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4/10/2018

CHRONIC PAIN:
The Power of Lifestyle Redesign® Informed
programs to turn the tide
Michal Atkins, MA, OTR/L
April 19, 2018

Objectives:
1. Define chronic pain and pain typologies
2. Describe the impact of pain on people’s lives
3. Identify the key elements of providing an OT Lifestyle
Redesign® Informed program for individuals with
chronic pain.
4. List Pain assessments most relevant to Lifestyle
Redesign® Informed programs
5. Value the important contribution of OT Lifestyle
Redesign® Informed program for the person with
chronic pain.

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From what pains does this woman


suffer?

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Stroke pain
• Central post-stroke pain • Other post stroke pain:
(SPSP)- Neuropathic • Shoulder pain
pain syndrome
30-40%
Characterized by:
Motor and sensory
• Pain deficits
• Sensory abnormalities • Painful spasticity.
• Tension-type headache.

(Klit, H. Finnerup, N. B. & Jenson, 2009).

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What kind of physical challenges do


people with disabilities have which
complicate chronic pain conditions?
• Weakness • Mobility
• Muscle imbalance • Neuropathic origin
• Overuse • Aging
• Residuals of initial • Multiple pains
trauma

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What non-physical challenges


must this woman overcome?

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What kind of non-physical challenges


do people with disabilities have
which complicate chronic pain
conditions?
• Depression and anxiety • Financial burdens
• Stress • Routine disruptions
• Fear and avoidance • Role disruptions
• Social isolation • Lack of meaningful
• Unemployment activities

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Impact on Occupational
Performance
• Performance components
• Sensorymotor
• Cognition
• Psychological
• Social

(Hanson, R. A., & Atchinson, B. A, 2000).

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Impact on Occupational
Performance
Performance areas:
• ADL
•Work
•Leisure
•Rest and sleep

(Hanson, R. A., & Atchinson, B. A, 2000).


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What is chronic pain?


Persistent pain, which can be either
continuous or recurrent and of sufficient
duration and intensity to adversely affect
a patient’s well being, level of function,
and quality of life” (Wisconsin Medical
Society Task Force on Pain Management,
2004). www.icsi.org

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Neuropathic pain- “Abnormal processing of sensory


input by the peripheral or central nervous system.”
McCaffery, M. & Pasero, C. (1999).

• Sharp, shooting, burning, electric, abnormal


responsiveness

Nociceptive pain- “Normal processing of noxious


stimuli”. (Institute for Clinical Systems Improvement,
2011).

• dull, aching, cramping, localized


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SCI pain

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Nociceptive vs. Neuropathic Pain

Nociceptive Mixed Neuropathic


Arthritis Neuropathic low-back
Fibromyalgia pain
Mechanical low back
Headache Polyneuropathy (diabetic,
pain
HIV)
Post-operative pain Low back pain
Postherpetic neuralgia
Myofascial pain
Sickle cell crisis
syndrome Trigeminal neuralgia
Sports/Exercise Injury Skeletal Muscle
SCI
pain

1.Pain Management: Theory and Practice. Philadelphia, PA: FA Davis Company;1996:4.


2.. A Clinical Guide
M. to Neuropathic
Atkins, 2018 Pain. Minneapolis, MN: McGraw-Hill Companies Inc;
14 2000:8-9.

Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain
. Pain. 2011;152(3 Suppl):S2-15. doi:10.1016/j.pain.2010.09.030.

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Pain amplification

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Definitions:
• Allodynia- Pain evoked by stimuli that is usually not
painful (touch or brush).
• Hyperalgesia-An increased response to a stimulus
that is normally painful.
• Paraesthesia-An abnormal but non-painful (and
not unpleasant) sensation, either spontaneous or
evoked.
• Dysaesthesia- An abnormal unpleasant sensation,
either spontaneous or evoked.
(Klit, H.,Pinnerup, NB, Jensen, TS, 2009).

