Patients’ experiences of occupational therapy within a multidisciplinary pain management programme: A qualitative study

Abstract

Background

Occupational problems are common for adults experiencing chronic pain, but occupational therapists are not always accessed as part of the multidisciplinary team. Despite evidence of benefit for work-focused interventions, there is limited evidence for broader benefit from occupational therapy interventions within the context of multidisciplinary pain management. The aim of this study was to explore the experiences of programme attendees who received structured intervention from an occupational therapist as part of a multidisciplinary pain management programme, and gain an understanding as to how they felt it influenced changes they made to occupational participation.

Method

A qualitative approach was undertaken with 9 individual patients recruited from a group pain management programme for adults with chronic low back pain. Semi-structured interviews were carried out, recorded and transcribed. Thematic analysis was used to identify themes in the data.

Results

Three key themes were identified: 1) the helpfulness of activity pacing techniques 2) the value of participating in a therapeutic activity-based session and 3) an increased understanding of the importance of leisure and creative activities in the context of their lives.

Conclusion

Participants perceived the specific occupational therapy content of the programme to be helpful in a number of different ways. The findings suggest that occupational therapy can be important in facilitating patients to apply theoretical techniques in the real world, thereby increasing the likelihood of long term benefit.

Introduction

National Institute for Health and Care Excellence (NICE) guidelines (2016) ¹ recommend combined physical and psychological programmes for people experiencing chronic low back pain, using a cognitive behavioural therapy (CBT)-based approach; these are usually provided by a multidisciplinary team in a group setting. The mix of professions within the multidisciplinary team can vary, with physiotherapists, psychologists and medical practitioners most often making up the team (British Pain Society 2020), ² and occupational therapists not always being included (Ravenek et al., 2010). ³ This may be due to a lack of understanding of the role of occupational therapy with this patient group, combined with a lack of evidence for individual components of CBT-based pain management programmes (Williams, Eccleston and Morley 2012). ⁴ Occupational therapy is a discipline which has occupation as the focus for intervention, taking into account what is important to the individual. Occupational therapy addresses activities such as self-care, productivity, leisure and social activities and considers all areas of a persons’ needs, whether those are physical, psychological, social or environmental. The aim of occupational therapy is to help people overcome barriers to occupation, such as physical and/or mental health difficulties, and support them to achieve their goals in relation to those valued activities (Royal College of Occupational Therapists 2019). ⁵ The NICE guidelines (2016) ¹ recommend that return to work interventions should be encouraged as part of all treatments for people with chronic low back pain: occupational therapy has an important role with regard to supporting patients with work-related issues and return to employment (Désiron et al., 2011, Sheppard and Frost 2016),^6,7 although other activities and unpaid occupations might be more important for many people with chronic pain for whom return to paid employment might not be relevant (NICE 2016). ¹ The British Pain Society (2013) described chronic pain as ‘a complex sensory, emotional, cognitive and behavioural long-term health condition’. ⁸ Occupational therapists are trained in using a biopsychosocial approach (Royal College of Occupational Therapists 2019), ⁵ taking into account patients’ emotional and social concerns together with their physical difficulties; this fits well with the field of chronic pain, where the biopsychosocial approach is specifically recommended (British Pain Society 2013). ⁸ Occupational therapy training is directed towards both mental and physical health and wellbeing (Royal College of Occupational Therapists 2019). ⁵ Many people with chronic pain also experience mental health problems, especially depression (Fishbain et al. 1997, Currie and Wang 2004),^9,10 therefore occupational therapists are well-placed to be able to help people experiencing chronic pain.

The study reported here took place in an NHS district general hospital where occupational therapy was included within the multidisciplinary team providing pain management programmes for people experiencing chronic low back pain. The aim of the study was to gain an understanding of patients’ perception of the occupational therapy they received while attending the programme. The study focused on the occupational therapy–specific sessions within the programme, which were led or under the supervision of an occupational therapist, and which had an occupational focus.

