Evaluate pain-relieving strategies Was child able to tolerate procedure? Can procedure or coping strategies be modi \201 ed t o improve e \200 ectiveness or pain relief? Source: data from von Baeyer, C.L. and Tupper, S.M, Procedural pain management for children receiving physiotherapy, Physiotherapy Canada , Volume 62, Number 4, pp.327 \200\223337, C opyright 2010 University of Toronto Press. CHAPTER 56 physical therapy interventions for pain in childhood and adolescence 587 Th erapist behaviors also infl uence pain and distress responses during painful procedures. Miller et al. (2001) found that when PTs promoted use of coping strategies, there was redu ced distress and increased coping in children with CP, whereas reassuring com- ments such a s \200\230it \200\231s almost over \200\231 and criticism increased distress and reduced c oping during rehabilitation. Physical therapy initial assessment: On observation, Will dis- played a left resting claw-h and deformity, wasting of the thenar eminence and fi rst interosseous muscles, oedema, and signifi - cant color changes (purple/blue skin color over the dorsal and palmar surface of the left hand and all digits to the distal third of the forearm). Active and passive range of motion, resisted tests, and strength testing could not be performed due to intense pain. Sensory examination revealed left hand and forearm light touch allodynia with temporal sum mation, decreased sensation and increased pain in response to cold stimulus, and pin prick hyperalgesia. Th ere was a positive modifi ed upper limb neuro- dynamic test 1. Will \200 \231s overall presentation was consistent with the Budapest clinical diagnostic criteria fo r CRPS probable type I (Harden et al., 2007). Cognitive behavioral methods that may be appropriate to lessen pain experiences of children during PT procedures include distrac- tion, guided imagery, relaxation, breathing exercise s, and thought stopping (von Baeyer and Tupper, 2010). Th e PT or caregiver may reinforce t he child \200\231s use of coping strategies by providing positive statements or tangible re wards, such as stickers, prizes, or praise. Th e PT should refl ect upon the procedure and evaluate the measures that were used to alle viate distress and pain responses. Questions to be considered include: Physical therapy management: PT management consisted of a 2-week trial of daily mirror ther apy. CRPS is considered a cen- tral nervous system condition with changes to the primary mo tor and sensory maps that represent the painful body part (McCabe, 2011). Mirror visual fee dback may correct sensory and motor remapping through short term cortical plasticity, there by reliev- ing pain. Th e mirror therapy approach involved Will placing his left hand behin d a mirror which was situated in front of his chest in a sagittal plane. Th is positioning hid his aff ected hand from view, allowing him to view the refl ection of his asymptomatic hand as if it were the aff ected side. Will performed a series of hand exercises with his r ight (asymptomatic) hand while observ- ing this hand refl ected in the mirror. Movement act ivities were structured according to diffi culty and were tailored to simulate his treatmen t goals. Each session began with cardinal hand and wrist active range or motion followed by more complex func- tional tasks requiring more upper extremity dexterity. Mirror therapy w as performed twice daily for 30 min each session. \227\206 Was the strategy appropriate for the child \200\231s developmental level? \227\206 Are the parent and child satisfi ed with the strategy for prevention of pain? \227\206 Was the strategy adequately eff ective in preventing or alleviating the child \200\231s pain? \227\206 Was it paired with pharmaceutical interventions if appropriate (i.e. burn care or post-surgical rehabilitation)? \227\206 If the procedure was experienced as painful despite appropriate measures, is ther e research to justify continuing with this proce- dure or can an alternative treatment be i mplemented? Recommendations PTs are an integral component of multidisciplinary management of pain in ch ildren. However, in view of the paucity of evidence supporting the use of passive therapies for pain management in this population, therapists are encouraged to consider a compre- he nsive theory-based