Pain Assessment and Management, 2nd Edition _ _________________________________________________
ERGONOMICS The International Ergonomics Association (2018) defines ergonomics as a science that seeks to understand the interac- tions between an individual and the physical, cognitive, and organizational components of a system. The role of therapy is to optimize the ability of a client to function using the skills and knowledge of anatomy, physiology, and activity analysis (Dorsey et al., 2017). These techniques can be used with any individual who is having difficulty performing their various life roles due to chronic pain. Shariat et al. (2018) recommend a participatory ergonomics intervention, in which the practitioner works with the patient to engage in stretching exercises along with environmental modifications for improvement in neck, shoulder, and low back pain. Proper body posture should be addressed during all activity, as well as repetitive motions and reaching that can exacerbate pain. Ergonomic modifications are not limited to posture alone. Repetitive motions, lack of rest or stretch breaks, and environmental factors (e.g., lighting) can all exacerbate pain and should be examined. Pacing of Activity and Energy Conservation Practitioners teach a client with chronic pain to break down activities in order to understand the physical and mental components of performing those activities is a valuable lesson on self-pacing. One of the earliest definitions of pacing is that “pacing involves breaking down activities into smaller steps, resting between steps and doing small amounts regularly rather than a large amount of activity in one go” (Kavanagh, 1995, p. 417). Antcliff et al. (2018) defines pacing as a multifaceted coping strategy whereby individuals can adjust time spent on activities, plan for activities, engage in consistent activity levels, accept their current abilities and gradually increase time spent participating in activities and setting goals around activity levels. Guy et al. (2019) found that there is evidence to support the use of pacing to reduce fatigue and joint stiff- ness; however, it does not assist in reducing pain. In a study by Scott-Dempster et al. (2017), pacing was found to be effective for both clients and practitioners. These authors identified several themes, including providing a tangible structure that is flexible and allowing the client to reframe thinking where less is more. Pacing can involve not just the components of a single, specific activity but also a more general sense of how a person manages the overall activities of their day. Both aspects of pacing will be discussed. Pacing of a specific activity can involve breaking down the activity into more manageable chunks of time, incorporating self-monitoring of pain. For example, if a client needs to com- plete 20 minutes of ironing but can stand for only 5 minutes at a time before their pain starts to flare up, the client can break down the ironing activity into four 5-minute segments with a rest period between segments.
Clients should be taught that pacing a specific activity could also involve adapting their posture or adding equipment to make the activity tolerable. An adaptation of posture can involve changing to a sitting position or adjusting the place- ment of items (e.g., in a cupboard) to be within easier reach in order to lessen strain. Adaptive equipment includes the familiar list of home management and self-care equipment that practitioners use as well as more recently developed technology or equipment, such as a sit-to-stand office desk. To improve awareness of the demands of an activity, it is helpful to break down the steps of the activity, the amount of exertion demanded, and the estimated time to complete each step. The practitioner can break down the steps of an activity and then ask the client to estimate the time and effort needed to complete each step. Time is the number of minutes (or hours) it will take the client to complete the activity, and effort is the amount of physical exertion the activity will require, with a score of 1 indicating the “least amount of effort” and a score of 5 indicating a “great deal of effort.” Although this scale is not validated, it is a subjective measure that may be useful in gathering information in a session. The client can look back later, after completing the activity, to reflect on whether the activity took longer than they anticipated and involved more or less effort than expected. This exercise is the beginning step of helping a client analyze parts of an activity for themselves. For example, the client may report increased pain from doing certain chores. Specifically, the client wishes to unload the dishwasher but finds that doing so increases back pain. The task can be broken down into four steps. Step 1: Unload the top drawer of the dishwasher and place the items on the counter. Time estimated is 5 minutes. Effort is ranked as a score of 3 because there is minimal bending and reaching involved. Step 2: Move the items from the counter into the cabinets. Time estimated is 5 minutes. Effort is ranked as 3.5 as a result of having to reach up into the cabinet. Step 3: Unload the bottom drawer of the dish- washer and place the items on the counter. Time estimated is 5 minutes. Effort is ranked as 4 because the bottom drawer of the dishwasher is likely to contain heavier items. Step 4: Move the items on the counter into the cabi- nets.
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