Occupational therapy interventions have previously been considered within the context of pain management. A systematic review by Hesselstrand, Samuelsson and Liedberg (2015) ¹¹ focused on occupational therapy interventions with individuals with chronic pain. They concluded that although some of the studies they found provided enough evidence to guide clinical practice, more well-designed studies were needed. Many of the studies they reviewed included interventions less applicable to a group setting, for example, ergonomic assessment. Other studies have evaluated interventions which were carried out by occupational therapists, but which also contained generic pain management content, some of which were not specifically occupation focused, for example, mindfulness or relaxation and exercise (Poole and Siegel 2017, Simon and Collins 2017).^12,13

There has been limited research exploring multidisciplinary pain management programmes which incorporate occupational therapy. A systematic review by Ravenek et al. (2010) of outcomes in the management of chronic low back pain and the contribution of occupational therapists found only 3 studies which included occupational therapists as part of the multidisciplinary team and therefore recommended further research. ³ Wideman et al. (2016) carried out a mixed-methods study exploring how people with chronic pain experienced group or individual rehabilitation provided by an interdisciplinary team, which included occupational therapy. ¹⁴ They found limited improvements on quantitative measures such as pain, but from the qualitative data found that patients described a sense of ‘personal growth’ which was enduring. The nature and degree of occupational therapy intervention, however, was not stated. A randomised controlled trial by Amris et al. (2019) evaluated the benefit of adding an occupational therapy intervention programme or a physiotherapy intervention programme to a standardised group-based programme for patients with chronic widespread pain and found that although there were no significant differences in observation-based measures of function, or in the majority of self-reported outcomes, they did demonstrate improvements in overall mental well-being, when compared to the control group, in the groups who received either the occupational therapy or physiotherapy additional interventions. ¹⁵

Activity pacing is often the focus of occupational therapists working with people with chronic pain (Birkholtz, Aylwin and Harman 2004). ¹⁶ A qualitative study by Andrews et al. (2015) focused specifically on exploring activity patterns commonly encountered by people with chronic pain, and the value of activity pacing as a treatment strategy. ¹⁷ The study findings supported the value of activity pacing as a treatment strategy, but suggested that pacing is difficult to put into practice and that education alone may not be sufficient to bring about a change in behaviour. Findings from several studies exploring occupation in people with chronic pain, indicate that occupational participation is a key concern (Keponen and Kielhofner 2006, Fisher et al. 2007, Persson et al. 2013),^18–20 and it is essential that interventions aiming to improve ‘occupational wellbeing’ meet the needs of and are acceptable to patients. Occupational therapists have the skills and expertise to address these concerns in a patient-centred way. However, the experiences of patients receiving occupational therapy within a pain management programme setting have not been previously reported.

The purpose of the study reported here was to explore participants’ experiences of the occupational therapy content of a multidisciplinary pain management programme along with its perceived impact on occupational engagement and participation.

Method

Design

A qualitative research design was used, in accordance with Thematic Analysis as described by Braun and Clarke (2013), ²¹ using semi-structured interviews. The researcher also used a phenomenological perspective when planning the study: the aim of the study was concerned with exploration of patients’ lived experience of the occupational therapy components of the pain management programme (Finlay 2011, Holloway and Galvin 2017).^22,23 This suggested that a phenomenological perspective might provide most insight into the question of what it is that patients experience through attending these sessions (Finlay 2011), ²² as it could be argued that occupational therapy within a pain management programme is a ‘phenomenon’ about which little is known (Holloway and Galvin 2017). ²³ Finlay (2011) ²² suggested that a phenomenological approach can be useful for therapists in helping them gain a deeper understanding of therapy practice, including the processes involved, and Denscombe (2014) ²⁴ suggested that it can help healthcare professionals gain an understanding of their patients’ thinking. Use of a phenomenological perspective aided the researcher in exploring possible ‘multiple realities’ within patients’ experiences of occupational therapy (Denscombe, 2014), ²⁴ especially as a pain management programme could be considered to be a complex social phenomenon in which different patients saw things differently (Denscombe, 2014) ²⁴ . Ethical approval was gained from the Health Research Authority and institutional approval from the hospital.

Researcher characteristics and reflexivity

The main author and researcher was an experienced female occupational therapist who had worked in the study setting for a number of years. Participants were informed that the research was towards a master’s degree and focused on the occupational therapy content of the programme. The researcher kept a reflective log during the project, including after each interview, in order to explore her own assumptions and beliefs, and to try to keep the possibility of different perceptions in sight.

Participants, sampling and recruitment

Study participants were patients attending group multidisciplinary pain management programmes at an NHS Foundation Trust Hospital in the East Midlands, UK. The programme ran for 1 day a week for 10 weeks and had 12 participants in each group who started and finished the programme together. Sessions were run by the occupational therapist, physiotherapist, clinical psychologist, specialist nurse and technical instructors, either on their own or jointly, depending on topic. The key occupation-focused sessions led by the occupational therapists on the pain management programme were as follows: a) three interactive educational sessions which covered the importance of leisure activities, activity pacing techniques, and approaches for managing back pain in specific daily tasks; b) six therapeutic activity-based sessions under the guidance of an occupational therapist. The session on activity pacing techniques in the study setting included a discussion about common behavioural adaptations made by people experiencing chronic pain, such as activity cycling (overdoing it on a ‘good’ day) and activity avoidance. The occupational therapist then discussed and suggested a range of activity management techniques as an alternative approach. These included breaking activities up into manageable chunks, planning rest breaks beforehand, avoiding activity cycling, the use of time or some other quota for determining amounts of activity rather than level of pain, and how to work out a baseline for an activity and then gradually increase activity levels over time.

