Occupational therapists’ perspectives on current practice in chronic pain and sleep disturbances

Abstract

Background

Chronic pain and sleep disturbances are often co-morbid. Sleep disturbances can negatively affect self-care occupations, cognition, mood, emotional functioning and physical wellbeing.

Aim

To explore occupational therapists’ experience working with clients with chronic pain and sleep difficulties.

Method

Semi-structured interviews were conducted with 11 occupational therapists with experience working with clients with sleep disturbances and chronic pain.

Findings

The relationship between sleep disturbances and chronic pain was described as being complex and multifaceted. Participants believed they were uniquely placed to work with clients experiencing these two conditions. They felt inadequately equipped to treat sleep disturbances and chronic pain. Participants indicated that best practice required multiple interventions and a team-based approach. Finally, the participants noted that sleep disturbances and chronic pain are a growing area of practice.

Conclusion

The findings suggest that occupational therapists tailor their intervention strategies to be early, multi-pronged and individualised. Institutional barriers need to be addressed to further develop occupational therapists’ skill set when working in the areas of sleep and chronic pain. Further research to support the interventions currently used in practice to treat these two conditions is needed.

Keywords

sleep disturbances chronic pain occupational therapy

Introduction

Sleep, a behaviour that takes up one-third of our lives, is essential for survival and ensuring homoeostasis is maintained for optimal function (Finan et al., 2013). Environmental changes, social pressures, psychological functioning and pathological factors are key reasons associated with sleep disruption (Hillman, 2017). Sleep disturbances are defined as a reduction in one or more of the following categories: quality of sleep, time asleep and/or sleep duration (Hillman, 2017) and represent a significant public health burden. In Australia, the cost of inadequate sleep was approximately $50 billion in 2017, with four out of every ten people being impacted by sleep disturbances (Sleep Health Foundation, 2017). Sleep disturbances can negatively affect self-care occupations, cognition, mood, emotional functioning and physical wellbeing (Fung et al., 2013).

Pain can also lead to a lower quality of life and overall wellbeing (McNamee and Mendolia, 2014). Chronic pain is typically defined as the experience of persistent pain for a period longer than three to six months (Seroussi, 2015). People who live with chronic pain may experience disruption to sleep, physical weakness and inability to perform activities of daily living (Seroussi, 2015). Chronic pain affects 3.2 million people living in Australia, and many require daily assistance to manage their symptoms (Pain Australia, 2018). While chronic pain is estimated to cost Australia almost $150 billion in 2018, this number is expected to grow each year (Pain Australia, 2018). This high prevalence and the economic burden of chronic pain is particularly concerning when considering the ever-increasing ageing population (Fayaz et al., 2016).

Chronic pain shares a bi-directional relationship with sleep quality (Finan et al., 2013; Gerhart et al., 2016). In people experiencing chronic pain, 67%–88% also reported poor sleep quality as a co-morbid issue (Finan et al., 2013). Studies found that sleep disturbances are associated with an increased risk of chronic pain developing (Mork et al., 2013). Good sleep quality has been associated with dissipation in chronic pain over time (Finan et al., 2013). Conversely, recent research suggests that poor sleep quality has a greater impact on pain compared to the impact chronic pain has on sleep (Whibley et al., 2019). Sleep disturbances and chronic pain can both negatively impact an individual’s occupational performance and engagement (Fung et al., 2013; Robinson et al., 2011). Those clients who experience both chronic pain and poor sleep often experience increased symptom severity, longer periods of experiencing symptoms and increased numbers of co-morbidities (Husak and Bair, 2020). The bi-directional impact of sleep disturbance and chronic pain presents a significant challenge for many clients that occupational therapists see in daily practice.

Despite the importance of sleep for physical and mental health, it has only been classified as an independent area of occupation within the Occupational Therapy Practice Framework since 2008 (Leland et al., 2014). There is emerging evidence supporting interventions to improve sleep in occupational therapy (Ho and Siu, 2018). Acknowledging the suitability of occupational therapists to treat sleep disturbances is due to the ability to utilise a holistic approach and provide multiple intervention strategies for each client (Green and Brown, 2015; Robinson et al., 2011). Occupational therapy sleep interventions could include cognitive behavioural therapy, environmental strategies, lifestyle changes and activity (Ho and Siu, 2018). As noted previously, sleep disturbances often co-occur with chronic pain, and an effective intervention needs to also be cognisant of this.

