Pain Assessment and Management, 2nd Edition _ _________________________________________________
found that nonrestorative sleep, stress, and inactivity are risk factors for chronic pain. Helpful treatments for poor sleep include screening for a sleep disorder (e.g., sleep apnea) and an examination of the individual’s body positioning, sleep hygiene practices, and sleeping environment. Investigation of the client’s typical sleep routine, starting hours before bedtime, can reveal if earlier engagement in activities is alerting or calming. Discussion of calming routines and strategies to limit alerting sensory input, such as lighting from the television or computer screen, is helpful in establishing a new sleep routine. Incorporating daily exercise and a regular daily routine of activity can also encourage regular sleep hours. RELATIONSHIP BETWEEN PAIN AND SENSORY PROCESSING A client’s ability to register and process sensory stimuli can affect their pain perception and reactions. Sensory processing occurs via the nervous system, which regulates sensory input; processing occurs as stimuli are sent to the brain, exceed a threshold for the amount of stimulation needed, and are then interpreted to produce an action (Dunn, 2009). Recently, through the use of MRI, there has been a better understand- ing of the changes in brain structure and function for those who experience chronic pain. The brain regions and networks include those involved with pain processing and other sensory tasks (Gombaut & Holmes, 2022; Malfliet et al., 2017). Dunn categorized patterns of sensory processing related to the pain threshold and self-regulation as sensory seeking, sensory avoiding, sensory sensitivity, and low registration (Dunn, 2009). Sensory seeking is characterized by a high threshold for stimuli and active self-regulation behavior; sensory avoiding involves a low threshold for stimuli and active self-regulation behavior; sensory sensitivity involves a low threshold for stimuli and a passive self-regulation behavior; and low registration is characterized by a high threshold for stimuli and a passive self-regulation behavior (Dunn, 2009). These process patterns can affect how an individual functions in day-to-day activities as they respond to internal or external stimuli. In a study specifically addressing the associations between sensory sensitivity and pain, Meredith et al. (2015) found that low registration and sensation seeking were correlated with ignoring pain and catastrophizing. Sensory sensitivity and sen- sation avoiding were positively associated with catastrophizing (Meredith et al., 2015). Individuals with high thresholds and low registration may not notice pain triggers in their environ- ment until the threshold is so high that they feel the pain “out of nowhere” and consequently feel less control over their pain management. Individuals with low sensory thresholds may be more sensitive to stimuli such as loud noises or movement. As a result, they may be higher in sensory avoiding behaviors, such as limiting exposure to large crowds or unexpected events. Asarian et al. (2019) find that rescripting of the pain mental image has been effective in the reduction of pain intensity of patients with chronic pain (p = 0.001, α 2 = 0.58). These authors
define rescripting as changing the contributory qualities of the mental image, addressing the sensory displacement, and then challenging the meaning in the mental image in subsequent sessions. The intent is to reduce the emotional effect of the mental image of pain. The Adolescent/Adult Sensory Profile (Brown & Dunn, 2002) is an easy test to administer and gives helpful strategies to improve sensory modulation. One helpful strategy for a per- son with low registration might be to take frequent breaks. A person who is sensitive to sensory stimuli may want to organize and simplify their workspace to improve focus. Careful atten- tion to sensory avoidance can alert a practitioner to a client’s tendency to isolate. Interventions here can involve planned and graded exposure to social situations. VIGNETTE Rebecca is a 23-year-old graduate student with a diagnosis of fibromy- algia and chronic headaches. She is invited to attend a concert at a small venue in the city with her friends but is fearful about her pain and does not want to be a burden on the others. The entire event sounds too risky to her, and Rebecca decides to tell her friends that she is busy. She is upset that she cannot go and tells her practitioner, “I feel like I can’t even do normal things that young people do. I don’t know why they even ask me anymore.” Music is an identified leisure activity for Rebecca, and spending time with her friends addresses her social needs as well as being a part of her role as a young college student. After ascertaining that participation in this occupation is important to Rebecca’s leisure, social, and role participation, the therapy practitio- ner can begin to problem-solve with the client about possible solutions and adaptations to successfully participate in this desired occupation. Details of the trip are planned out to acknowledge the realistic demands of the activity, which begin even before the activity starts. The client needs to consider the entire day and the physical demands of getting ready (self-care) and driving. The demands of the environment are explored: Does the venue have seats? At what time realistically will the band play? Will the noise or smells (e.g., perfume) trigger a headache? Then the client and practi- tioner mutually identify solutions such as: • Spreading out the self-care activities of showering, applying makeup, and doing hair slowly throughout the day, with breaks • Calling ahead to see if there are seats • Asking to carpool with a friend who can drive • Communicating with that friend about her pain and the possible need to leave early • Planning to take breaks in the car if the noise or smells get too aggravating • Making a back-up plan to get a ride home (family/ friend/taxi) if she needs to leave • Planning for rest and exercise the following day to recover
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