Abstract
The National Institutes of Health (NIH) Interagency Pain Research Coordinating Committee (2016) reported that chronic pain affects an estimated 100 million people in the United States and is a complex biopsychosocial condition ranging in severity that requires a multidisciplinary team of professionals to manage all aspects of health. Chronic pain is a multifaceted epidemic that encompasses many different diagnoses and requires multimodal management (NIH Interagency Pain Research Coordinating Committee, 2016).
In the United States, chronic pain management often happens at primary care levels, and prescription pain medications are typically the only intervention offered to patients (Institute of Medicine Committee on Advancing Pain Research, Care, and Education, 2011), which is contrary to the Centers for Disease Control and Prevention (CDC; 2016) best practice guidelines. The CDC recommends using nonopioid treatment methods for chronic pain conditions when possible, including self-care training, interdisciplinary treatment, cognitive–behavioral therapy, and patient education.
Interdisciplinary treatment is typically based on the biopsychosocial approach to pain management to comprehensively address the complexities and ever-changing nature of chronic pain (Gatchel & Okifuji, 2006). Research surrounding interdisciplinary pain programs has demonstrated that these models are effective in reducing pain severity, improving mood, and restoring function (Gatchel & Okifuji, 2006; Morley, Eccleston, & Williams, 1999; Oslund et al., 2009) as well as being cost effective and decreasing health care utilization (Gatchel & Okifuji, 2006). Occupational therapy is represented in some reviews of interdisciplinary pain programs; however, physical therapy and psychology are more commonly identified professions (Oslund et al., 2009).
Although the literature frequently uses the term comprehensive to describe interdisciplinary pain programs, most programs do not include lifestyle-based interventions that address a broad range of self-care occupations (e.g., meal preparation, rest and sleep, daily routine development, leisure), even when occupational therapy is included (Gatchel & Okifuji, 2006; Morley et al., 1999; Oslund et al., 2009). Lack of evidence regarding the value of lifestyle interventions in chronic pain management likely contributes to this scarcity of involvement. Given the pervasive nature of chronic pain, patients experience significant disruptions to daily routines and changes in occupational engagement that require them to adapt or change their daily habits to create sustainable lifestyles that will support successful pain management.
The purpose of this article is to describe the efficacy of an outpatient clinic–based Lifestyle Redesign® intervention for people living with chronic pain on quality of life (QOL), function, self-efficacy, and pain levels.
Method
Design
This was a retrospective study conducted to determine the benefits of lifestyle-based occupational therapy for patients who finished treatment. Clinical outcomes were collected from patients who completed an individual clinic-based outpatient Lifestyle Redesign occupational therapy program for chronic pain as part of their usual plan of medical care. Patients were all referred to Lifestyle Redesign by their physicians, and all lived in southern California. For some patients, their plan of medical care included physical therapy, psychotherapy, or both. Patient data were excluded if the patient did not complete discharge measures.
Procedures
Lifestyle Redesign is a manualized occupational therapy treatment method grounded in occupational science research, with a focus on facilitating patient development of healthy self-care routines and habits to prevent and manage chronic conditions. Through randomized controlled trials, namely, the University of Southern California (USC) Well Elderly Studies (Clark et al., 1997, 2012), Lifestyle Redesign has been shown to reduce health risks and health care costs associated with chronic conditions.
According to the most recent manual by Clark et al. (2015), the Lifestyle Redesign method includes didactic presentation, peer exchange, direct experience, and personal exploration. Treatment focuses on patient education, occupational self-analysis, problem solving, motivation building, and implementation of behaviors.
Lifestyle Redesign includes the use of treatment topics, or modules, to promote patient education and implementation of behavior changes into daily routines (Clark et al., 2015). Module topics, and duration of treatment spent on each module, were determined by the therapist’s evaluation and ongoing assessment of the patient’s needs. Module topics were compiled with a review of evidence-based practice, the Lifestyle Redesign manual (Clark et al., 2015), and the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association, 2014). A list of modules specific to chronic pain, along with a brief description of each topic, is shown in Table 1.
Modules of Lifestyle Redesign for Chronic Pain Management
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
In the Well Elderly studies, both group and individual sessions were used, and research protocols included 2 hr of weekly group-based occupational therapy, with a 1-hr individual session of occupational therapy monthly (Clark et al., 1997, 2012). In contrast, only individual sessions were used in this study because the treatment site did not offer groups at the time services were rendered and also because this model promoted increased patient-centeredness and personalized treatment planning. Given the range of chronic pain conditions treated, individual sessions allowed for in-depth patient education and tailoring of interventions to address diagnosis-specific lifestyle factors.