Occupational therapists can play many vital roles in managing chronic pain, including but not limited to enabling occupational engagement and maximising performance through environmental modifications (Lagueux et al., 2018). These roles allow occupational therapists to facilitate a focus on participation through symptom management and coping (Hill, 2016). Occupational therapists often utilise an eclectic array of strategies to achieve the therapeutic goals of their clients, but the depth of evidence remains limited (Hesselstrand et al., 2015). However, the holistic nature of occupational therapy ensures that all of the areas of the person that are affected by chronic pain are addressed in some way.

Occupational therapists are well suited to manage sleep disturbances and chronic pain due to the profession’s holistic nature and understanding of both personal and contextual influences on sleep and pain. It is therefore important to gain an understanding of occupational therapists’ experience of managing sleep disturbances and pain. This study aimed to explore occupational therapists’ experience working with clients with sleep disturbances and chronic pain. Additionally, a description of the enablers and barriers that contribute to occupational therapists’ delivering best practice to their clients was explored.

Method

Research design

Interpretative Phenomenological Analysis (IPA) methodology was used to guide this study. The IPA approach encourages participants to reflect on their experience while the researcher interprets this sense-making. This double hermeneutic approach of IPA is well suited to the aim of this study. The reflective process is well suited to explore the participants’ experience of working in this area of clinical practice. Semi-structured interviews were conducted to explore occupational therapists’ experience, with specific reference to sleep disturbances synonymous to chronic pain. The interviews allowed for the depth and flexibility of the participants’ responses (Merriam & Tisdell, 2016).

Participants

A total of 11 occupational therapists were recruited from a variety of occupational therapy fields within Western Australia. Data collection ceased once the saturation of themes emerged (Dworkin, 2012). The researchers maintained reflective diaries to monitor their experiences and themes discussed. Saturation of themes was deemed to be achieved when no new themes were identified in more than two consecutive interviews. Participants had spent an average of 13.5 years working as occupational therapists and had spent an average of 7.6 years working within a sleep and chronic pain setting (see Table 1 for further details).

Table 1.

Demographics of participants at time of interview.

Name*	Gender	Years working as an occupational therapist	Years working in chronic pain and sleep	Area of practice**	Public or private sector
Robert	M	8	7	MH and N	Private
Daphne	F	20	4	A	Public
Maggie	F	12	10	MH	Private
Phoebe	F	27	5	MH, N and O	Private
Anna	F	12	3	MH	Private
Jenna	F	4	4	HV/AT	Both
Kim	F	32	20	P, HV/AT and VR	Both
Sarah	F	2	2	HV/AT	Both
Beth	F	9	9	HV/AT	Private
Cathy	F	3	3	H and HV/AT	Private
Louise	F	20+	12	H and OP	Public

* Pseudonyms have been used to preserve anonymity.

** Areas of practice: MH, Mental Health; N, Neurology; A, Amputee; O, Orthopaedics; HV/AT, Home Visiting and Assistive technology; P, Paediatrics, VR, Vocational Rehabilitation; H, Hospital; OP, Outpatient.

Participants were recruited using purposive sampling by distributing flyers to online specialist interest groups, professional development courses, professional networks and word-of-mouth. Following an expression of interest, each participant received an information package outlining the research process. Participants were included in the study if they were registered with the Australian Health Practitioner Regulation Agency for a minimum of 2 years and had at least 1 year of experience working with clients who have sleep disturbances and chronic pain.

Materials

The researchers developed twelve questions to guide the semi-structured interviews, Table 2. Prior to data collection, the questions were critiqued by two senior members of the research team and a practicing occupational therapist. As the interviews were dynamic, participants were given the flexibility to explore ideas further when the opportunity arose.

Table 2.

Semi-structured interview guide.