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MultiModal Pain
Management
Over the Counter
-acetaminophen, NSAIDs, topicals
Antidepressants
-Tricyclic (TCAs)-amitriptyline, nortriptyline, desipramine
-Serotonin and Norepinephrine reuptake inhibitors (SNRIs)-
duloxetine, venlafaxine
Anticonvulsants
-carbamazepine-trigeminal neuralgia
-gabapentin-postherpetic neuralgia, neuropathic pain
-pregabalin-postherpetic neuralgia, neuropathic pain d/t
diabetes and spinal cord injury
Non-pharmacological
-weight loss, massage,
acupuncture, TENS,CBT,
Lifestyle design® Manworren R., Multimodal Pain Management and the
Future of a Personalized Medicine Approach to Pain, http://www.aorn.org/CE, March 2015.

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Pharmacology Cont’d
Opioids (i.e., morphine, Tramdol, Codeine,
Hydrocodone).
Know as much as you can
Facilitate correct and optimal adherence through:
• Double check with the client, go to clinic
with them, help them come up with the
right questions
• Incorporate into daily habits
• Help find solutions for correct dispensing and
administering of meds.

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Incidence Number of Sufferers (millions)

100

25.8
16.3
11.9
7

Chronic Pain Diabetes Heart Disease Stroke Cancer


(AAPM, 2013)

http://www.painmed.org/patientcenter/facts_on_pain.aspx#incidence
The American Academy of Pain Medicine

Incidence

Low back pain Neck Pain (15%) Facial ache or


Severe headache or pain (4%)
(27%) migraine pain (15%)

(AAPM, 2013)

American Academy of Pain Medicine


http://www.painmed.org/files/facts-and-figures-on-pain.pdf

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Rancho’s chronic pain patients:


Stroke, SCI, TBI, MS, Arthritis and back pain

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Common Comorbidities:
• Overweight or obesity
• Diabetes
• Psychiatric conditions: Depression
and anxiety

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Table 1: Aspects of the Domain of Occupational Therapy


from the OTPF 3rd edition
Occupations Client Performance Performance Contexts and
factors skills pattern environments
Activities of daily Values, Motor skills Habits Cultural
living (ADLs) beliefs and Process Routines Personal
Instrumental spirituality skills Rituals Physical
ADLs (IADLs) Body Social Roles Social
Rest and sleep functions interaction Temporal
Education Body skills Virtual
Work structures
Play
Leisure
Social
participation

AJOT, September 2017, Vol. 68, S1-S48. doi:10.5014/ajot.2014.682006

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Lifestyle Redesign ®

• Occupational Lifestyle Redesign is the process of


developing and infusing healthy occupations into
day-to-day occupational routines. (Mandel et al.,
1999)
• At Rancho: Pain; Stroke; Diabetes, Weight
Management; SCI; Cardiac, Epilepsy and Caregiver

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OT Chronic Pain and


Lifestyle Redesign®
Informed program

The New Yorker, 2012

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How do we embed healthy behaviors in


everyday life with individuals with chronic
pain?
1. Occupational self-analysis
2. Individual goal setting
3. Motivational building
4. Didactic content- MODULES
5. Individually tailored

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Occupational Self Analysis:


• Occupational identify- Roles
• Typical day- Routines
• Meaningful and engaging occupations
• Occupational challenges
• Occupational history

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How do we embed healthy behaviors in


everyday life in individuals with chronic pain?

6. Practice new habits/occupations


7. Facilitate and celebrate self management
8. Problem solve/ self-reflect/discuss
9. Repeat habits/occupations (time element)
10. Celebrate success

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What is the evidence?

• Lifestyle Redesign® studies


• Lifestyle Redesign® for Chronic Pain Management: A
Retrospective Clinical Efficacy Study (Uyeshiro Simon,
A. & Collins C. E. R (AJOT, 2017).
• Related OT studies
• Related studies of other disciplines.

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What is the evidence?


Lifestyle Redesign® for Chronic Pain
Management: A Retrospective Clinical Efficacy
Study (Uyeshiro Simon, A. & Collins C. E. R (AJOT,
2017).
Objective: “To determine the efficacy of a
Lifestyle Redesign® intervention for people living
with chronic pain on QOL, function, self-efficacy,
and pain levels.” (AJOT, 7104190040p1).

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What is the evidence?


