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). …