Occupational therapy lifestyle intervention REVEAL(OT) added to multidisciplinary chronic pain treatment at a Danish pain centre

Introduction: Interventions addressing daily activities and lifestyle seem relevant for people living with chronic pain. Previous research showed that occupational therapy lifestyle management could benefit the chronic pain population. However, its effectiveness needs further investigation. Occupational therapy intervention REVEAL(OT) - Redesign your EVEryday Activities and Lifestyle with Occupational Therapy - targeting meaningful activities, daily physical activity and eating habits (Clinicaltrials.gov reg. NCT03903900) was developed as an add-on to multidisciplinary cognitivebehavioural therapy-based treatment at a Danish pain centre. No occupational therapy lifestyle management was previously included in the current treatment. Before initiating a full-scale randomised controlled trial (RCT), the intervention for feasibility.

Objectives: Based on knowledge derived from the development and feasibility evaluation process of the occupational therapy lifestyle intervention REVEAL(OT) added to standard multidisciplinary chronic pain treatment, this Ph.D.-project aimed to prepare an RCT that would investigate in the intervention effectiveness. Besides the presentation and methodological discussion of the research process represented in four scientifical studies, this Ph.D.-thesis attempted to set the REVEAL(OT) intervention in a broader perspective of non-pharmacological chronic pain treatment. 

Methods: The REVEAL(OT) development and evaluation process followed the Medical Research Council (MRC) recommendations allowing a multifactorial iterative approach to intervention development and conduct. The research complied with the principles of The World Medical Association’s (WMA) Declaration of Helsinki. In the intervention development phase, a systematic review with a meta-analysis investigated the effect of interventions including occupational engagement on lifestyle factors. In a survey, the associations between quality of life, health, pain, and lifestyle factors in the target population was investigated, inclusive motivation for initiating lifestyle changes as a part of chronic pain treatment. A qualitative mid-term evaluation with eight outpatients and four clinicians involved in the REVEAL(OT) using focus group methodology gained in-depth opinions on their participation derived from the data-driven thematical analysis and inspired to further intervention improvement. In total, the REVEAL(OT) went through three feasibility rounds between January 2019 and June 2021 and included eight groups (40 adults, 85.0% females, 46.6±10.9 (23-64) years old, average pain duration = 10 (9.3) years). Structural adjustments between the feasibility rounds reflected the outpatients and clinicians’ feedback. Primary outcomes were predefined research progression criteria based on “the traffic light” system (the red-amber-green method), including recruitment rate, participant retention, program adherence, assessment procedure acceptance, patients’ selfperceived relevance, timing, and mode of delivery, adverse and the fidelity of delivery. No comparator or blinding was applied. Secondary outcomes included were self-reported health-related quality of life (EQ-5D-5L, HRQoL) and occupational performance and satisfaction (The Canadian Occupational Performance Measure, COPM). 

Results: Research progression criteria for feasibility regarding program adherence; patients’ selfperceived relevance, timing, and mode of delivery; assessment procedure acceptance; and adverse events were overall feasible. Recruitment rate, participant retention and fidelity of delivery needed to be optimised before a randomised controlled trial. We found no improvement in HRQoL, mean = .04 (SD .16; 95% CI -.03; .12) assessed in 23 pre-post reports but significant change in the COPM scores, mean occupational performance = 1.80 (SD 1.44; 95% CI 1.25; 2.35) and mean satisfaction with occupational performance =1.95 (SD 2.34; 95% CI 1.06; 2.84), assessed in 29 pre-post reports. The recommended COPM cut-off for minimal clinically important difference (MCID) was 13.8% and 24.1%, respectively.  

Conclusion: Occupational engagement included in chronic pain interventions can support lifestyle improvements in adults. Interventions targeting pain, sleep, lifestyle and daily activities are needed to improve quality of life and health in people living with chronic pain. The REVEAL(OT) added to the multidisciplinary chronic pain treatment strengthened acceptance of living with chronic pain in adult chronic pain patients and empowered them for initiating lifestyle changes. The REVEAL(OT) satisfactory fulfilled its research progression criteria regarding programme adherence; patients’ selfperceived relevance, timing, and mode of delivery; assessment procedure acceptance; and adverse events, and thus was overall feasible. However, the recruitment, participant retention and delivery strategy of the REVEAL(OT) programme need optimisation before initiating an RCT. Improved interdisciplinary treatment delivery context will benefit the intervention feasibility