The activity-based sessions consisted of a small woodwork project carried out with direction from a technical instructor and volunteer. This was carried out in the occupational therapy heavy workshop, where participants were given the choice of projects such as making a wooden planter or a bird table. The main aim of the workshop sessions was to help participants put pacing skills into practice, rather than woodwork itself. The clinical reasoning behind using woodwork was always carefully explained to patients during preparation for the programme: that the process of the task and the transferable skills gained which could be applied to their everyday lives and occupations were more important than the end product, with most patients agreeing to participate and appearing to understand the purpose. The number of hours on the programme dedicated to specific occupational therapy content was 7 hours out of a total of around 50 hours of the programme as a whole. Individual assessment of workplace issues was not a focus of these group-based programmes.

A purposive sample of patients attending two consecutive pain management programmes was recruited. The researcher was not the occupational therapist on the programmes sampled, although was known to some of the participants as a member of the wider team and might have carried out their pre-programme occupational therapy assessment, which would have taken place a number of weeks prior to recruitment. Potential participants were approached face-to face on day 6 of the programme and given some brief verbal and written information about the study. Those that were still interested on day 7 were then booked in for an interview on day 8, 9 or 10.

The intention was to recruit 6–10 participants across 2 programmes. It was felt that this number would provide a reasonable amount of data from the group being sampled, was manageable within the given time frame and was suggested by Braun and Clarke (2013) ²¹ as sufficient for a small interview-based project. There was an option of recruiting from a third programme if the number of volunteers was low.

Data collection

Following the gaining of consent for the study, semi-structured interviews were carried out by the researcher on one of the last 3 days of the 10 day programme, by which time participants had had experience of all the occupational therapy sessions. The interviews took place in clinic rooms in the hospital setting. No-one other than the researcher and the participant was present during the interviews. The researcher used an interview guide as a basis for each interview, although this was used in a flexible manner depending on the direction of each interview. Prompts and probes were used to elicit elaboration where appropriate.

Interviews comprised 2 parts, first exploring their experiences of the occupational therapy components of the programme and then exploring their incorporation of learning from the programmes into their usual occupations. Participants were shown photographs to remind them of the occupational therapy–led sessions relevant to the study; they were then asked to describe their experiences of taking part in those sessions. Examples of interview question types:

‘Can you describe for me what it was like taking part in these sessions?’

‘Can you tell me what these sessions meant to you?’

‘Can you tell me about anything in these sessions that you felt was particularly important for you?...or difficult for you?

In the second part of the interview, participants were shown photographs of specific occupational domains, e.g. work, social, leisure. They were then asked to describe any changes that had taken place with regard to these activities as a result of attending the programme. If participants described using pacing techniques, they were asked further about their experiences with regard to this, including which aspects of the programme had been most helpful in terms of putting pacing into practice. The interviews were audio recorded using a digital voice recorder and lasted between 20 and 30 minutes. Following the interviews, the recordings were transcribed verbatim by the researcher and anonymised.

Data analysis

The interview data from both parts of each interview were coded using open coding by the researcher, with a sample of the coding checked by a second occupational therapist who was not based in the clinical setting. The aim of this was to check that the codes being used made sense to others. Coding was also re-checked by the researcher at a later date to ensure consistency. The resulting codes were then grouped together into candidate themes using Nvivo qualitative data analysis software. The researcher returned regularly to the original data to ensure the themes remained consistent with participants’ contributions.