Interview questions
Sleep and chronic pain What is the role of occupational therapy in sleep and chronic pain? How confident are you working with sleep and chronic pain? Sleep What experience do you have working with sleep difficulties? How does sleep affect daily living activities?
Pain What experience do you have working with chronic pain? How does pain affect daily living activities?
Strategies What strategies do you use to manage sleep difficulties? What strategies do you use to manage chronic pain? How did you develop your strategies to manage sleep and chronic pain?

Procedure

The interview time and location were decided based on participant convenience. Interviews were completed by VM, MC, SS and JMM, lasting approximately 30 min and were recorded using a digital audio recorder. Ten interviews were conducted in person and one over-the-phone. The audio recordings were transcribed verbatim by MC and SS in preparation for data analysis. The de-identified interview transcripts were emailed to the participants for member checking, and no participant suggested any changes. Member checking was used to improve reliability and credibility.

Data analysis

The seven stepwise process of IPA analysis (Smith et al., 2009) was employed to analyse the data in Nvivo (QSR International Pty Ltd., 2018). Step one involved the researchers immersing themselves in the data. The second step required the authors to make initial notes associated with the data. Step three was the development of emerging themes, and in step four, the researchers looked for connections between these emerging themes. Step five was the repetition of these steps with other transcripts, which facilitated step six, whereby the researcher looked for patterns across the transcripts. In step seven, the researchers deepened their analysis and looking for symbolic meaning or links with theory. Steps one to five were completed by VM, MC, SS and JMM; JM, MC, VM, JMM, SS and CT participated in steps six and seven of the data analysis process. Step six served as a process of peer-reviewing the data analysis to provide further rigour. SH independently reviewed the final results.

Ethical considerations

Ethical approval was received from the Human Research Ethics Committee at Curtin University (HRE2019-0152). Verbal and written consent was obtained, and pseudonyms were used to maintain anonymity.

Results

Five themes emerged from the data in the analysis process: (i) Sleep disturbances and chronic pain are complex; (ii) Occupational therapists are uniquely placed; (iii) Institutional barriers; (iv) Requires multiple interventions with a team-based approach and (v) An emerging area of practice. The themes centred on the complexity of sleep and chronic pain, the role occupational therapists play in treating these conditions, what barriers and enablers impact occupational therapists to do so and what is being done to explore the area further.

Sleep disturbances and chronic pain are complex

There was a strong consensus from the participant interviews that their clients rarely experience sleep disturbances and chronic pain exclusively. Sleep disturbances and chronic pain were described as co-morbid and complex. Robert noted that because of these complexities, recommending treatment ‘is not as simple as just pain equals less sleep. There may be other things happening as well’. Participants reported that co-morbid sleep disturbances and chronic pain impede occupational performance and engagement, hindering independence. Sarah stated that when she has worked with a client with these co-morbid conditions, it is evident that ‘their ability to participate in activities of daily living [was also] affected’.

Participants also reported a psychological component should be considered when treating sleep disturbances and chronic pain. Specifically, focus on negative mindsets during treatment. Maggie stated that ‘pain, sleep and thoughts are all interrelated’. Phoebe explained that clients may have been independently managing their symptoms and were often reluctant to try alternative treatments. Phoebe spoke about how poor quality of life due to sleep disturbances and chronic pain do not have to be the ‘norm’ and that instilling hope in clients is an important initial step in managing these conditions.

Occupational therapists are uniquely placed

Participants recognised their role as being well suited to provide assessments and interventions for clients who experience sleep disturbances and chronic pain. Anna expressed, ‘I think we’re actually very uniquely placed. I think our perspective is very well-suited to helping people with their sleep [disturbances]’. Anna mentioned that her holistic understanding of what factors can impact occupational performance and engagement equipped her with a unique skill set to help manage sleep and chronic pain problems. Robert supported the notion further by stating:

As an occupational therapist, usually we would look at what they are doing and all [their] environmental factors first because that’s often overlooked. ... People come to us because we are caring individuals, so it takes a lot, it’s hard work, it’s really hard work. We are not the fixers, we are not there to fix someone, but we are there to care for them so that they can steer and get back to the point where they can start caring for themselves.

Furthermore, participants described the importance of recognising sleep as a core occupation, thus cementing ‘sleep’ as an area aligned to the occupational therapy profession. Louise emphasised that sleep ‘is just an occupation, it’s just exactly like any other occupation... it’s got a purpose, it’s something that people value’.