approach to treatment with an emphasis on active therapies. Treatment pl anning must be focused on return- ing children to patient or care-giver identifi ed partici pation goals. Th erapists are encouraged to provide opportunities early in the therapeutic process for the child to tell in their own words the story about their pain experience in o rder to identify treatment goals and establish a benefi cial therapeutic alliance. Inactivi ty and fear of movement should be addressed through motivational interviewing, education, a nd graded activity programs. Many PT procedures are painful for young patients, and therapi sts are recommended to consider applying a wide range of procedural pain management techniq ues to minimize or eliminate pain during therapy. Outcomes: Will reported immediate pain reduction following each mirror therapy session by 2 to 4 points on a 10-point scale which was maintained for an increased amount of time with each successive session. In addition, Will reported a signifi cant decrease in the burning sensation and a \200\230more normal feeling \200\231 in his left hand following each sessi on. Aft er 2 weeks of daily mirror therapy, the distribution of his symptoms was reduced an d Will reported his baseline pain at 5/10 which he now characterized as \200\230tingling \200\231 over the palmar aspect of the third digit. On physical re-assessment, Will display ed persistent wasting of the left thenar eminence and fi rst interosseous, however the vaso motor and sudomotor changes observed on initial assessment were resolved. Full active range of motion of the hand, wrist, and forearm was observed. Sensory examination revealed the p resence of residual pin prick hyperalge- sia over the palmar aspect of the left third digit only. No allodynia and normal sensation to cold stimuli was noted. Despite persistent base line pain at 5/10, Will was able to successfully return to playing video games aft er the 2 -week PT mirror therapy. Case example: mirror therapy for unilateral upper extremity pain Patient history: Will, a 17-year-old male, was referred to PT by his palliative care physic ian, diagnosed with a nasopharyngeal rhadomyosarcoma with an abdominal recurrence of metast atic dis- ease. He received radical abdominal surgery including a nephrec- tomy, splenectom y, and distal pancreatectomy (see Box 56.1) . Acknowledgement Susan Tupper is the Coordinator of Integrated Pain Strategy and Research fo r the Saskatoon Health Region, and Clinical Assistant Professor at the School of Physical T h erapy, University of Saskatchewan. Medications: fentanyl and morphine as a part of abdominal surgery pain management. Gabapent in at 300 mg three times daily was added at the same time as the consult to PT. SECTION 8 physical interventions 588 Goldstein, D. N., Cohn, E., and Coster, W. (2004). Enhancing participation for children wit h disabilities: application of the ICF enablement framework to pediatric physical therapy p ractice. Pediatr Phys Th er , 16 , 114 \200\223120 . Hadden, K. and von Baeyer, C. (2002). Pain in children with cerebral palsy: Box 56.1 Patient history for case example 7-day history of acute left hand pain and decreased sensation following routine, uncomplica ted arterial line insertion. common triggers and expressive behaviors. Pain , 99 ( 1 \200\2232 ), 281 . Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., and Ferreira, M. L. (2010). Th e i nfl uence of the therapist-patient relationship on treatment outcome in physical rehabilita tion: a systematic review. Phys Th er , 90 (8), 1099 \200\2231110 . Initially located in thumb, spread to palmar aspect of his index and middle \201 ngers wi thin 24 h of onset, on removal of arterial line, pain spread through entire hand and was de scribed as a \200\230glove \200\231 that extended to distal third of forearm. Harden, R. N., Bruehl, S., Stanton-Hicks, M., and Wilson, P. R. (2007). Proposed new diagno stic criteria for complex regional pain syndrome. Pain Med , 8 (4), 326 \200\223331 . 