Example of how data analysis was carried out leading to the development of themes

Original data	Codes derived from the data	Themes/sub-themes developed from examples here
'.. but I’ve not really done any serious woodwork since I left high school [….], so I found it really enjoyable [….] and the fact that you’ve actually got something to show for it at the end of it, erm.. you know.. you can still do things even with the level of back pain that we all suffer when we come to this clinic, we can still be productive […] P2	Workshop activity perceived as enjoyable Good to have end product End product provides proof of ability Can be productive despite pain Feelings of self-efficacy	The workshop was helpful The workshop helped with learning pacing The workshop showed what was possible despite high pain levels/work alongside your pain/can be productive
‘I’ve had a couple of highlights..I really like the exercise and I really enjoyed the practical stuff that we do in the workshop ([…] because, once I got over my fear, that I’m not going to chop a finger off, I’m not gonna nail me fingers to the bench, erm actually physically being able to do something, and create something, see something through, has been brilliant [….] yeah, can’t wait to see the end product’ P3	Workshop activity perceived as enjoyable Worry of injury prior to attending workshop Workshop activity perceived as manageable Good to have end product Importance of doing something creative
‘Cos normally I don’t finish with things, I just push it to the side and think ‘oh I’ll do it whenever’, when I feel up to it. But here.. you have to do it every week and I enjoyed it, because you can see from the start to the finish now, so yeah, I loved that one’. P4	Then versus now Sessions make you do a bit each week Workshop perceived as enjoyable Workshop enables you to see something through
'Because of it, I mean I kind of kept having flare-ups, and because I couldn’t time things, what I was doing before was making the odd thing, like [……], I’ve done that, but I crashed down after making it. Now with the fact of building the woodwork [….], made me realise I can still do the odd thing, even if I have reactions, you just have to have to manage your time […], so that means you will be able to have your hobbies, but manage your time.'P5	Then versus now Overdoing activities leads to flare-ups Workshop showed what’s possible despite pain Workshop helps you learn pacing Pacing enables getting back to hobbies Pacing by time important	Pacing is a helpful technique Importance of using time as a quota Importance of a graded approach to activity
‘…it’s an understanding of, you can overpower and do other things and just pace yourself, that you’re not completely useless, which I think before I came on this, I did think, because I ‘ave flare-ups so badly, I never thought that I’d be able to do anything [….], because it’s been so bad for so many years, and to actually accomplish making the box that I did in the woodwork is an amazing achievement,…[……….] but I think once you get in it and the understanding of it that you’re not as useless as what you think, and if you put your mind to anything, it’s not that you can overcome your pain, but you can work along with it, which is a thing that I never actually thought I would be able to do ……'P6	Pacing as a helpful technique Pacing enables you to do more Pacing gives sense of control over pain Pacing leads to feelings of self-efficacy Used to feel useless Then versus now Pride in achievement Workshop leads to feelings of self-efficacy Shows you can work alongside your pain Workshop session showed what’s possible despite high pain levels
‘‘I’ve got a lot of machinery in the garage, which I thought ‘oh I’m not going to bother using now because it’ll hurt’ [….], but it.. along with this pacing, erm hopefully I can combine everythink and, you know, and get all the jobs done that I need doing…’ P9	Then versus now How they used to do things Pacing enables participation in hobbies Practical aspects of programme helped putting theory into practice Workshop as impetus to doing DIY at home again

Results

Ten out of a possible 12 patients volunteered initially from the first programme. Two withdrew at their own request when they were informed that names would have to be drawn from a hat due to the high volume of volunteers, one withdrew at their own request due to going down a different treatment route, and another was withdrawn for clinical reasons at the request of the multidisciplinary team with the patient’s agreement, leaving a total of 6 participants from the first programme. On the second programme, 6 patients volunteered out of a possible 8 patients. Two volunteers declined to take part on the day of the interview for health reasons, and one was unable to attend the final programme day therefore missing the interview, leaving a total of 3 participants from the second programme.

The total number of participants recruited was 9. Participants consisted of 1 man and 8 women, age range 30’s–70’s with the median age being 50 years, and with duration of lower back pain from 1–20+ years. Three participants described themselves as currently employed, 4 described themselves as on sick leave/not working, 2 described themselves as retired/semi-retired. Patterns identified in the data which appeared to be meaningful and important with respect to the occupational therapy content of the pain management programme are outlined below. No new candidate themes were identified from the interviews with the last 3 participants, indicating the possibility of data saturation.

Theme 1. ‘Activity pacing is a helpful technique’

All of the participants in the study described positive experiences with regard to activity pacing, describing a number of changes they had made in their lives as a result of learning about pacing and providing detail on the specific benefits they had obtained when they paced themselves well. Some spoke at length about how pacing had enabled them to participate more effectively with regard to housework, employment, family, social and leisure activities. One participant summed up their overall experience and perceived benefits of pacing with the following:

‘Erm, so it’s helping me to work at what I want to do, longer, [….] that’s the key thing isn’t it […] you know, [….] you get more work done, pacing yourself, stopping, pacing yourself, than trying to do it all in one go, and then at the end of the day, at the end of whatever you’re doing, you feel better because you haven’t got that flare-up, you know. Actually it’s a brilliant concept really, why we hadn’t thought of it when all this started, I don’t know [laughs].’(Participant 9)

Activity pacing was a major focus for occupational therapists working on this programme, reinforced by programme content delivered by other members of the multidisciplinary team. Many participants made links to specific work they had done with the occupational therapy team.