Individual sessions also offered more flexibility in patient scheduling because pain often interfered with regular attendance at medical appointments, and some patients had more than one health care appointment per week because of their participation in multidisciplinary care. As such, the number of sessions and duration (weeks) of treatment varied depending on the patient’s plan of care, which was determined by the treating occupational therapist after evaluation. Each session was approximately 45–60 min long. All interventions were performed at one outpatient clinic facility, with the exception of some patients receiving in-home safety evaluations for one session as part of their plan of care.
Instruments
Outcome measures were selected on the basis of client-centeredness, with an emphasis on occupation and function, applicability, and reliability. A range of measures were chosen to capture the multifaceted nature of pain and the effects of Lifestyle Redesign.
Canadian Occupational Performance Measure.
The Canadian Occupational Performance Measure (COPM; Law et al., 2014) is an assessment tool that measures perceived performance and satisfaction over time. It allows patients to self-identify areas of occupational deficit, creating a client-centered and highly occupation-based measurement of progress. Performance and satisfaction scores range from 1 to 10, with higher scores indicating better perceived performance and satisfaction. The COPM has been used to measure functional progress with various pain populations (Carpenter, Baker, & Tyldesley, 2001; Moscony, 2002; Persson, Lexell, Rivano-Fischer, & Eklund, 2013; Persson, Rivano-Fischer, & Eklund, 2004). Change between initial and subsequent scores of 2 or more points is considered clinically significant (Carswell et al., 2004).
36-Item Short-Form Survey.
The 36-Item Short-Form Survey (SF–36; Ware, Snow, Kosinski, & Gandek, 1993) is a self-reported general QOL survey that measures eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy and fatigue, and general health. It also measures general health compared with 1 yr ago. Each health concept is scored from 0 to 100, with higher scores indicating higher QOL. No overall or total score is calculated. Despite the wide use of the SF–36 in measuring health-related QOL, no standards for clinically significant changes have been determined (Ferguson, Robinson, & Splaine, 2002).
Brief Pain Inventory.
The Brief Pain Inventory (BPI; Cleeland, 2009) is a commonly used pain assessment tool that allows users to rate their pain severity on average, its highest and lowest in the past 24 hr, and the degree to which their pain interferes with different dimensions of feeling and function. Higher scores indicate higher levels of pain or more impact of pain on functional domains. Questions using the numeric rating scale about pain at its worst, least, and on average can be used independently, and a pain severity composite score of these three questions can also be calculated. A pain interference composite score can be obtained by averaging questions about pain's hindrance to daily activities. Dworkin et al. (2008) reported the minimally important change (MIC) for numeric rating scales of pain to be approximately 1 point or percentage changes of 15% to 20% and suggested a BPI interference composite score change of 1 point as a good benchmark for identifying MIC.
Pain Self-Efficacy Questionnaire.
Self-efficacy is a person’s belief in his or her ability to enact behaviors needed to produce a desired outcome (Carey & Forsyth, 2016). In this context, it refers to the patient’s perceived ability to engage in daily activities of living, despite having chronic pain. The Pain Self-Efficacy Questionnaire (PSEQ; Nicholas, 2007) is used to rate how confident people feel in performing different activities, despite pain. A total score is calculated by adding all item answers together; higher scores indicate higher self-efficacy (Nicholas, 2007). Limited information about interpretability and MIC is available at this time (Miles, Pincus, Carnes, Taylor, & Underwood, 2011); however, one study for patients with chronic low-back pain demonstrated a MIC of 5.5 for the PSEQ (Chiarotto et al., 2016).
Data Collection and Analysis
Outcome measures were collected during evaluation and discharge sessions. Data from patient charts were entered by research assistants who were not involved in treatment delivery. We trained all data collectors using written step-by-step instructions and through in-person training sessions. We analyzed pre- and posttreatment scores using paired-samples t tests. JMP Pro 12 statistical software (SAS Institute, Cary, NC) was used to analyze data. Data regarding which patients were also receiving physical therapy or psychology services at the time occupational therapy services were provided were unavailable at the time of this study and were therefore not included as a component of this analysis.