Institutional barriers

All participants acknowledged numerous institutional barriers impacting the treatment of sleep disturbances and chronic pain. These include workplace regulations, insufficient funding, gaps in formal education and limited opportunities for professional development.

Workplace regulations

Time restraints within the workplace were commonly reported to inhibit clients from receiving best practice. Beth mentioned that sleep disturbances and chronic pain are ‘brushed over a little bit due to time restraints’. With specific reference to sleep interventions, Anna recognised that ‘in group therapy, you don’t necessarily see them again’; therefore, many clients are discharged without receiving comprehensive treatment. Robert reported that he too had experienced barriers concerning workplace regulations, ‘it’s difficult because you are confined sometimes to your workplace policy’.

Insufficient funding

There was a consensus that funding is limited in the area of treating sleep disturbances and chronic pain. Participants explained that perhaps poor funding is due to occupational therapists’ role in the area being unrecognised and undervalued. Therefore, the ability for occupational therapists to expand treatment strategies is indefinitely capped.

Gaps in formal education

All participants reported that there was limited education in occupational therapy curriculum regarding sleep and chronic pain. Louise expressed that ‘sleep and chronic pain certainly wasn’t taught when I was at university’ and that ‘it would be good to have some formal input’. Jenna acknowledged her experience at university was similar to Louise’s by stating, ‘I definitely think there could be more training and education at university. I don’t think I really touched upon sleep from as much as I can remember’. Despite there being gaps in tertiary education, Robert reported he felt that his degree taught him ‘the techniques to learn’ rather than the facts about sleep and chronic pain themselves and therefore provided him with a base knowledge to build upon.

Limited professional development

Due to the gaps in formal education as stated above, participants reported the need to independently source further training concerning sleep disturbances and chronic pain. Louise stated, ‘sometimes I do worry that I don’t know enough about [sleep and chronic pain]’. However, she also noted that her additional training consists only of reading up-to-date literature. Similarly, Jenna mentioned she was ‘not very confident’ about treating complex sleep and chronic pain, as ‘[she] hasn’t had specialist or further training’. These statements support the common notion that many occupational therapists do not feel confident when faced with treating sleep disturbances and chronic pain. Daphne stated that occupational therapists need to be ‘aware of what else is out there and go to different courses and practices’ to build confidence. Despite the fact, the participants noted there were limited opportunities to become confident through professional development.

Requires multiple interventions with a team-based approach

Participants expressed that when providing best practice for sleep disturbances and chronic pain, multiple interventions utilising a team-based approach is necessary. Louise noted that multiple interventions are required to help solve the complexities of sleep disturbances and chronic pain.

If you think about [treatment of] chronic pain, medications are only a very small component. Sleep’s another bit, activity [is] another bit, returning to valued life activities, reducing avoidance, reducing fear of movement. If you only work [on one aspect], say medications, you can only ever expect to [address] 30% of the problem.

Similarly, Robert stated that ‘In order to be confident in helping someone, you must not go in with one [or] two interventions, you’ve got to have lots and lots of options’. Participants reported that it is common to utilise a stepwise approach to practice starting with simple strategies followed by complex interventions, both being person-centred and guided by a holistic framework. Table 3 shows a list of common interventions reported by the practising occupational therapists from the current study.

Table 3.

Common interventions reported by therapist-participants for clients experiencing sleep disturbances and chronic pain.

Cognitive-Behavioural Strategies	Equipment	Education	Sensory
• Cognitive Behavioural Therapy (CBT) • Acceptance and Commitment Therapy (ACT) • Counselling • Motivational interviewing • Goal-setting • Anxiety management • Mindfulness • Breathing techniques	• Bedside commode • Bed wedges • Urinal bottle	• Sleep hygiene • Sleep diary • Positioning • Cushioning • Seating • Bed mobility • Transfer techniques • Energy conservation • Pacing • Task simplification • Exercise and stretching • Occupational engagement • Limit technology use • Medication management	• Weighted blanket • Lighting • Temperature • Thermoregulation • Mattress/bedding • Scent – Lavender • Stimulus control