Three sub-themes related to pacing were identified: a) importance of using time as a quota when activity pacing, b) importance of using a graded approach to activity and c) that activity pacing is difficult to put into practice and that just knowing the theory may not be sufficient.

Sub-theme a). Importance of using time as a quota when activity pacing

The occupational therapy content of the programme included sessions in an occupational therapy heavy workshop which involved making a small woodwork project. An individualised pacing plan was agreed with each patient and encouragement was given to use a timer as a reminder to change position or take a rest. A number of participants talked about how learning to pace by using a timer, or by deciding on the duration of an activity beforehand, was particularly important for them.

‘We had to pace ourselves, which was also a very good thing, because it makes you aware then of what you are doing, and, you know, I mean I am terrible for going all on at things [….], I am no good at pacing, so for me it was really, really good, because I had a little clock, so when that clock went, I had to sit back, and I had to wait.’(Participant 8)

Sub-theme b). Importance of using a graded approach to activity

Several participants talked about the importance of starting with small amounts of an activity and building up gradually in order to increase the amount they are able to do. This graded approach was explained in detail with regard to day to day activities in the session on ‘pacing techniques’ with the occupational therapist and was reinforced by the physiotherapist with regard to exercise:

‘It’s like rather than going out for a walk and being out 2 hours […], I’m sort of doing short walks. I’m up to 20 minutes at a time now, erm.. and building it up slowly.. it’s the consistency that’s key’ (Participant 2)

‘In the woodwork sessions, I think the biggest thing was…erm..two big things, actually,.. bringing stuff towards you, [……..] you can do things.. start small and work up to finishing something…’ (Participant 3)

Sub-theme c). That activity pacing is difficult to put into practice and that just knowing the theory may not be sufficient

Several participants identified pacing as something they found difficult to put into practice or had not managed to take on board in the past, despite being introduced to it in other settings. A couple of participants observed that just having knowledge about pacing might be insufficient, and that successful implementation requires a deeper level of understanding and experience:

‘The pacing, pacing’s always.., I came on the mini sessions.. …[ a physiotherapy-led short programme] and tried to get my head round pacing there..but I couldn’t..but this is..’ (Participant 3)

‘.. knowing you need to do it is one thing, understanding why you need to do it is different and the understanding comes a little bit slower than the knowing [….], so yeah, that, that took a… I am not saying I did not do it from the off because I did do what I was told because these guys know what they are talking about, but it did take a while to sink in why.’ (Participant 2)

Theme 2: The therapeutic activity in the occupational therapy workshop was helpful

All participants talked about finding the therapeutic woodwork activity helpful. Three sub-themes emerged in relation to the workshop activity: a) the workshop sessions helped with learning pacing b) they showed what was achievable despite high pain levels and c) individual guidance from the occupational therapist was helpful.

Sub-theme a) The workshop sessions helped with learning pacing

‘See.. like the workshop, erm, we had to pace ourselves, like sitting down for so long, then remembering to get up, so we do not get stiff, and doing stuff standing up, so that’s helped, with the workshop, ‘cos I thought ‘ahh, I will not be able to do that’, but by pacing myself, I managed to get it done, so I was quite proud of myself, that I did not drop out, that I did not leave it, kept on going [….]’ (Participant 4)

‘Which, which programme sessions do you think have been key with regard to pacing?’ (Researcher) ‘[….] Well, the woodwork, because they give you a form, that you have got to sit down for 8 minutes and stand for 1 minute, they have worked that out, I say personally for me (yeah) 8 minutes, erm, so that, that’s helped as well, you know, doing the woodwork …’ (Participant 9)

Sub-theme b) The occupational therapy workshop showed what was achievable despite high pain levels, that it is possible to work alongside the pain and be productive

A number of participants identified that undertaking the workshop project demonstrated to them what it was possible to achieve, despite the pain, but without trying to combat it, suggesting a level of acceptance.