Results
Outcomes from 45 patients were included in this study. Mean age was 42.6 yr, and gender distribution was 32 women, 12 men, and 1 person who did not answer. Twenty-three patients reported their race as White; 5, as Hispanic; 3, as Black; 1, as Asian; and 1, as American Indian; 12 patients did not report. The mean number of occupational therapy sessions was 9.04, and the mode was 8 sessions. The mean duration of provided therapy was 18 wk. The most common diagnoses were lumbago, myalgia (including fibromyalgia), and complex regional pain syndrome. Not all outcomes were completed for all patients.
Results can be found in Table 2. Missing data were attributed to patient error (incorrectly completing measures or missed questions) or therapist error (not including an outcome in the discharge packet).
Outcome Measure Results
Note. BPI = Brief Pain Inventory; COPM = Canadian Occupational Performance Measure; df = degree of freedom; M = mean; PSEQ = Pain Self-Efficacy Questionnaire; SF–36 = 36-Item Short-Form Survey.
p < .05. **p < .01. ***p < .001.
Means of COPM performance and satisfaction measures increased significantly (by 2.02 and 2.78 points, respectively), indicating improved perceived occupational performance and satisfaction in occupational areas of difficulty identified at the start of treatment. Both COPM measures showed ps < .001, demonstrating strong significance in score changes.
Most health concepts of the SF–36 showed significant improvement, demonstrating increased QOL. Role limitations due to physical health increased by 20.16 points, role limitations due to emotional problems increased by 25.27 points, and social functioning increased by 15.23 points; these concepts revealed the most significant changes (ps = .0013, .0041, and .0004, respectively). The emotional well-being and pain concepts of the SF–36 displayed small improvements in score but were not statistically significant.
PSEQ total scores increased by 4.46 points on average, which was significant (p = .0030), and demonstrated an improvement in the patient’s perceived ability to engage in functional activity despite pain. BPI scores showed small decreases in average and worst pain levels as well as in pain interference and pain severity composite scores, but none of these changes were statistically significant.
Discussion
Lifestyle Redesign has a significant effect on the QOL, self-efficacy, and functional abilities of people living with chronic pain. Both COPM components, PSEQ score, and seven of the nine SF–36 health concepts all showed significant changes after the intervention. These findings support previous Lifestyle Redesign studies (Clark et al., 1997, 2012) that showed lifestyle modifications can effectively manage chronic conditions and improve overall QOL. These results also support chronic pain literature demonstrating that interdisciplinary pain programs can increase functional restoration (Gatchel & Okifuji, 2006), social role functioning (Morley et al., 1999), and active coping strategies (Morley et al., 1999; Oslund et al., 2009) and therefore improve QOL despite minimal to no changes in pain levels (Gatchel & Okifuji, 2006).
COPM scores likely showed the most statistically significant improvements because of the ability to measure performance and satisfaction with daily habits and routines, which is directly what Lifestyle Redesign targets. Mean changes in both Performance score and Satisfaction score were over the 2-point clinical significance threshold for the COPM. In addition, therapists were able to directly address the patient-identified areas of occupational difficulty in treatment, targeting the areas that were most important to the patient.
Nonsignificant findings were obtained for the SF–36 emotional well-being and pain health concepts as well as for all BPI items. However, all changes in mean were trending toward improvements in QOL and pain levels, particularly the BPI interference composite score, for which the mean change was −.62 (suggested MIC is 1 point). It is possible that these health concepts did not show significance because of a lack in statistical power caused by a small sample size, which made it difficult to detect small changes in mean.
The lack of significant changes in all pain intensity measures (SF–36 pain health concept and all BPI items) can possibly be attributed to the focus of treatment on self-management of pain and improved functional engagement, not on decreasing pain levels directly. Although some treatments provided in Lifestyle Redesign do sometimes affect pain intensity (e.g., self-regulation training, activity pacing), this outcome is not the primary focus of treatment.
Clinical Applications
This study shows lifestyle interventions are likely to be an important component of chronic pain treatment and that occupational therapists working with patients who have chronic pain should consider incorporating this technique into their practice. Lifestyle Redesign principles can be applied in any treatment setting, and occupational therapists should familiarize themselves with the modules and concepts outlined in Lifestyle Redesign manuals and literature (Clark et al., 1997, 2012, 2015) to be able to administer this type of intervention confidently. These findings should also prompt occupational therapists to reconsider best practice guidelines for chronic pain management to address all the complexities of chronic pain: functional engagement, lifestyle and routine disruption, difficulty with behavior change, physical disabilities, and psychosocial struggles.
