Megan Silvia and Shealyn O’Donnell

Pediatric chronic pain is surprisingly common, with 44% of school-aged youth reporting at least weekly pain in the last six months (Gobina et al., 2019). Youth pain presentations are heterogeneous, and can include persistent headaches, abdominal pain, musculoskeletal pain, or neuropathic pain, in singular or multiple sites. These conditions have long been associated with decreased engagement in nearly all daily activities, such as self-care, sleep, school, socialization, and leisure participation (Roth-Isigkeit et al., 2005). Such impairment indicates the need for comprehensive, multi-modal pain management and rehabilitation, which often benefits from the inclusion of occupational therapy (OT; Harrison et al., 2019; Rabin et al., 2017). In their position statement on pain, the American Occupational Therapy Association (AOTA, 2021) asserts that occupational therapy practitioners (OTPs) possess the interprofessional training necessary to collaborate on pain treatment teams to ensure youth who are impacted by pain can engage in their desired occupations. OTPs define “occupations” as meaningful activities in which individuals need or want to participate. OT focuses on improving participation in valued occupations to enhance overall health, wellness, and quality of life (AOTA, 2020). In this article, we describe the overarching role of OT within a multidisciplinary pain treatment team and highlight OTPs’ unique contributions to the functional restoration of youth with pain.

Frameworks Guiding Pain Treatment and OT

Together with their multidisciplinary colleagues, OTPs are well-versed in using evidence-based models to guide pain treatment. For instance, OTPs are familiar with the constructs of the Biopsychosocial (BPS) Model of Pain, the established framework of intersecting factors influencing the chronic pain experience (Liossi & Howard, 2016). This model provides the foundation for the success of multidisciplinary outpatient treatment (Odell & Logan, 2013) and intensive interdisciplinary pain treatment programs (Hechler et al., 2015). The BPS model parallels existing occupation-based models, such as the Person-Environment-Occupation-Performance (PEOP) Model. Like the BPS model, the PEOP model similarly expands on the biomedical model and considers the whole person, including personal characteristics and environmental factors influencing occupational performance (Baum et al., 2015). Both models are patient-centered and acknowledge the complex relationships between the intrinsic and extrinsic factors impacting participation in daily life. As such, OTPs utilize these models as frameworks for exploring the dynamic, interconnected factors that can precipitate, exacerbate, and maintain an individual’s pain as they pursue meaningful occupations.

OT Assessment in Pain Treatment

A crucial component of the initial OT evaluation for youth with chronic pain is the semi-structured interview, known as an Occupational Profile. Here, the OTP gathers detailed information from the patient and caregivers, establishing a complete occupational history. This allows the OTP to understand the biopsychosocial factors impacting both pain itself and engagement in valued occupations. The Occupational Profile pinpoints the patient’s current functioning, relative to their functioning prior to pain onset, by assessing how a patient is participating in their occupations and the quality of their participation. For example, when assessing participation in self-care, a patient may initially report independence with dressing and bathing. With further questioning, the OTP learns the patient avoids wearing certain shoes and showers less frequently due to pain. These nuances are critical, yet rarely captured in standardized assessments.

To complement the Occupational Profile, the OTP carefully selects objective measures to evaluate body function/structures, and subjective measures to assess activity limitations and participation restrictions. Specific patient-reported outcome measures, such as the Canadian Occupational Performance Measure (Dorich & Cornwall, 2020), the Upper Extremity Functional Index (Stratford et al., 2001), and the PROMIS Pediatric Pain Interference measure (Varni et al., 2010), can be used in conjunction with clinical observations to establish a baseline. Pairing objective and subjective measures not only provides meaningful data for tracking progress, but it also highlights clients’ self-perception, which may, in turn, impact their performance (Kempert et al., 2017). All collected information is synthesized to develop a patient-centered treatment plan focused on increasing engagement and improving the quality of participation in valued occupations (Hurtubise et al., 2020).

OT Interventions to Support Pain Management

While OT interventions for pediatric chronic pain are highly individualized, there are universal, empirically supported treatment elements that help patients to meet their goals. OT interventions for pediatric pain prioritize functional engagement, performance in daily occupations, and participation in re-established or newly established roles, routines, and responsibilities. These interventions emphasize functional restoration, an overarching, clinically effective approach to pediatric chronic pain (Friedrichsdorf et al., 2016), which de-emphasizes pain reduction as the primary outcome. Instead, the approach facilitates the reduction of disability first, followed by pain reduction over time (Hechler et al, 2014; Randall et al., 2018). The functional restoration approach seamlessly aligns with and is indeed an essential component of OT treatment. Importantly, rather than recommending lifestyle modifications to avoid pain, OTPs gradually re-introduce patients to previously avoided but valued occupations. Increasing participation in meaningful, developmentally appropriate occupations serves as both the intervention and the primary outcome. To promote successful functional restoration in youth with pain, OTPs employ specialized interventions, each rooted in evidence-based psychoeducation, sensory reeducation, functional use of the affected body part, and caregiver involvement (Tay & Rider, 2024).