Participants expressed that in addition to using multi-component interventions, input from other health professionals is integral. When participants were questioned which health professionals play the most important roles in treating sleep disturbances and chronic pain, the most common responses were general practitioners, physiotherapists and psychologists. All participants highlighted the importance of having a team-based approach consisting of medical and allied health professionals. Phoebe recognised, ‘you just can’t do it on your own’. Similarly, Louise summed up her feelings towards a team-based approach by saying, ‘I wouldn’t feel confident if I didn’t work in a team. I wouldn’t feel confident to take them [clients] on by myself…I just know that doesn’t work’. Jenna further acknowledged that ‘I don’t think it’s something that occupational therapy can just fix. We can definitely give our input, but we need to work within a team’.

An emerging area of practice

Participants agreed that the body of knowledge surrounding sleep and chronic pain is emerging. Kim noted that over her 32 years of experience, she found that ‘there’s a lot of interest around sleep’, which has grown significantly in recent years. Kim noted that just as the co-morbid conditions are related, they are also increasing simultaneously, ‘there has been a real movement around pain … and understanding the importance of sleep’. In doing so, occupational therapists can become more knowledgeable about sleep disturbances and chronic pain. Daphne reinforces that, regarding sleep, ‘the more we become aware of it, the more we address it, the more we consider it as a part of our skills’. As the occupational therapy profession develops, Robert noted: ‘the most important thing we can do is to let our clients and our patients advocate for themselves and also to express to the community how much they have benefited from occupational therapy’.

Discussion

The current study provides insight into occupational therapists’ perspectives working with clients experiencing sleep disturbances and chronic pain. Five themes emerged from this study that may have notable implications for occupational therapy practice. Themes revolved around the complexity of the conditions, considerations for interventions and the importance of recognising the valuable and unique role that occupational therapists play in the area of sleep disturbances and chronic pain.

Sleep disturbances and chronic pain can depend on each other in an inverse relationship (Finan et al., 2013; Gerhart et al., 2016). The results from this study highlighted that participants understood this complex relationship between sleep disturbances and chronic pain. In the practice setting, sleep disturbances and chronic pain often present as secondary diagnoses, and therefore, they may not be the primary focus of occupational therapy intervention (Finan et al., 2013; O’Brien et al., 2011). The subordinate focus on sleep disturbances and chronic pain may result in them both being overlooked. Individuals who do not seek early intervention for their conditions may exacerbate their conditions in the long term and develop counterproductive coping strategies (Finan et al., 2013).

Sleep disturbances and chronic pain have ubiquitous impacts on participation in meaningful occupations(Fung et al., 2013; Robinson et al., 2011). Occupational therapists use a holistic approach in their practice, fitting with the all-encompassing challenges of sleep disturbances and chronic pain (Fung et al., 2013; Robinson et al., 2011). It is within an occupational therapist’s scope of practice to assess, set goals and provide interventions specifically to improve clients’ sleep quality and chronic pain (Fung et al., 2013; Robinson et al., 2011). Participants of the current study support the idea of occupational therapists playing a role in managing these two conditions. Despite this, participants identified sleep as a domain often overlooked within occupational therapy practice (Fung et al., 2013). On the other hand, the area of chronic pain is already well understood by occupational therapists (Robinson et al., 2011). However, if sleep continues to be neglected as an area of practice, therapists will be unable to develop an evidence-based skill set. Although occupational therapists are well placed to treat these co-occurring conditions, numerous institutional barriers may impede practice.

Participants in the current study acknowledged that their ability to provide treatment within the areas of sleep disturbances and chronic pain is often impacted by institutional factors. Participants recalled situations in practice whereby clients experiencing sleep disturbances and chronic pain received inadequate treatment due to the lack of funding allocated to treat these conditions. If this lack of funding continues, it is likely that clients’ difficulties will remain unchanged (Green and Brown, 2015). For this to change, funding bodies need to be aware of the importance of addressing these two complex conditions, the implications for practice and how occupational therapists can contribute to the management of these prevalent, intertwined and complex conditions (Green and Brown, 2015). Moreover, participants in the current study felt they received limited education at university on the topics of sleep disturbances and chronic pain. They noted because of this, their first experiences of dealing with sleep disturbances and chronic pain in the workforce required them to problem solve independently. The findings of this study suggest that complex commodities such as chronic pain and sleep disturbances could be incorporated into case studies within the curriculum to reinforce the importance of a holistic approach to occupational therapy (Green and Brown, 2015; Smallfield and Molitor, 2018). Furthermore, participants identified the need for opportunities for professional development to improve clinical skills to treat these two conditions. Despite these institutional barriers impeding practice, there remains an array of enablers identified by participants in the current study, which were reported to help achieve positive outcomes.