9/10 (constant) on a 0 to 10 numeric rating scale, with 10 being maximum pain. Burning, cutting, numbness, and tingling with spontaneous intolerable pain episodes charact erized as \200\230lightning for no reason. \200\231 Hayes, N. M., and Bezilla, T. A. (2006). Incidence of iatrogenesis associated with osteopat hic manipulative treatment of pediatric patients. J Am Osteopath Assoc , 106 (10), 605 \200 \223608 . Color changes reported, unable to tolerate weight of bed sheet on hand due to intense pain. Houghton, P. E., Nussbaum, E. L., and Hoens, A. M. (2010). Electrophysical agents \200\224c ontraindications and precautions: an evidence-based approach to clinical decision making in physical therapy. Physiother Can , 62 (5), 1 \200\22380 . Humphreys, B. K. (2010). Possibl e adverse events in children treated by manual therapy: a review. Chiropract Osteopat , 18 (12). [Online] Available at: <http://chiromt.com/content/18/1/12>. Reported having no left hand function which limited ability to play video games; primary go al was to be able to return to playing video games. References Ayling-Campos , A. , Amaria, K., Campbell, F., and McGrath, P.A. (2011). Clinica l impact and evidence base for physiotherapy in treating childhood chronic pain. Physiother Can , 63 (1), 21 \200\22333 . Jewell, D. V. (2011). Guide to evidence-based physical therapist practice (2nd edn). Sudbury, MA : Jones & Bartlett Learning . Johnson, M. I., Ashton, C. H., and Th ompson, J. W. (1991). 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J Hand Th er , 24 (2), 170 \200\223178 . Chambers, C. T., Craig, K. D., and Bennett, S. M. (2002). Th e impact of maternal behavior on children \200\231s pain experiences: an experimental analysis. J Pediatr Psychol , 27 (3 ), 293 \200\223301 . McCarthy, C. F., Shea, A. M., and Sullivan, P. (2003). Physical therapy management of pain in children. In N. L. Schechter, C. B. Berde, and M. Yaster (eds) Pain in infants, children , and adolescents , pp. 434 \200\223448 . Philadelphia, PA : Lippincott Williams & Wilkins . Chorney, J. M., McGrath, P., and Finley, G. A. (2010). Pain as the neglected adverse event. Can Med Assoc J , 182 (7), 732 . McKearnan, K. A., Kieckhefer, G. M., Engel, J. M., Jensen, M. P., and Labyak, S. (2004). Pa in in children with cerebral palsy: a review. J Neurosci Nurs , 36 (5), 252 \200\223259 . Chung, H., Dai, T., Sharma, S. K., Huang, Y. Y., Carroll, J. D., and Hamblin, M. R. (2012). Th e nuts and bolts of low-level laser (light) therapy. 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A comparison of doctors \200\231, parents \200\231 and children \200\231s reports of health states and h ealth-related quality of life in children with chronic conditions. Child Care Health Dev , 38 (2), 186 \200\223195 . Flor, H. and Diers, M. (2009). Sensorimotor training and cortical reorganization. Neurorehabilitation , 25 (1), 19 \200\22327 . CHAPTER 56 physical therapy interventions for pain in childhood and adolescence 589 Th iel, H. W., Bolton, J. E., Docherty, S., and Portlock, J. C. (2007). Safety of chiroprac tic manipulation of the cervical spine: a prospective national survey. Spine , 32 (21), 237 5 \200\2232378 . Moseley, G. L., Gallace, A., and Spence, C. (2012). Bodily illusions in health and disease: Physiological and clinical perspectives and the concept of a cortical \200\230body matrix \200\231. Neurosci Biobehav Rev , 36 (1), 34 \200\22346 . Tremblay, M. S., Warburton, D. E., Janssen, I., Paterson, D. H., Latimer, A. E., Rhodes, R. E., et al . (2011). New Canadian physical activity guidelines. Appl Physiol Nutr Metab , 3 6 (1), 36 \200\22358 . Nnoaham, K. E. and Kumbang, J. (2008). Transcutaneous electrical nerve stimulation (TENS) f or chronic pain. Cochrane Database Syst Rev , 3 , CD003222 . Van Oosterwijck, J., Nijs, J., Meeus, M., Truijen, S., Craps, J., Van den Keybus, N., et al . (2011). Pain neurophysiology education improves cognitions, pain thresholds, and movemen t performance in people with chronic whiplash: a pilot study. J Rehabil Res Dev , 48 (1), 4 3 \200\22358 . Parlak Gurol, A., Polat, S., and Akcay, M. N. (2010). Itching, pain, and anxiety levels are reduced with massage therapy in burned adolescents. J Burn Care Res , 31 (3), 429 \200\223 432 . Posadzki, P. and Ernst, E. (2011). Spinal manipulations for cervicogenic headaches: a syste matic review of randomized clinical trials. Headache , 51 (7), 1132 \200\2231139 . von Baeyer, C. L. and Tupper, S. M. (2010). Procedural pain management for children receivi ng physiotherapy. Physiother Can , 62 (4), 327 \200\223337 . von Stulpnagel, C., Reilich, P ., Straube, A., Schafer, J., Blaschek, A., Lee, S. H., et