‘…it is an understanding of, you can overpower and do other things and just pace yourself, that you are not completely useless, which I think before I came on this, I did think, because I ‘ave flare-ups so badly, I never thought that I’d be able to do anything [….], because it is been so bad for so many years, and to actually accomplish making the box that I did in the woodwork is an amazing achievement,…[……….] but I think once you get in it and the understanding of it that you are not as useless as what you think, and if you put your mind to anything, it is not that you can overcome your pain, but you can work along with it, which is a thing that I never actually thought I would be able to do ……‘ (Participant 6)

‘.. but I have not really done any serious woodwork since I left high school [….], so I found it really enjoyable [….] and the fact that you have actually got something to show for it at the end of it, erm.. you know.. you can still do things even with the level of back pain that we all suffer when we come to this clinic, we can still be productive …’ (Participant 2)

Several participants also talked about how doing the woodwork had improved their confidence and feelings of self-efficacy, and that it was important that they had the opportunity over the weeks to see a project through to completion. Participant 2 articulated both these points clearly:

‘….so to actually do a physical therapy like that where you’ve actually got proof at the end of it, you know, I made this regardless of the problems that I’ve got.. I might have had a fair bit of help from [the technical instructor] and the other guy in there, nevertheless, what I take home with me next week I have made, so, yes it is, it’s confidence boost on top.’ (Participant 2)

Participant 9 described feeling able to try the same techniques at home, highlighting the transferability of the skills to other settings and occupations:

‘…but it gives you a bit of incentive as well, that’s to think ‘right, I will do it, I’ve done it in the workshop so I can carry on and do it at home’, which is the whole idea of it, isn’t it?’ (Participant 9)

Sub-theme c) Individual guidance from occupational therapist in the workshop was helpful

Several participants spoke about how it was important to have the occupational therapist present during the workshop sessions, providing advice and guidance, particularly with regard to pacing the activity. Participant 6 described the importance of this guidance:

‘…. but like I say with [the occupational therapist] being in there she could see the flare-up was getting the better of me so, I think if she wasn’t there, I would have pushed myself too far, [….], err, but I think between her and me, we got an understanding of how far I could actually push myself, I think it was more upsetting that I missed, I feel like I missed half of the sessions because everybody else was still in there ‘til the end [….] and I was always the one that was chucked out for a cup of tea early, but I understand now why, erm.. but I think it’s, like I say, if [the occupational therapist] hadn’t happened to be in there, I would have pushed myself way too far, and then I would have had a week ‘til I came back the next week where I wouldn’t have been able to do anything’ (Participant 6)

Theme 3. The importance of leisure and creative activities

Nearly all the participants talked about either re-connecting with hobbies or leisure activities as a result of attending the programme, and of being more aware of the positive impact these activities could have on their lives. Two sub-themes were identified regarding a)how participation in leisure/hobby activities provided a wide variety of benefits and b)that the occupational therapy workshop activity fulfilled a desire to be creative.

Sub-theme a) Perception that participation in leisure/hobby activities provides a wide variety of benefits

Participants related a number of potential gains they felt could come about from this re-connection with hobbies and leisure. These included benefits to relationships, distraction from pain, enjoyment, and in the case of DIY, financial benefits. Some participants acknowledged that leisure activities had been an important part of their lives in the past which had been lost during their battle with ongoing pain. The occupation-focused sessions had been a reminder of this importance.

…. And [a creative activity is] something for me and the husband to do together [….], so it will bring our relationship together a bit more [….] so it is helped me quite a lot and I just enjoyed doing it ‘cos it just takes your mind somewhere else [….], it just takes it off the pain, off how you are feeling [….] and concentrating on doing something [….] so has helped quite a bit …..’ (Participant 4)

‘Erm.. the second session, the leisure side of things… I knew that sort of thing was important to start off with but there’s a bigger emphasis on it than you would have initially thought because it ties into so many other things doesn't it? ‘(Participant 2)

Sub-theme b) That the occupational therapy workshop activity fulfilled a desire to be creative

Some participants felt that the workshop project tapped into a wish to develop their creative side more. Participant 1 described finding that this inspired them to continue at home afterwards:

‘But yeah, I’ve always wanted to make a birdtable [….] for donkey’s years, so as soon as I saw it on this, ‘yep I’ll have that.’ I’ve already said to [the technical instructor], I’ve said ‘I’ll tell you what, pal, I’ll be taking this apart when I get home, and getting all the measurements and that..’ (Participant 1)

‘I really enjoyed the practical stuff that we do in the workshop […], because, once I got over my fear, that I am not going to chop a finger off, I am not gonna nail me fingers to the bench, erm actually physically being able to do something, and create something, see something through, has been brilliant [….] yeah, cannot wait to see the end product.’ (Participant 3)

Discussion

This qualitative study highlights the importance placed by participants on occupational therapy and activity-related outcomes for people living with chronic low back pain who participate in multidisciplinary pain management programmes. In particular, participants highlighted the importance of activity pacing, the value of using a creative therapeutic activity with guidance from the therapist, and the importance of leisure and creative activities in their lives.

