WHY REFER EARLY IN OCCUPATIONAL THERAPY?

The practice guidelines [i] demonstrate the following: early management improves the prognosis for returning to usual activities. Staying active is one of the key components for a positive development after an injury.

Unfortunately, the injured individual will often behave in the opposite way than recommended as a protective mechanism, focusing on rest and stopping activities which may increase the pain. Admittedly, in the acute phase, this form of protection is appropriate, but too often, these avoidance behaviors become predominant and persist over time.

However, we wonder: why are the patients not referred to occupational therapy earlier?

In the case of low back pain, for example, from the acute phase (0 to 4 weeks), although specific exercises and strengthening are not shown to be effective at this stage [ii], maintain an active lifestyle by respecting the symptoms rather than rest contributes to the favorable evolution of the condition [iii]. The occupational therapist thus becomes a professional of choice to encourage the patient to remain active while guiding him/her in the continuation or gradual resumption of usual activities. In order to quickly break the fear-avoidance cycle, the occupational therapist can:

• Begin educating on the condition and the principles of postural hygiene to be adopted;

• Identify energy and pain management strategies;

• Address more quickly the various individual or environmental obstacles linked to returning to work.

Then, during the subacute phase (4 to 12 weeks), passive treatments (eg physiotherapy, massage therapy and osteopathy) have been shown to be more effective combined with exercises and education [iv]. Occupational therapy, advocating an active approach, thus becomes a complementary service of choice to the physiotherapy approach. In order to gradually improve the skills prior to resuming problematic daily activities and work, the occupational therapist may:

• Establish a personalized program of graduated functional exercises with the patient;

• Facilitate the gradual integration of different skills by simulating different functional tasks.

In addition, the occupational therapist:                                             

• Assesses work capacities in order to present a plan that will respect the worker’s capacities while encouraging the job link to be kept secure

• Thus becomes an important ally for the doctor and the insurer regarding return to work

In short, by promoting graduated activity while respecting painful symptoms from the start of rehabilitation, the occupational therapist acts upstream to prevent the installation of psychosocial factors that have been shown to be factors of chronicity of pain (e.g. fears and beliefs, catastrophism, kinesiophobia) becoming major obstacles to resuming daily and productive activities.

References :

[i] Public Health Department – Montreal Health and Social Services Agency. (2006). “Clinic of Interdisciplinary Low Back Pain in First Line (CLIP)”.

[ii] Van Tulder, M. W., A. Malmivaara, et al. (2000). “Exercise therapy for low back pain.” Spine 25 (21): 2784-2796.

[iii] Hilde, G., K. B. Hagen, et al. (2004). “Advice to stay active as a single treatment for low-back pain and sciatica.” The Cochrane Database of Systematic Reviews 2.

[iv] Furlan, A. D., L. Brosseau, et al. (2005). “Massage for low-back pain.” The Cochrane Database of Systematic Reviews 2.

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