al . (2009). Myofascial trigger p oints in children with tension-type headache: a new diagnostic and therapeutic option. J Ch ild Neurol , 24 (4), 406 \200\223409 . Prentice, W. E. (2011). Th erapeutic modalities in rehabilitation (4th edn). New York : McGraw Hill Medical . Ratcliff , S., Brown, A., Rosenberg, L., Rosenberg, M., Robert, R., Cuervo, L., et al . (20 06). Th e eff ectiveness of a pain and anxiety protocol to treat the acute pediatric burn p atient. Burns , 32 (5), 554 . Woods, M. P. and Asmundson, G. J. (2008). Evaluating the effi cacy of graded in vivo exposu re for the treatment of fear in patients with chronic back pain: a randomized controlled cl inical trial. Pain , 136 (3), 271 \200\223280 . Rutjes, A. W., Nuesch, E., Sterchi, R., and Juni, P. (2010). Th erapeutic ultrasound for os teoarthritis of the knee or hip. Cochrane Database Syst Rev , 1 , CD003132 . Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and Scheuer, L. and Black, S. M. (2004). Th e juvenile skeleton . San Diego, CA : treatment of pain. Pain , 152 (Suppl 3), S2 \200\223S15 . Elsevier Academic Press . World Health Organization. (2012). Global strategy on diet, physical activity and health: P hysical activity and young people [Online]. Available at: <http://www.who.int/dietphysicala ctivity/factsheet_young_people/en/ index.html>. Sermet-Gaudelus, I., De Villartay, P., de Dreuzy, P., Clairicia, M., Vrielynck, S., Canoui, P., et al . (2009). Pain in children and adults with cystic fi brosis: a comparative study . J Pain Symptom Manage , 38 (2), 281 \200\223290 . Suarez, M. and Mullins, S. (2008). Motivational interviewing and pediatric health behavior interventions. J Dev Behav Pediatr , 29 (5), 417 \200\223428 . Suresh, S., Wang, S., Porfyr is, S., Kamasinski-Sol, R., and Steinhorn, D. M. (2008). Massage therapy in outpatient pedi atric chronic pain patients: do they facilitate signifi cant reductions in levels of distre ss, pain, tension, discomfort, and mood alterations? Paediatr Anaesth , 18 (9), 884 \200 \223887 . Tecklin, J. S. (ed) (2008). Pediatric physical therapy (4th edn). Philadelphia, World Health Organization. (2007). ICF-CY: International classifi cation of functioning, di sability and health children and youth version . Geneva : World Health Organization . Yameen, F., Shahbaz, N. N., Hasan, Y., Fauz, R., and Abdullah, M. (2011). Effi cacy of tran scutaneous electrical nerve stimulation and its diff erent modes in patients with trigemina l neuralgia. J Pak Med Assoc , 61 (5), 437 \200\223439 . PA : Lippincott Williams & Wilkins . CHAPTER 57 Occupational therapy Liisa Holsti , Catherine L. Backman , and Joyce M. Engel Summary Occupational therapists specialize in how pain impacts the develop- ment and mainte nance of the occupations (self-care, productivity, leisure) of the daily lives of infants a nd youth in pain. Occupational therapists, working with families and other members of the h ealth care team, use both generic and specifi c theoretical frameworks and models to guide clinical practice. Th ese models ensure that a client-centered approach is used. In the eve ryday settings of the child, and using evidence-based practice, occupational therapists fac ilitate the treatment goals of children and families by integrating specifi c strategies, s uch as feeding, positioning, energy conserva- tion, and adaptive equipment. with headaches. Th e most current reports estimate rates of pain in the general population of youths as high as 70% (Du et al., 2011), and self-reported pain in adolescents can be as high as 40% (Dunn et al., 2011) or higher (King et al., 2011). A more detailed review of t he epidemiology of pain in children can be found in this volume in Chapter 2 by Stevens and Zempsky. Irrespective of the under- lying cause, pain may limit an infant \200\231s, child \200\231s or youth \200\231s ability to perform everyday occupations necessary to maintain health and well-being. Background Th e goals of occupational therapy for pediatric clients in pain are to develop, to maintain, and/or to restore their ability to participate in the occupations of their da ily lives. Occupation has a broad mean- ing; it is everything people do to occupy themselve s including activi- ties related to self-care, to productivity, and to leisure (Townsend an d Polatajko, 