All the participants in this study perceived activity pacing to be a helpful technique with regard to pain self-management, supporting findings from some previous studies (Van Huet, Innes and Whiteford 2009, Kallhead and Mårtensson 2018),^25,26 which also found pacing and activity management strategies to be important to people experiencing chronic pain. Despite this, some studies have found that pacing was not associated with higher levels of functioning (McCracken and Samuel 2007, Kindermans et al. 2011).^27,28 This apparent contradiction in the literature may be due to a lack of clarity about the definition of ‘pacing’ (Jamieson-Lega, Berry and Brown 2013, Andrews and Deen 2016).^29,30 UK occupational therapists appeared to feel more certain of their own definition of activity pacing in a survey-based study by Birkholtz, Aylwin and Harman (2004) ³¹ ; the findings from their study suggested that occupational therapists felt that pacing by time was beneficial, that it helped with habit formation, and that ‘building up’ or increasing activity was an important element of this. Timers may not be utilised universally by occupational therapists working in chronic pain settings and may not be appropriate in all situations; however, occupational therapists in the study setting found that initial use of timers in the workshop setting helped patients to experience ‘pacing by time’ for themselves and enabled the customisation of pacing techniques to an individuals’ needs. Timer availability on smartphones in recent years has made this approach easy to use outside of the clinic setting.

Studies by Van Huet, Innes and Whiteford (2009), ²⁵ and Andrews et al. (2015) ¹⁷ showed that activity pacing is something that some patients perceive as difficult to put into practice. The findings from this study build on this previous work by exploring a way in which those difficulties might be addressed. The occupational therapy intervention described in this study goes further than providing generic, educational style sessions on pacing because it provides an individualised, experiential approach which gives the patient an opportunity to ‘experiment’ with pacing in a real-life situation, under guidance, leading to a fuller understanding of how to apply pacing theory effectively in their day to day activities. Future research needs to be done to investigate the efficacy of this type of intervention, for example, through a randomised-controlled trial.

There is a dearth of literature about the therapeutic use of a practical activity on pain management programmes. The use of the workshop on the programme was viewed to be a key component in this study setting, with the main aim being to help teach pacing techniques. This element of the programme had previously scored highly in patient satisfaction questionnaires (unpublished data). The researcher was interested in understanding the variety of perceived benefits that participants attributed to the workshop. Some study participants felt that the workshop had indeed helped them to learn pacing techniques, as explained by participant 6. However, other benefits described by participants were that the project showed them what could be achieved despite high pain levels, and that having support and guidance from the occupational therapist while undertaking the activity was important.

The use of a single therapeutic activity in this way with limited opportunity for choice presents a potential ‘ethical dilemma’ for occupational therapists (Chaparro and Ranka 2008). ³² It may be in conflict with occupational therapy values which emphasise autonomy and the importance of patients making their own decisions about activity participation (Drolet and Désormeaux- Moreau 2016, Royal College of Occupational Therapists 2021).^33,34 The experiences of the study participants reflected the situation found in clinical practice, that working in collaboration with patients and gaining their understanding prior to commencement of the activity, led to them providing informed consent for participation in the workshop.

One major theme which emerged was around the recognition of the importance of hobby and leisure activities, with many participants talking about the benefits they obtained, in particular from participating in creative activities. The benefits of participating in creative activities as described by some participants was suggestive of the experience of ‘flow,’ as described by Csikszentmihalyi (2008), ³⁵ with participants describing the task as enjoyable, with their minds being taken elsewhere, while having a feeling that the task was achievable. ‘Flow’ is thought to occur when we become skilled at an activity which we find rewarding and are engrossed in it but where this is balanced by the level of challenge. Csikszentmihalyi (2008) ³⁵ explored what makes people happy, and discovered that experiencing flow can contribute to increasing levels of happiness and wellbeing, which suggested that happiness comes from within. Participants’ observations that their minds ‘were taken elsewhere’ while undertaking the woodwork were interpreted by the authors as meaning that the ‘spotlight of their attention’ had moved from their pain to focus on the present moment and the activity that they were undertaking. This felt consistent with the Acceptance and Commitment Therapeutic (ACT) approach used on the programme (Hayes, Strosahl and Wilson 2011). ³⁶