• Fisher, G. S., Emerson, L, Firpo, C., Ptak, J.,
Wonn, J. & Bartolacci, G. (2007). Chronic pain
and occupation: An exploration of the lived
experience. AJOT, 61, 290-302.

• Objective: Examine the relationship between


pain and occupation.

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Results: The Themes:


• Chronic pain is life changing
It triggers emotional distress, reveals the
strength of relationships.
• Chronic pain and occupation are reciprocally
related forces.
• Chronic pain elicits innovative adaptive responses
Resourcefully modified routines and tasks.
Found enhance meaning in favored
occupations.
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What did the participants recommend to others


with chronic pain?

• Diverting occupations
• Exercise and physical activity
• Meditation

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The Flow Experience:


Flow is an optimal subjective psychological state “in
which people are so involved in an activity that
nothing else seems to matter; the experience itself is
so enjoyable that people will do it even at great cost,
for the sheer sake of doing it” (Csikszentmihalyi, 1990,
pg. 4).”

Robinson, K., Kennedy, N., & Harman, D. (summer, 2012).


The flow experiences of people with chronic pain.
The occupational Therapy Journal of Research. 104-112.

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Hypotheses:
• 1. Pain intensity will be significantly lower while
people with chronic pain are in flow compared to
other states.
• Flow is an optimal experience for people with chronic
pain.
• Frequency of flow experiences will differ across the
contexts of “at home” and “somewhere other than
home”.
• Frequency of flow experienced will differ across “self
care”, “work”, and “leisure”.
Robinson, K., Kennedy, N., & Harman, D. (summer, 2012). The flow experiences of people with chronic pain. The
occupational Therapy Journal of Research. 104-112.

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Findings:
• 1. Pain intensity was not significantly lower while
people with chronic pain were in flow compared to
other states.
• Yes. Flow is an optimal experience for people with
chronic pain.
• Frequency of flow experiences were greater at
“somewhere other than home” and not at “home”.
• Flow was most experienced during “work”, and not
during “self care” or “leisure”.

Robinson, K., Kennedy, N., & Harman, D. (summer, 2012). The flow experiences of people with chronic pain. The
occupational Therapy Journal of Research. 104-112.

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Assessments
• Medical Hx.
• Physical exam. varies
by Dx.
• Numeric Pain Scale
• COPM
• Typical day

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The Canadian Occupational Performance Measure


Initial Discharge

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Assessments Cont’d
• Observation
• Function
• Pain inventory
• What makes it better
• What makes it worse
• Self-management skills
• Self efficacy

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How do you manage living with


your chronic pain right now? or
What do you do to manage your
pain right now?

“I don’t”
“I do nothing”

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Goal setting:
• Allows us to
understand the
person and “meet”
where he/she is.
• Keeps us grounded
• Key to success

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My personal goal sheet


My goal for this week:
_____________________________________

Did I achieve the goal? If, no what were the barriers?


__________________________________________
__________________________________________

M.
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2012 45

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When is OT Lifestyle Redesign®


Informed effective?

Acute Post Ready!

An in d ivid u a l t ime lin e

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Care Processes

Support Self-Esteem
System Rapport Context &
Environment
Peer Agenda
Check-In Setting
Mentoring Occupational
Occupational Self-Analysis
Group Engagement:
Goals Activity
Dynamics Habits, Roles
& Routines Occupational
Problem Profile &
Motivational Education Experience
solving
Interviewing
Self-
Patient
Advocacy
Activation
Legend
Sequence of a Care Session
Leland, N. & Gillies, H., 2015
Core Therapeutic Processes

Care Processes

Support Self-Esteem
System Rapport Context &
Environment
Peer Agenda
Check-In Setting
Mentoring Occupational
Occupational Self-Analysis
Group Engagement:
Goals Activity
Dynamics Habits, Roles
& Routines Occupational
Problem Profile &
Motivational Education Experience
solving
Interviewing
Self-
Patient
Advocacy
Activation
Legend
Sequence of a Care Session
Leland, N. & Gillies, H., 2015
Core Therapeutic Processes

Motivation

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Motivational Interviewing + Activities = Motivation