Limitations
Only those patients who completed the program were included in this study because pre- and posttreatment outcome measures were required to calculate change. Outcomes of those patients who did not complete treatment were not included, so it is possible that there were differences between those patients who completed the program and those patients who did not, but these demographics were not compared, and differences between groups at the start of treatment were not analyzed. For the group that did not complete treatment, reasons for not doing so were not recorded.
Despite the methodological similarities between the Lifestyle Redesign manual (Clark et al., 2015) and this analysis, the delivery of treatment differed greatly because of time, cost, and patient burden constraints. This treatment was administered individually, at most once per week; the USC Well Elderly studies were provided in groups that met twice weekly in addition to one individual session per month. As a result, the peer exchange component that occurred in the USC Well Elderly studies was not a factor here.
Another limitation is the interference of other therapies (physical therapy, psychology) on the outcomes. Data regarding which patients were attending physical therapy or psychology were unavailable and thus could not be accounted for in this analysis. Because this was a retrospective study that was based on regular medical care, patients who were receiving other forms of treatment were not excluded, which may have influenced the results.
This sample size provided enough power to demonstrate significant effects in most dimensions. However, a larger sample size may have been more capable of showing significance with the BPI and with other scales that had smaller changes in mean.
Future Research
In future studies, researchers should aim to greatly increase sample sizes to increase statistical power, to be able to identify smaller significant changes, and to have the ability to compare outcomes among different groups (e.g., those patients who received occupational therapy only, those patients who received physical therapy and occupational therapy, those patients who received psychology and occupational therapy, those patients who received all three). Control or waitlist groups should also be introduced to determine the efficacy of Lifestyle Redesign treatment compared with standard or no treatment, and a larger scope of chronic pain diagnoses should also be included. In the future, manualized treatment guidelines specific to Lifestyle Redesign for chronic pain management can be implemented to provide uniformity and therapist fidelity.
Other areas of future research include determining whether Lifestyle Redesign occupational therapy for chronic pain resulted in lower costs or decreased pain medication usage. It would also be beneficial to track reasons for ceasing therapy to be able to better understand why some people do not complete the program. Finally, an encouraging area of future research would be in applying the Lifestyle Redesign technique to other ethnic and socioeconomic populations as well as to other diagnostic groups, such as people with autism spectrum disorder, overweight and obesity, or mental illness.
Implications for Occupational Therapy Practice
Little evidence for the use and value of Lifestyle Redesign occupational therapy in chronic pain management currently exists. This study contributes to research showing the benefits and efficacy of Lifestyle Redesign occupational therapy in a real-life clinical setting to practitioners who are hesitant to use lifestyle-based treatments, insurance companies, and lawmakers. The findings of this study have the following implications for occupational therapy practice:
Occupational therapy practitioners may increase their use of lifestyle-based treatments with clients who experience chronic pain by incorporating some of the aforementioned modules into treatment plans, by using similar standardized outcome measures to show clinical progress, and by reporting on any significant findings.
Increased support for reimbursement of lifestyle and behavioral occupational therapy treatment by insurance companies may occur through effective documentation of these services, consistently reported patient outcomes, and citation of articles (such as this article) within documentation or when contending with payment denials.
Endorsement for the inclusion of occupational therapy in prevention and chronic condition management legislation may occur through increased advocacy and research demonstrating the unique value of lifestyle-based occupational therapy in chronic pain management.
Conclusion
Lifestyle Redesign occupational therapy, when integrated into a patient’s medical plan of care for chronic pain, can significantly improve patient functioning, pain self-efficacy, and QOL. More rigorous research about lifestyle-based occupational therapy treatment is warranted, both with chronic pain and with other chronic conditions. This study—which demonstrates the need for more occupational therapists incorporating lifestyle techniques into existing practices—moreover shows the need to routinely incorporate occupational therapy into chronic pain management care and attests to the efficacy of lifestyle-based occupational therapy treatment for payers and legislators alike.
Footnotes
Acknowledgments
We thank the therapists at the USC Occupational Therapy Faculty Practice who performed these Lifestyle Redesign interventions and the student research assistants who completed data entry. We also thank Florence Clark, Grace Baranek, Katie Jordan, and Natalie Leland for their support in the development of this study.