It might be argued that the theme of leisure and creativity was ‘led’ by the fact that one of the occupational therapist–run sessions was entitled ‘The importance of leisure’ and that this was on one of the prompt cards used in the interviews. Participants talked at length about their enjoyment of getting back to valued activities. This was a good fit with the ACT approach of the programme, which encouraged ‘dropping the struggle’ with pain and instead moving towards living a life according to ones’ values (Hayes, Strosahl and Wilson 2011). ³⁶ Fulfilment of the desire to be creative overlapped with other sub-themes, such as the ability to be productive despite the pain, self-efficacy and the need for acknowledgement of one’s skill by other people. A fulfilment of the desire to be creative may be of particular importance to people with chronic pain; several participants spoke about feeling ‘useless,’ which in turn could contribute to feelings of despair and depression. It is possible that being creatively productive could help to reverse the descent into despair experienced by many people with chronic pain. There appears to be little written in the literature about creativity and chronic pain. A qualitative study by Reynolds, Vivat and Prior (2008) ³⁷ explored the impacts of leisure-based craft activities on the wellbeing of women with chronic fatigue syndrome/ME and reported a number of benefits including improved self-image; participants felt that earlier professional support with relation to creative activities, such as occupational therapy, would have been helpful in their adjustment to living with their chronic illness. Although Reynolds, Vivat and Prior (2008) ³⁷ focused their study on people with chronic fatigue syndrome/ME, this condition often overlaps with chronic pain and occupational therapy interventions are broadly similar (Cox 2000). ³⁸ A qualitative study by Lynch et al. (2013) ³⁹ explored the experiences of artists with chronic pain, who found that producing their artwork contributed to feelings of self-worth, personal growth, a sense of fulfilment, and that it gave their lives meaning. The current study builds on the findings from these studies and indicates that the encouragement of creative leisure activities in patients with chronic pain may provide important benefits. This finding points to the need for further research into the possibility of using creative activity as a tool in long-term self-management for people experiencing chronic pain.

Limitations

This study is subject to several inevitable limitations. The pain management programme is an integrated intervention, designed by the multidisciplinary team, such that it is not possible to determine which participant experiences are specifically attributable to programme activities delivered by occupational therapists rather than by other team members. This integrated approach is essential to ensure reinforcement rather than create contradictions within a holistic, patient-centred approach. Participants displayed some difficulty viewing programme elements in isolation and often discussed content provided by other members of the multidisciplinary team.

The way that the data were analysed and the emerging themes will have been heavily influenced by the researcher’s own experience and preconceptions; a different researcher may have found different patterns in the data and come to different conclusions. The researcher might have been biased towards the findings being positive, in favour of occupational therapy, and had an idea that certain elements, such as pacing and the workshop, would emerge as helpful.

The researcher was known to the participants as a member of the wider team in the department, and this may have influenced their responses in interviews.

Although interviews were not repeated and transcripts were not checked by participants, consistency of themes between participants suggests the validity of their content. The recruitment of only a single male participant may limit the transferability of our findings to male participants. Polit and Beck (2009) ⁴⁰ reported on gender bias in female-led nursing research, in favour of female participants, with this being even greater in qualitative studies, and questioned whether researchers are adequately inclusive of certain patient groups. Future research should explore ways to increase participation from men, and also of seldom heard patient groups. The observation that all the participants recruited for the study were positive in their experience of the occupational therapy components is also a possible limitation, suggesting a degree of response bias, and brings into question whether data saturation was achieved, and whether continued sampling would have eventually gathered less positive data.

Conclusion/Implications for practice

This study points to the potential benefits of a multidisciplinary approach which includes occupational therapy within the context of pain management programmes. The participants’ experiences as reported in this study suggest that activity pacing is a key programme component. Activity pacing is an occupation-focused skill which sits comfortably within the domain of occupational therapy, even though it may be taught by and encouraged by all members of the multidisciplinary team. This study suggests that the opportunity provided by the occupational therapy approach to try out and receive guidance on pacing skills in a real-life setting may offer benefits over a purely theoretical or educational approach, increasing the likelihood of permanent behaviour change. The findings also suggest that the use of a creative therapeutic activity is greatly valued by patients. This may be of interest to occupational therapists working with people with chronic pain in any setting, and although few will have access to the type of workshop available in this study setting, the use of some form of creative activity may provide some of the of the benefits described by the participants above.

The findings from this study suggest that occupational therapy can have an important and distinct role within the multidisciplinary team, which is complementary to the other disciplines, and which adds to the quality and depth of the patient experience. Future randomised-controlled trials of pain management programmes should address the occupational needs of people with chronic pain and explore how specific occupational therapy content can help people to increase their participation in valued activities.