Techniques/ CBT to change

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Atkins,2018
2018 52

Table 1: Aspects of the Domain of Occupational Therapy


from the OTPF 3rd edition
Occupations Client Performance Performance Contexts and
factors skills pattern environments
Activities of daily Values, Motor skills Habits Cultural
living (ADLs) beliefs and Process Routines Personal
Instrumental spirituality skills Rituals Physical
ADLs (IADLs) Body Social Roles Social
Rest and sleep functions interaction Temporal
Education Body skills Virtual
Work structures
Play
Leisure
Social
participation

AJOT, September 2017, Vol. 68, S1-S48. doi:10.5014/ajot.2014.682006

M. Atkins, 2018

Client’s goal setting is an excellent indicator of


their progress.

Examples for 1st weeks: “I want my arm to hurt less”


“I want to have a normal life again”.

Somewhat later: “I want to understand better what I


can do to hurt less” “I want to manage my
medications better”

Even later: “I want to play with my grandchildren for


1 hour a day” “I want to learn to relax better”.

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Common intervention modules:

• Being healthy and being well


• Living with chronic pain
• Body mechanics
• Ergonomics
• Exercise and physical activity
• Food, nutrition and weight management
• Fatigue, rest , pacing and sleep
• Self care and home skills

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Common intervention themes (modules)


informed by Lifestyle Redesign® (Cont’d)
• Stress management and relaxation
• Occupations: necessary and meaningful
• Relationships, social support, and community
resources
• Community, outdoor participation
• Pharmacology
• Holistic, alternative, complimentary interventions
• Routine and habits
• Balancing it all
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The “sleep module”


The importance of a good night sleep:
Having chronic pain is exhausting!
Gather details
Medication routines
Position in bed
Assessing equipment
Education

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Sleep Hygiene:
• Maintain a regular sleep routine
• Avoid naps if possible
• Don’t stay in bed awake for more than 5-10
minutes
• Don’t watch TV or read in bed
• Watch your caffeine intake. Remember that soda
and tea contain caffeine.
• Exercise regularly
• Have a quiet comfortable bed
• Develop sleep ritual
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Resting/Sleeping

(Consortium for Spinal Cord Medicine, 2008).

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The Pacing Module

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Activity Cycle:
Over-activity

Underactivity

(Birkholtz, M., Aylwin, L., & Harman, R. M., 2004).

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Pacing consists of:


(a) changing position to time,
(b) taking frequent short rests,
(c) breaking tasks into manageable bits,
(d) alternating positions and tasks frequently,
(e) slowing down
(f) increasing activity amounts gradually.
(i) people who are normally too cautious or fear-avoidant can
benefit from speeding up instead of slowing down.
(ii) the reduction of tension/effort behavior during activities,
because even a perfectly planned work session, for
example, is unlikely to be satisfying if tasks are carried out
with a high degree of tension.
(Birkholtz, M., Aylwin, L., & Harman, R. M., 2004).
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Important points to
remember:
 Ground goals in OT and in Occupations!

 Value the power of HOPE and work


toward restoring a sense of control

 Communicate regularly with the rest of


the pain team

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The challenge:
Decrease Occupations

“can do
attitude”

Hopelessness MOTIVATION

Venting Increase

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Mr. A.
• Med history: 25 y/o Latino male with a Dx. Of
Peripheral Sensory Neuropathy and LBP
Ambulatory
• OT referral for Lifestyle Redesign for Chronic Pain
• Occupational Hx.:
• Began college but stopped 2nd to pain
• Lives with grandparents, father and a younger brother
• Works part time in a PT clinic

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The Canadian Occupational Performance Measure


Initial Discharge

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Mr. D.
• Med history: 53 y/o AA male SCI (T5 AIS B) 2nd to
GSW when he was 14. R shoulder rotator cuff Sx.
2007; Pressure ulcer flap Sx. 2014; Carpal tunnel
Sx. 2016
• OT referral for Lifestyle Redesign for Chronic Pain
• Occupational Hx.:
Pt. lives alone
His girlfriend is also his caregiver
He has not worked but has gone to school and “likes
to hang out”.