2007). For infants, the earliest occupations include changes in behavioral sta tes and movements which indicate self- regulation and purposeful engagement with the enviro nment (Holsti and Grunau, 2007a). For older infants and youths, self-care activities includ e engaging in their environment, feeding, sleeping, bathing, dressing, and mobility. Activi ties related to productivity are playing, participating in daycare and school, and in house hold, volunteer, or paid work. Leisure activities may also include play along with other ta sks, such as social and recreational activities. Introduction Infants born as early as 24 weeks of gestation respond peripher- ally, central ly, and cortically to nociceptive stimulation (Bartocci et al., 2006; Beggs and Fitzgerald, 2007; Fabrizi et al., 2011). Pain experienced early in life is associated with signifi can t long-term consequences including functional alterations in pain processing, in stress-res ponse systems, and in development (Grunau and Tu, 2007; Hohmeister et al., 2010). Not only is it unethical to let pain and suff ering in infants and youths go untreated (Johnston, 20 11), but failure to treat pain places this population at greater risk for negative health o utcomes as they mature (Koupil, 2007; Sullivan et al., 2008). Early referral to occupational therapy services can prevent fur- ther disability and can pr ovide critical support to family members. In order to understand more fully the unique cont ributions that occupational therapists make in restoring function and in mitigat- ing pain in infants and youths, the purposes of this chapter are the following: As in adults, infants and youths can experience acute and chronic pain in a number of ways. Undergoing painful, medical diagnos- tic and therapeutic procedures may be necessary to su stain life for infants or those who are born critically ill, preterm, or who have an acute trauma requiring emergency care (Stevens et al., 2011). In addition, pediatric clients may experience pain associated with preventative health care (immunizations); with trauma, such as from burns or physical abuse; with disease processes (e.g. arthritis); or with physical disabilities (Engel and Kartin, 2004; Engel, 2011; Parkinson et al., 2010). Moreover, pain may be a primary reason for seeking health care services (e.g. over-use syndromes associ- ated with computer use; Siu et al., 2009), or may occur as a result of rehabilitative proce dures, such as stretching. Finally, pain may arise and continue without a readily identifi able cause, such as (1) To describe occupational therapy theory and common practice frameworks. (2) To describe the impact/in \202 uence of pain on daily activities/ occupational performance. (3) To describe the occupational therapy practice process for infants and youths with pain including assessment, goal-set- ting, intervention, monitoring and modifying treatment, and evaluation. CHAPTER 57 occupational therapy 591 participation. Collectively, the conceptual framework guides the therapist to consider all areas of occupation as topics for assess- ment and intervention, together with the child \200\231s performance skills and characteristics of the environment in which the child perf orms those occupations. (4) To describe occupational therapy intervention strategies used to treat pain in infants and youth. Th e occupational therapy perspective Occupational therapy theory Th eory is a tool for thi nking about clinical practice. McColl and colleagues (2003) have classifi ed occupational t herapy theory, iden- tifying generic and specifi c theories pertaining to everyday occupa- tion, and a range of theories from \200\230small t \200\231 theory, such as theoretical id eas or propositions to \200\230big T \200\231 theory, encompassing more formal, well-artic ulated, and researched theoretical models (McColl et al., 2003). Occupational therapy profe ssional organizations promote generic occupational therapy theoretical frameworks that iden - tify occupational therapy \200\231s domain of concern and foster commu- nication and prof essional unity. For example, both the Canadian Association of Occupational Th erapists (CAO T) and the American Occupational Th erapy Association (AOTA) have published general theoret ical references that form a basis for the education of occupa- tional