Most participants in the present study felt that to enable successful outcomes, management strategies needed to address both sleep disturbances and chronic pain, using a multi-pronged approach. Participants established that they could provide sleep hygiene education, recommend environmental changes and provide energy conservation strategies to target an individual’s sleep quality and chronic pain experience (Finan et al., 2013; Robinson et al., 2011). Providing interventions for one of these conditions may positively impact the other (De la Vega et al., 2019; Wei et al., 2018). The current study’s findings highlight the multifaceted nature of these conditions and the multiple intervention strategy approaches that are needed to see improvements (Whibley et al., 2019).

The results of this study should be interpreted with the following limitations in mind. The qualitative nature of the study means that researcher bias is a potential consideration in interpreting the data (Madill and Gough, 2016). Purposive sampling meant that the population was limited in geographical scope. The participants were also from a variety of practice settings. Therefore, the findings may not be applicable to other populations. It was necessary to interview occupational therapists to understand their perspectives, and this creates the potential for response bias due to a desire to promote the profession positively.

Implications for practice

The study adds to the already available literature, which purports that occupational therapists working are ideally placed to work in the area of sleep disturbances and chronic pain. The current study also identified potential strategies to overcome the numerous institutional barriers to achieve positive long-term outcomes for clients. Furthermore, it is recommended that occupational therapists provide early intervention in multiple individualised strategies, each tailored to the client’s needs and symptoms. These findings suggest how occupational therapists can design their individualised care plans to manage these co-morbid conditions.

Future direction

Future research could explore the experience of occupational therapists working with chronic pain and sleep disturbances in different practice settings, such as paediatrics, adult mental health and hand therapy. Further research is required regarding the efficacy of interventions in order to achieve evidence-based guidelines of what should and should not be included in occupational therapy practice. The institutional barriers, as identified above, should be addressed to enable occupational therapists to provide best practice. Addressing these barriers should allow occupational therapists to work holistically to meet the needs of individuals with co-morbidities and complex needs. Universities should continue to stress the importance of practicing holistically to ensure future occupational therapists are equipped to work with individuals experiencing chronic pain and sleep disturbances.

Conclusion

This study identified occupational therapists’ perspectives of the relationship between sleep disturbances and chronic pain. The five themes presented provide a starting point for further research. This study highlights the complexity of sleep and chronic pain problems and speaks to occupational therapists’ unique position to help manage clients with chronic pain and sleep disturbances. This study has also identified institutional enablers and barriers to this area of practice.

Key findings

• Occupational therapists are uniquely placed to treat these two complex conditions.

• There are multiple enablers and barriers impacting occupational therapists’ ability to treat clients experiencing sleep disturbances and chronic pain.

• Occupational therapists currently have some of the requisite skills to work with clients with sleep disturbances and chronic pain.

• Further research is required to establish a specific evidence-based practice.

Footnotes

Acknowledgements

The researchers want to thank all of the participants for their invaluable contribution to this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Research ethics

Ethical approval was received from the Human Research Ethics Committee at Curtin University in 2019 (HRE2019-0152).

Statement of contributorship

JM, MC, VM, JMM, SS and CT researched literature and conceived the study. JM, MC, VM, JMM, SS and CT were involved in protocol development and gaining ethical approval. MC, VM, JMM and SS were involved in recruitment and initial data analysis. JM, MC, VM, JMM, SS and CT contributed to the final stages of data analysis. SH independently reviewed the data and data analysis. VM and JMM wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Patient and public involvement data

During the development, progress, and reporting of the submitted research, Patient and Public Involvement in the research was not included at any stage of the research.

ORCID iD

C Thompson

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