Pain Neuroscience Education. Given that chronic pain treatment is often counterintuitive for patients and families, providing a solid explanation of the biopsychosocial approach, via pain neuroscience education (Moseley et al., 2015), is an essential precursor to the development of the adaptive self-regulation and coping strategies needed for functional restoration. Evidence in adults suggests that fully understanding pain decreases its threat value, thereby promoting more effective pain coping. Robins and colleagues (2016) argue this rationale is equally relevant for enhancing youth engagement in treatment for pain.

Pain Coping & Self-Regulation. Youth self-efficacy (Kalapurakkel et al., 2015) and willingness to (Logan et al., 2012) self-manage chronic pain are associated with functional improvements, psychological well-being, and resilience. To facilitate self-management of pain, OTPs teach youth to independently identify and utilize active

(vs. passive) coping skills to sustain functioning instead of terminating an activity. Such skills (e.g., distractions, relaxation techniques, and movement-based strategies), are critical in retraining the nervous system, promoting neuroplasticity, and enhancing functioning (Harrison et al., 2019). Additionally, OTPs can draw upon their wealth of self-regulation knowledge to diversify and individualize a coping “tool-box.” Given that atypical sensory processing and modulation patterns are associated with decreased function in youth with chronic pain (Sinclair et al., 2019), sensory-informed interventions (i.e., with consideration of unique sensory processing systems and presentations) can further facilitate participation in occupations and improve quality of life.

Sensory Reeducation & Graded Exposure. When pain persists, youth may develop a conditioned fear of pain/movement, resulting in avoidance of activity and established performance patterns without intervention (Simons & Kaczynski, 2012). To break this cycle, decrease fear, and improve functioning, OTPs apply principles of graded exposure and sensory re-education to gradually re-introduce avoided stimuli. This is commonly achieved via desensitization (Tay & Rider, 2023), an intervention typically used to reduce sensory sensitivities to tactile, auditory, and visual stimuli. These principles can also be applied to any facet of school, community, and leisure reintegration. When graded exposures delivered by OTPs are paired with active coping and repeated until habituation is reached, youth demonstrate increased tolerance and normalized responses to stimuli (Simons et al., 2020).

Habits & Routines. Oftentimes youth experiencing chronic pain disengage from previous routines or fail to establish developmentally appropriate routines. While abundant evidence supports normative functioning in the presence of pain as a pathway to long-term pain reduction (Lynch-Jordan et al., 2014), patients/caregivers may find this counterintuitive. To address this, OTPs incorporate pain neuroscience education and elements of psychotherapy to promote behavior change, encourage healthy habits, and re-establish daily routines. Using structured frameworks to organize and guide treatment, OTPs collaborate with patients/caregivers to implement clear functional expectations, reduce activity avoidance, and improve consistency with daily functioning (Smith & Bryant, 2020).

Activity Pacing. Many individuals with chronic pain experience difficulty with activity pacing (i.e., significant inactivity/activity avoidance, over-engagement in activity, or a combination thereof; Birkholtz, et al., 2004). Such maladaptive patterns can lead to considerable fatigue and disrupted participation in valued occupations. OTPs provide education on pacing and energy conservation techniques that support consistent, sustainable participation in daily activity. OTPs perform a thorough activity analysis, which identifies the “demands” that support or inhibit activity engagement. This knowledge is translated into helping patients determine the ideal balance of activity to sustain participation in occupations throughout the day, from one day to the next, while pain is present. Indeed, though activity pacing may not decrease pain severity, it can reduce the impact of fatigue upon daily function (Guy et al., 2019) and promote better balance (i.e., productivity vs. leisure/relaxation), all without negatively impacting overall activity participation (Andrews et al., 2018).

Conclusion

Pediatric chronic pain is prevalent, complex, and consequential, presenting risk for functional disability and decreased participation in developmentally appropriate, valued occupations. Though empirical evidence is still emerging (Caes et al., 2018; Suder et al., 2023), OTPs offer a specialized lens and unique expertise which are well-versed to treat pediatric pain, in collaboration with other providers. Through their patient-centered, comprehensive approach, OTPs can help restore occupational performance and establish new activity patterns among youth with chronic pain.

Megan Silvia, OTD, OTR

Assistant Professor, School of Occupational Therapy, Massachusetts College of Pharmacy and Health Sciences, Worcester, MA

email: megan.silvia@mcphs.edu

Shealyn O’Donnell, MS, OTR

Lead Occupational Therapist, Mayo Family Pediatric Pain Rehabilitation Center, Young Adult Pain Rehabilitation Center, Department of Physical and Occupational Therapy, Boston

Children’s Hospital, Boston, MA

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