therapists and serve as national guidelines for practice. Th e Canadian Model of Occupational Performance and En gagement (CMOP-E; Polatajko et al., 2007) and the Occupational Th erapy Practice Framework: Domain and Process (Framework-II; AOTA Commission on Practice, 2008) outline an occupation -based domain of concern. Th ese models/frameworks provide the build- ing blocks for thinki ng about the concepts that occupational thera- pists address in practice. Th ey are generic models, applicable to any practice setting. Both the CAOT and AOTA documents cited briefl y off er generic models for thinking about pr actice with any client or client group. In contrast to generic occupational therapy theorie s, specifi c theo- ries are those that explain particular concepts and the relationships am ong them that apply to a more targeted population, issue, or problem. Examples of these inc lude sensory integration theories (e.g. Ayres, 1979), motor planning theories (e.g. Zwicker and Harris, 2009), neurodevelopmental theories (e.g. Wilson, 2005), and the gate control t heory (Melzack and Wall, 1965) or the biopsychoso- cial model (Loeser and Fordyce, 1983). F or neonates or infants, the synactive theory of development (Als, 1982) or the early life s tress model (Loman and Gunnar, 2010) may also be used to inform assessment and treatment. L ike other health professionals, occupa- tional therapists oft en draw upon several theories simultaneously to inform thinking and action. In conjunction with process models, which pr ovide a framework for action or problem-solving, generic and specifi c conceptual models gu ide professional reasoning. Th e Occupational Performance Process Model (OPPM; Fearing and Clark, 2000) and Canadian Pr actice Process Framework (CPPF; Davis et al., 2007) are two process models that were design ed to be compatible with the CMOP/CMOP-E and other conceptual theo- ries. Both are step-by- step problem-solving processes to guide the identifi cation of occupational performance iss ues or problems, the assessment or gathering of data about occupational perform- ance areas , the child \200\231s personal and environmental characteristics, the development of interv ention plans, and the monitoring of the eff ect of interventions. Th e AOTA Framework-II il lustrates how the concepts defi ning the domain of occupational therapy are inextricably li nked to its problem-solving process, which centers on collaboration between the practitione r and the client/family (AOTA Commission on Education, 2008). Th is practice process has th ree defi ning operations: evaluation, intervention, and out- comes. Evaluation requires tha t the therapist identify the client \200\231s occupational profi le (what the child needs a nd wants to do) and an occupational analysis (the demands of the child \200\231s occupation s and the extent to which the child can engage in them). Intervention involves developing g oals and plans, then implementing and moni- toring the plan. Th e outcomes stage refers to selecting appropriate outcome measures and applying them to determine whether or not occupa tional therapy achieved the intended goals and contributed to the child \200\231s health an d participation in life (AOTA Commission on Education, 2008). Th e CMOP-E, for example, explains three occupational per- formance areas \200\224self-care , productivity, and leisure \200\224as a way of classifying what people do in everyday life (Polatajko et al., 2007). Furthermore, the characteristics a person possesses are conceptu al- ized as spiritual, aff ective, cognitive, and physical. Th us, this generic theoretical model guides an occupational therapist to consider assessing what is important to a child and what motivates that child to act (spirituality), their feelings and mood, (aff ective c omponent), their capacity to learn and solve problems, (cognitive component), and their abi lity to move, (physical component), all in the context of their usual self-care, productive , and leisure occupations (bath- ing, dressing, eating; school or lessons; and play). Addit ionally, everyday occupations are performed in context \200\224a social, cultural, institut ional, and physical environment. Using CMOP-E, occupa- tional therapy intervention can then focus on modifying the envi- ronment, the demands of the