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The Canadian Occupational Performance Measure


Initial Discharge

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Challenges and
opportunities:

• Marketing the
program
• Explaining what we
do
• Role in Primary
Care
• Individual vs. Group
therapy

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Atkins,
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2018 74

Our education,
skills, ability to
solve problems,
goal oriented hands
on activity based
approach, enables
us to empower
individuals with
chronic pain to
greatly improve
their health and
quality of life.

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E
• Dr. Heather Tick-Nutrition tips for chronic pain
http://heathertickmd.com/

• Australian 5 minute video about Chronic Pain:


https://www.youtube.com/watch?v=C_3phB93rvI

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Atkins, 2018
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References:
Birkholtz, M., Aylwin, L., Harman, R. M. (2004). Activity Pacing in Chronic Pain Management: One aim, but which
method? Part One: Introduction and literature review. The British Journal of Occupational Therapy, 67 (10),
447-452.
Birkholtz, M., Aylwin, L., Harman, R. M. (2004). Activity Pacing in Chronic Pain Management: One aim, but which
method? Part two: National activity pacing survey. The British Journal of Occupational Therapy, 67 (11), 481-
487.
 Clark, F. A., Blanchard, J., Sleight, A., Cogan, A., Florindez, L., Gleason, S.,…Vigen, C. (2015). Lifestyle Redesign®:
The intervention tested in the USC Well Elderly Studies, Second Edition. Bethesda, MD: AOTA Press.
Clark, F., Sanders, K., Carlson, M., Blanche, E. & Jackson, J. (2007). Synthesis of habit theory. Occupational
Therapy Journal of Research: Occupation, Participation and Health. 27, Supplement 1-17.
 Fisher, G. S., Emerson, L, Firpo, C., Ptak, J., Wonn, J. & Bartolacci, G. (2007). Chronic pain and occupation: An
exploration of the lived experience. AJOT, 61, 290-302.
Heck Edwards, C. (2000). Chronic Pain. In Hanson, R. & Atchison, B. (Eds). Conditions in Occupational Therapy:
Effect on Occupational Performance. (2nd edition). Philadelphia: PA. Lippincott, Williams and Wilkins.
Jackson, J., Carlson, M., Mandel, D., Zemke, R. & Clark, F. (1998). Occupation in lifestyle redesign: The well elderly
study occupational therapy program. American Journal of Occupational Therapy, 52, 326-336.
Klit, H. Finnerup, N. B. & Jenson, T. S. (2009). Central post-stroke pain: Clinical characteristics, pathophysiology
and management. Lancet Neurology 8, 857-68. www.thelancet.com/neurology

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References
Lorig, K. L. (2003). Self-management education, more than a nice extra. Medical Care, 41, 699–701.
Mandel, D., Jackson, J., Zemke, R., Nelson, L. & Clark, F. (1999). Lifestyle Redesign: Implementing the well elderly
program. Bethesda, MD: The American Occupational Therapy Association, Inc.

 Mulroy, S. J., Thompson, L., Kemp, B., Hatchett, P. P., Newsam, C. J., Lupold, D. G., Haubert, L. L., Eberly, V., Ge,
T. T., Azen, S. P., Winstein, C. J., Gordon, J. (2011).Strengthening and optimal movements for painful shoulders
(STOMPS) in chronic spinal cord injury: a randomized controlled trial. Physical Therapy. 91(3), 305-324.
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153-163. SienceDirect www.sciencedirect.com
Radomski, M. V. (2000). Self-efficacy: Improving occupational therapy outcomes by helping patients say “I can”.
Physical Disabilities Special Interest Section Quarterly, 23, 1–3. Bethesda, MD: American Occupational
Therapy Association.
Siddall, P. J., Yezierski, R. P. & Loeser, J. D. (2000). Pain following spinal cord injury: Clinical features, prevalence
and taxonomy. IASP Newsletter. 3, 3-7.
 Uyeshiro Simon, A., & Collins, C. E. R. (2017). Lifestyle Redesign® for chronic pain management: A retrospective
clinical efficacy study. American Journal of Occupational Therapy, 71, 7104190040.
http://doi.org/10.5014/ajot.2017.025502
Wood, W., Quinn, J. & Kashy, D. (2002). Habits in everyday life: Thought, emotion, action. Journal of Personality and
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