Occupational performance and chronic pain   January 14th, 2020

‘Occupational therapy is a client-centred health profession concerned with promoting health and wellbeing through occupation’ (WFOT, 2012). It is based on the assumption that there is a relationship between occupation, health, and wellbeing and that engagement in occupations can enhance, maintain or restore health (Le Granse et al., 2017). Occupational therapists therefore try to maximize a person’s occupational performance, which is defined as ‘the ability to choose, organise, and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after oneself, enjoying life, and contributing to the social and economic fabric of a community’ (Townsend et al., 2002).

A significant life-event, such as acquiring a chronic illness, can limit a person’s ability to perform meaningful occupations and consequently alter a person’s occupational performance negatively. This blogpost gives a short overview of how patients with chronic pain experience their occupational performance and formulates important considerations for pain rehabilitation management.

Persson et al. (2013) used the Canadian Occupational Performance Measure (COPM) to identify limitations in everyday occupations most frequently experienced by patients with musculoskeletal pain currently following a rehabilitation programme (n = 152). The COPM evaluates changes in clients’ perspective towards their occupational performance (Le Granse, 2017) and categorizes all occupations in three categories: self-care, productivity, and leisure. Then a top five of the most important problems is constructed by the client and the top five activities are rated on a ‘performance’ and ‘satisfaction with performance’ scale (Persson, 2013). A total of 706 different problems were reported of which working (43,6%), sitting (41,6%), cleaning the house (39,6%), cooking (38,5%), and sleeping (31,4%) were most frequently reported. When asked to prioritize their occupational problems, the majority of the problems belonged to the self-care category, more specifically the personal care and functional mobility subcategory, with sleeping as most frequently reported specific problem.

In addition, statistically significant differences were present between sexes, with women having more everyday occupational problems (79%) and experiencing most limitations in the household management (productivity), functional mobility, and personal care (self-care) subcategories. Men reported most limitations in the functional mobility and personal care (self-care) subcategories (Persson et al., 2013).

This research reflects the diversity of occupational problems experienced by patients with musculoskeletal pain and gender-specific needs. Pain rehabilitation programmes should therefore assess each patient’s individual occupational problems and prioritize them to construct an optimal rehabilitation programme.

Besides the variety of occupational problems reported by patients with chronic pain, patients also described different strategies to attain occupational performance and cope with experienced pain.

Aegler et al. (2009) investigated how patients with chronic pain experience their occupational performance when having pain and found three themes. The first main theme was ‘Performing is an ongoing attraction’, where patients reported to have adopted different strategies to keep active, for example by changing the sequence, giving up the occupation or adapting it. They reported being able to plan and perform joyful occupations, but also that these occupations did not mediate their pain. To satisfactorily perform their joyful occupations, patients had the tendency to only perform them when they were not feeling much pain. The second theme was ‘Getting used to taking breaks is not easy’. Patients described that taking breaks became a behaviour pattern and dealing with the need for breaks was a major challenge. Focussing on the body (signs of pain), following a self-organized time schedule or following sub-goals were defined as three different ways to organize a break. When patients focussed on signs from the body they reported being more occupied with signs of pain so that their concentration for the actual occupation lowered. This caused difficulties in achieving the desired quality of performance. Following a time-schedule was helpful to plan breaks, but some patients found it frustrating as they could not always comply with it. The last strategy, following sub-goals, felt for patients as a lack of achievement or taking very small steps during a large amount of time. In conclusion, each strategy restricted their daily performance, but patients reported getting used to it and that they were happy to be doing something. On the other hand, frustration with these interruptions was also present from time to time. The third theme was ‘The challenge to finish performing’. Patients reported being motivated when starting an occupation, but were not always able to finish it. In other situations, they finished the occupation, not allowing themselves to take a break knowing that they would experience pain afterwards. Different reasons were formulated for this: pressure from social environment, reminder of good old times or not wanting constant interruptions (Aegler et al., 2009). Because patients adopt different strategies for achieving occupational performance and coping with pain, rehabilitation programmes should investigate the effectiveness of their used strategy and alter it when necessary to maximize their occupational performance.

Keponen and Kielhofner (2006) investigated how women with chronic pain experience and interpret their occupational performance and participation through an occupational narrative. They identified four different types of narratives and categorized them in the following four metaphors: moving forward, slowing down, fighting, and standing still. Each narrative had its own tone, meaning ascribed to doing, view of others in relation to one’s doing, and view of the future. The ‘moving forward’ narrative was characterized by a hopeful tone with occupations being seen as a source of enjoyment and a challenge. These patients help others understand and support their condition and have a positive view for participating in occupations in the future. The tone of the ‘slowing down’ narrative was more ambivalent and frustrated with a need for slowing down and enjoying small accomplishments when performing occupations. Their view of others in relation to their doing was that their slowing down affected others negatively. These patients want to perform occupations, but they report uncertainty regarding their future and focus on the here and now instead. The ‘fighting’ narrative had a fearful tone, with their doing focused on meeting obligations rather than enjoyment driven by the fear of what would happen if they could not continue performing their obligations. They want no help from others and try to hide their pain. They have difficulties imagining the future and expect solutions to come from elsewhere. Last, the ‘standing still’ narrative had a hopeless and unsatisfied tone. They could not perform occupations according to satisfaction until certain conditions were met, for example a better health. They could not perform occupations without help from others and found it impossible to plan for the future and to imagine having a meaningful occupational life.

The differences between narratives were subtle, but important for how these patients experienced and organized their occupations and lives (Keponen & Kielhofner, 2006). An important note made by the authors was that the narrative of these women was the only way for them to interpret and handle their situation and that they were not aware of different solutions to living with chronic pain (Keponen & Kielhofner, 2006). The differences between the narratives also highlight the heterogeneity of the experiences and interpretation of patients’ occupational performance and their coping strategies.

In conclusion, chronic pain causes various occupational problems and makes it difficult for patients to maintain their occupational performance. Different coping strategies to attain occupational performance are adopted, each with its own characteristics. Not all coping strategies are equally effective and should therefore be investigated during pain rehabilitation programmes and altered when necessary. Because occupational performance is individually determined, pain rehabilitation programmes should also assess each person’s individual occupational problems, prioritize them together with the patient and address them adequately for patients to achieve maximal occupational performance despite their experienced pain.

Kuni Vergauwen

Kuni Vergauwen is an occupational therapist, lecturer at AP College University and PhD researcher at University of Antwerp and Maastricht University with a focus on chronic fatigue syndrome and multiple osteochondromas.

2020Pain in Motion

References and further reading:

WFOT (2019). About Occupational Therapy. Retrieved December 30 2019, from https://www.wfot.org/about-occupational-therapy.

Le Granse M, van Hartingsveldt M, Kinébanian A. (2017). Grondslagen van de ergotherapie (5th ed.). Houten, Nederland: Bohn Stafleu van Loghum.

Townsend E, Stanton S, Law M, Polatajko HJ. Enabling occupation: An occupational therapy perspective. Revised ed. Ottawa: CAOT Publications ACE; 2002.

Persson E, Lexell J, Rivano-Fischer, Eklund M. Everyday occupational problems perceived by participants in a pain

rehabilitation programme. Scand J Occup Ther 2013;20:306-314.

Aegler B, Satink T. Performing occupations under pain: the experience of persons with chronic pain. Scand J Occup Ther 2009;16:49-56.

Keponen R, Kielhofner G. Occupation and meaning in the lives of women with chronic pain. Scand J Occup Ther 2006;13(4):211-220. DOI:10.1080/11038120600672975.