occupation, or the child \200\231 s skills in order to maintain or improve performance. Similarly, the AOTA Framework-II describes how occupational therapy supports health and par ticipation in life through occupa- tional engagement. Th e concepts comprising occupational thera- py \200\231s domain of concern are client factors, performance skills and patterns, activity demands and areas of occupation, and context and environment (AOTA Commission on Education, 2008). Th ese concepts provide a common language for thinking and learn- ing abo ut the way a child (or anyone) engages in the occupations they need and want to do througho ut their lives, and the impact of individual and environmental conditions on that performan ce. In this framework, areas of occupation are defi ned as activities of daily living (ADLs , such as bathing and dressing), instrumen- tal activities of daily living (IADLs, such as community mobility and safety), rest and sleep, education, work, play, leisure, and social Importantly, occupational therapists working with children in pain are part of a team that includes other professionals, the infant or youth, and the family. Th us, other theories an d process models may inform how the team works together to assess the situation and to deve lop an intervention plan. Occupational therapists may draw upon occupation-based theory to inform their specifi c contri- bution, as well as the team \200\231s specifi c philosophy o r interdisciplinary theoretical approach. For example, collaborative teams working with chi ldren and families in health, educational, or community settings may use biopsychosocial, d evelopmental, social, and/or ecological theories of human development to ensure the needs o f the child are met. Bronfenbrenner and Ceci (1994) introduced SECTION 8 physical interventions 592 a bio-ecological model of human development to explain envi- ronmental infl uences on the i ndividual that crosses disciplinary boundaries. It has been tested, adapted, and applied to supporting children of all ages, and cited widely. Occupation-based theories are not only compatible with such approaches, but help to make the occupational therapist \200\231s role explicit to the team and to the fam- ily. Hickman and colleagues review empirical evidence on applying developmental and movement science theories to early interven- tion practices (Hickman et al., 2011). Th ey indicate the importance of transdisciplinary approaches that support collaborative goal set- ting with the child and family as both a contributor to eff ective care and a challenge to maintain in complex care settings. a comparator for later outcome evaluation to determine if goals were achieved. Th e process begins by screening for occupational performance issues \200\224there is no need for more detailed assessment procedures unless the child \200\231s health status or symptoms, includ ing pain, have an impact on or threaten occupational performance. An initial observation of an infant or an interview with the child and/or caregiver helps to identify specifi c prob lems and factors contribut- ing to those problems, as well as resources to be considered in for- mulating an intervention plan. Th e assessment process may include observation, self- report, and performance-based tests in order to document baseline performance or identify i ndividual strengths and limitations for choosing particular treatment modalities. In the pr esence of pain, it may not be appropriate or possible to conduct a complete evaluation in a single session or at all; priorities need to be established in light of the presenting cir cumstances. Although dis- cussed as a discrete step, assessment is oft en ongoing and integ rated into the intervention process. How pain a \200 ects occupation Children engage in a range of roles aligned with their dev elopmen- tal stage. For example, one of the roles of an infant is to engage in the environm ent purposefully to ensure its survival. Roles are sup- ported by occupational engagement. Pain may prevent children from engaging in the occupations that contribute to, or are essen tial for, their life roles. One way to understand the potential impact of pain is to consid er a basic occupational taxonomy (such as presented by Crepeau and Schell (2009) or Polataj ko et al. (2004)) and how pain may interfere at any level of that hierarchy (see Figure 57. 