heather Tick-Nutrition tips for chronic pain
http://heathertickmd.com/
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References:
Birkholtz, M., Aylwin, L., Harman, R. M. (2004). Activity Pacing in Chronic Pain Management: One aim, but which
method? Part One: Introduction and literature review. The British Journal of Occupational Therapy, 67 (10),
447-452.
Birkholtz, M., Aylwin, L., Harman, R. M. (2004). Activity Pacing in Chronic Pain Management: One aim, but which
method? Part two: National activity pacing survey. The British Journal of Occupational Therapy, 67 (11), 481-
487.
Clark, F. A., Blanchard, J., Sleight, A., Cogan, A., Florindez, L., Gleason, S.,…Vigen, C. (2015). Lifestyle Redesign®:
The intervention tested in the USC Well Elderly Studies, Second Edition. Bethesda, MD: AOTA Press.
Clark, F., Sanders, K., Carlson, M., Blanche, E. & Jackson, J. (2007). Synthesis of habit theory. Occupational
Therapy Journal of Research: Occupation, Participation and Health. 27, Supplement 1-17.
Fisher, G. S., Emerson, L, Firpo, C., Ptak, J., Wonn, J. & Bartolacci, G. (2007). Chronic pain and occupation: An
exploration of the lived experience. AJOT, 61, 290-302.
Heck Edwards, C. (2000). Chronic Pain. In Hanson, R. & Atchison, B. (Eds). Conditions in Occupational Therapy:
Effect on Occupational Performance. (2nd edition). Philadelphia: PA. Lippincott, Williams and Wilkins.
Jackson, J., Carlson, M., Mandel, D., Zemke, R. & Clark, F. (1998). Occupation in lifestyle redesign: The well elderly
study occupational therapy program. American Journal of Occupational Therapy, 52, 326-336.
Klit, H. Finnerup, N. B. & Jenson, T. S. (2009). Central post-stroke pain: Clinical characteristics, pathophysiology
and management. Lancet Neurology 8, 857-68. www.thelancet.com/neurology
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References
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Mandel, D., Jackson, J., Zemke, R., Nelson, L. & Clark, F. (1999). Lifestyle Redesign: Implementing the well elderly
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