The basic concepts of Occupational Therapy center on four occupations of our daily lives: work, play, rest, and sleep. “Work” includes unpaid activities that have monetary value, for example cooking a meal is “work.” “Play” is what we do for fun. “Sleep” is sleep. “Rest” is activities that promote a sense of peace and calm. Occupational Therapy patient care goals relate to these four occupations. Since her 1978 graduation from USC, most of Candace’s career focused on the occupations “Work” and “Rest.”

Around 1983 she took a job in Sacred Heart Medical Center’s new regional rehabilitation program for people who had been injured on the job. The Injured Workers Program (IWP) was an all-day 4 week out-patient multi-disciplinary program. The care team included a Psychologist, Rehab. Medicine doctors, Vocational Counselors and three kinds of therapists—Occupational, Physical, and Recreational.

IWP’s approach to treating chronic pain was based on Melzack and Wall’s 1965 Gate Control Theory. The team was expected to help their patients “close the gate” between their brain and spinal cord to reduce their pain by the combination of biofeedback/relaxation training, gradually increasing activity and exercise levels, psychological treatment, and focusing on the hope of return to work. When oxycontin was being promoted as “safe” for people with chronic pain, it was occasionally prescribed for patients.

IWP’s overall goal was for patients to have the self-management skills, strength, and endurance to return to their regular jobs. Truck driving and millwork were the most common jobs.

As an Occupational Therapist, her primary role was to collaborate with the patient to identify their really challenging job tasks. Then think of a way to simulate those job tasks. They’d start at an easy level and gradually increase their physical capacities. She probably visited every type of mill there is to be able to more accurately simulate her patients’ job tasks.

When the Injured Workers Program was eliminated in 2001, she went to a brand-new Occupational Therapy job in the Employee Health & Safety Department, where she was an in-house consultant. Her task was to apply ergonomic principles to manual materials handling jobs, patient care jobs, and office jobs. She did Job Analyses and assisted with the return-to-work process for injured staff. Typically, pain and fear were the barriers to injured hospital staff’s return to regular work.
In the late 2000-teens she stumbled onto the You Tube video ‘Understanding pain in less than 5 minutes and what to do about it’, https://www.youtube.com/watch?v=C_3phB93rvI&t=17s. The video presented multiple factors contributing to pain which were already familiar to her, so it was easy to discuss with injured workers. She now realizes the frame of reference behind the Understanding Pain video was not the old familiar Gate Control Theory, but a pain-science-based understanding of how pain is constructed. At the time she still thought acute pain was very different from chronic pain. She didn’t really grasp the news that pain scientists had found that pain originates in the brain and not in the injured body part.

Thinking over her patient care experiences, it’s clear that both her IWP patients and her injured co-workers were afraid of overdoing it. They worried about increasing their pain level. They worried about causing bodily harm.

Although Candace hadn’t learned to see pain as a “Protector,” one focus of her Occupational Therapy practice was increasing injured workers’ sense of “Safety” and “Security.” During her Injured Workers Program days, the security and safety came from simulating key job tasks in the clinic and gradually increasing their level of physical demand to match the workers’ real-life jobs. During her Employee Health & Safety days, the doctor’s Return-to-Work Release served as a guide to safety and security.

The work release usually specified the amount of weight and force the injured worker could lift, carry, push, or pull. It might also set specific restrictions for walking, reaching, standing, and sitting. For example, if a Certified Nursing Assistant was released to 10 lb, intermittent reach above shoulder height, and no bending or twisting, Candace could the assure the C.N.A. that they were safe doing the following job tasks: greet and direct visitors, stock small supplies, collect meal trays and small patient care machines, assist patients with grooming & feeding, answer call lights, and prepare rooms for new admits (including moving the overbed table).

Another thing she did to build up an injured worker’s sense of safety and security as they performed physically active jobs was teaching them what she calls “Positions of Strength.” These are movement patterns based on biomechanical and ergonomic research. She would meet Sacred Heart injured workers at their job sites and they would practice these movement patterns.

Candace finds it ironic that she started to learn about the newer understanding of pain right when her job was being eliminated. In March 2019 at the Governor’s Occupational Safety and Health Conference she had the opportunity to hear a presentation by an OHSU Psychologist, Catriona Buist. In October 2019 at the Annual Conference of the Occupational Therapy Association of Oregon she heard a talk by Dr. Kevin Cuccaro about the new understanding of pain and met Physical Therapist Sharna Prasad who told her about the January 2020 Second Oregon Pain Summit. Since then she has taken classes from Dr. Cuccaro and read books by Lorimer Moseley.

Doing this presentation led Candace to remember her own worst experience with pain. It was a frozen right shoulder. Her car had a stick-shift so she had to take the bus to work. She was very angry about the hassle, the pain, and the inconvenience. Her Physical Therapist treated her with modalities and range-of-motion exercises. The pain went away and she was glad to drive a car again.

Why didn’t it all drag out? Candace asked herself: Was it because I trusted that my PT and my doctor knew what they were doing? Was it because they were sure of how long it would take me to get better and I believed them? Was it because my PT had a very soothing manner? With my new understanding of how pain works, I’d say it was everything put together—cognition, emotion, and sensation.

What’s next for her Occupational Therapy career and Pain Science? She hopes to teach POSITIONS OF STRENGTH in community settings–possibly Parks & Recreation Departments, Senior housing, community groups—and even 1:1 as the opportunity arises. POSITIONS OF STRENGTH aren’t directly related to Pain Science, but concepts such as safety, protection, and brain-body connections can be woven into the benefits of moving through POSITIONS OF STRENGTH.