1). Infant assessment Assessing pain in infants is complex for a number of reasons, the most ob vious one being that infants are not able to self-re- port. Th us, occupational therapists must fi rst assess the context in which pain may be present (e.g. as in postoperative pain or related to a disease process) and then rely upon a combination of behavioral and physiol ogical indices shown to be the most reliable and valid measures of pain. For infants, these indices usu- ally include specifi c, anatomically defi ned facial and body move- ments, ch anges in sleep/wake states, and changes in heart rate. Many of these indices have been incl uded in a number of reli- able and valid tools available for assessing acute pain in infant s, such as the Behavioral Indicators of Infant Pain (BIIP; Holsti and Grunau, 2007b), the P remature Infant Pain Profi le (PIPP; Stevens et al., 1996), the Neonatal Facial Coding Syst em (NFCS; Grunau and Craig, 1987), the Comfort Scale (Ambuel et al., 1992) and the FLACC sc ale (face, legs, activity, cry consolability; Merkel et al., 1997). Th e psychometric prope rties of neonatal and infant pain tools have been reviewed extensively in this volume by Le e and Stevens (Chapter 35) and elsewhere (Stevens et al., 2007). Most recently, technologie s, such as near infrared spectroscopy (NIRS) and electroencephalography (EEG) are providing researchers and clinicians with important complementary information regarding evaluating p ain responses in infants at a cortical level (as reviewed by Holsti et al., 2011). Pain may inhibit an action : pinching a button; a task : buttoning a shirt; an activity : g etting dressed; an occupation : completing morning self-care. As a result, pain at any leve l of occupational performance may limit the child \200\231s roles in life; in this example, the occupational therapist is concerned with supporting the child to develop inde- pendenc e in self care because it is a natural developmental milestone, and eff ective and appropri ate dress contributes to participation in other roles, such as playing dress-up, being in u niform for a sporting team, or being dressed for school or church. Th erefore, an occupa- t ional therapy assessment will identify which aspects of occupation are aff ected by pain; t he strengths and resources the child has; and provide direction for selecting interventions that will overcome the eff ect of pain on the occupations the child needs and wants to do. Assessment Overall purpose and process Th e purpose of the assessment is to establish a bas eline that in turn informs goal setting and an intervention plan, and provides An important consideration for occupational therapists \200\231 assessment of pain is wheth er or not to use a tool that combines behavioral and physiological indices into a single sc ore (a multi- dimensional approach) or to evaluate these categories of indicators separatel y (a unidimensional approach). Th is choice is important because in both infants and in chi ldren, dissociation between behavioral and physiological indicators is common (e.g. Morison et al., 2001). Including both behavioral and physiological indices is critical; however, i f a multidimensional tool is used, and the eff ects of any applied treatments are not evalu ated as to their eff ects on both the behavioral and physiological components, caregivers a nd researchers may miss important information as to the overall effi - cacy of the treatmen t. For example, sucrose is an oral solution given to infants to reduce acute procedural pai n (Stevens et al., 2010). Although sucrose consistently reduces the behavioral component Occupation Activity [e.g., 2nd grade student, ballet dancer, baseball player] [e.g., put on a shirt, color a picture, play a game] Task [e.g., fasten a button, climb stairs, throw a ball] Action [e.g., grasp, reach, step] Figure 57.1 Th e in \202 uence of pain on childrens \200\231 occupational roles. CHAPTER 57 occupational therapy 593 of the pain response, its eff ects on physiological responses can be variable (Stevens et a l., 2010). Th is type of \200\230split \200\231 response to a treat- ment raises the conce rn that failing to reduce the physiological response leaves infants vulnerable to the desta bilizing physiological eff ects of pain.