Addressing Self-Stigma in Fibromyalgia Using Pain Neuroscience Education: An Occupational Therapy Case Study

Abstract

The symptoms of fibromyalgia can be misperceived because they are often visibly undetectable, thereby leaving persons with fibromyalgia exposed to others’ incorrect understanding of their experience and physical capabilities. Persons with fibromyalgia may experience stigma, when nobody understands the condition or how it affects their daily occupations. This retrospective case study describes how occupational therapy, as part of a biopsychosocial and multidisciplinary team approach, can use pain neuroscience education as an effective treatment strategy for fibromyalgia and discusses the benefits of an educational approach to improve our understanding of fibromyalgia, as well as decrease self-stigma and increase occupational performance.

Keywords:

• Occupational therapy
• fibromyalgia
• self-stigma
• pain neuroscience education
• occupational performance

Introduction

Preparing the occupational profile of a client improves the understanding of the individual’s illness experience, including stigma attributed to certain health conditions. An occupational profile initiates an occupational therapist’s understanding of the client’s life history related to their experiences, occupational roles, values, and needs (American Occupational Therapy Association [AOTA], 2020). By understanding the client’s experience, we can discern how an illness affects the client and may better comprehend the stigma they experience.

This study explores the experiences of a person with fibromyalgia (FM) named June (pseudonymized for anonymity) and her improved results after interventions using Pain Neuroscience Education (PNE). June was referred to occupational therapy by a rheumatologist to address her concerns about FM’s impact on her daily life. When the occupational therapist (OT) met June to gather her occupational profile, she was vocal, honest, and disheartened when discussing her life story. The OT noted her fidgeting hands and teary eyes as she spoke of the trauma and struggles in her life, underscoring the psychosocial impact of the disease. The OT observed her optimism while setting her goals, as well as her dejection after identifying her current level of performance.

Research on occupational therapy applying concepts of neuroscience education in practice is scarce, yet there has been moderate evidence supporting the use of neuroscience education as an intervention for people experiencing chronic pain diagnoses such as FM (Snodgrass & Amini, 2017). PNE as an occupational therapy intervention is supported by the AOTA’s (2021) position statement on the role of occupational therapy in pain management. The position statement highlights PNE as an intervention strategy to support the achievement of a client’s occupational therapy goals as was used within this occupational therapy case example. Our case study also explores the use of a specific educational strategy in conjunction with traditional occupational approaches, and if such a strategy can reduce the effects of self-stigma and decreased occupational performance as perceived by a person with FM.

Understanding pain

Chronic pain is often viewed as a physical condition, which results in other unacknowledged types of pain that fail to fit this normative expectation. Health care providers often misdiagnose the source of other rarely detected pain experiences, such as FM, and assign a physical diagnosis to a neurophysiological condition. When FM is deemed a physical condition, it may become categorized as an observable disability. Perceiving pain as a physical manifestation of underlying pathology causes stigma when the measures to reduce or relieve the physical condition do not ensure pain relief. When symptoms are not evident, chronic pain conditions may be viewed as invisible illnesses, causing stigmatization because these infirmities rarely fit with the typical views of Western medical science on pathology, and thus, may not be observed objectively (Cohen et al., 2011).

Pain is a subjective experience that is unique to each individual. The International Association for the Study of Pain (IASP) (2020), defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” and includes additional notes to support understanding (Raja et al., 2020, p. 14). Experiencing pain which is typically associated with tissue damage, without any attributable injury or physical changes, can be frustrating and confusing not only for the individuals with pain, but for individuals trying to understand or empathize with their loved one’s pain experiences. When an individual with chronic pain does not receive support or empathy from their family and friends, and possibly their health care provider(s), it can further impact their mental health and occupational performance. Therefore, all healthcare providers involved in the care of clients with pain, including OTs, should share a common language and educate clients on how pain works to increase independence and understanding of the condition (Eneberg-Boldon et al., 2020).

Fibromyalgia

Persons with FM often experience pain regularly, without any visible, external symptoms, causing the disease to be labeled as an “invisible illness” (Armentor, 2017). According to the American College of Rheumatology (2019), FM affects 2–4% of the US population and is a neurological health condition characterized by widespread pain and weakness. People with FM experience symptoms such as fatigue, decreased thinking capacity and memory, and poor sleep. Furthermore, people with FM may experience migraines, anxiety, depression, digestive concerns, pelvic pain, and other health issues (American College of Rheumatology, 2019), which may be overlooked due to a lack of a physical manifestation.

As a controversial condition, FM often creates social stigma, primarily due to the lack of an explainable pathology. If health care providers struggle to understand the underlying pathology of a client’s symptoms, it may result in the stigmatization of persons with FM, because the disorder remains incompatible with the existing conceptual biomedical framework. These effects extend to society at large, embedding the stigmatization of persons with FM into our very culture and perceptions of pain (Cohen et al., 2011).

Applying a biomedical framework to diagnose and treat persons with FM will not explain their painful symptoms, and the limitations imposed upon self-care and daily activities. Waugh et al. (2014) discuss how the invisibility of chronic pain creates a negative stereotype of disability, dependency, and apathy, thereby forcing clients with chronic pain to “justify and defend their experience, often leading to feelings of invalidation” (p. 550e2). When a person’s experience is not validated by their health care provider, it may cause them to question their own pain experience. Health care providers and the general population may reduce such individuals’ pain experience and limitations to an inaccurate objective representation, based on their perceptions, denying the latter their own identity and agency.

Stigma

The relationship between pain and social stigmatization originates from the health care provider’s need to find a physical cause for pain. De Ruddere et al. (2016) found that the inability of an observer (such as a health care provider) to connect a person’s pain experience with a physical cause, often leads to stigmatization and social exclusion. If the health care providers employ a biomedical perspective and find no physical injury or illness, they focus on diagnosing a mental health issue instead of a physical concern (Cohen et al., 2011). The resultant stigma only serves to exclude the person who experiences pain from others, by replacing their actual identity with a virtual or perceived identity related to their pain experience (Goffman, 1997); Goffman explains that stigma can isolate a subject from others within their social domain. Health care providers’ failure to understand the connection between the biological, psychological, and social aspects that intersect within the pain experience worsens the situation. Unable to make these necessary connections, patients feel that no one understands them and hence they feel guilty, believing that others perceive their pain as imaginary.

A person may internalize the outward beliefs and stereotypes of others and develop conflicting beliefs about themselves, leading to self-stigma. Corrigan et al. (2009) described the process of developing self-stigma as having an awareness of the social beliefs and stereotypes about those with a particular condition, agreeing with the beliefs and stereotypes and then applying the beliefs and stereotypes to oneself. Perugino et al. (2022) noted that many people who experience chronic pain also experience self-stigma, and these numbers are similar to those who experience self-stigma related to mental health conditions. A person who experiences self-stigma related to FM, or other chronic pain conditions, may not understand their symptoms and may not have the confidence to confront the negative beliefs and stereotypes related to their condition. They may apply the outward beliefs of others, blame themselves for their symptoms, and experience other negative feelings, such as failure and worthlessness (Bean et al., 2022). To cope with self-stigmatization and the symptoms they are experiencing, a person may avoid certain activities and social gatherings (Bean et al., 2022), which may negatively impact how they spend their time and organize their daily routines. Waugh et al. (2014) found that pain self-efficacy was lower and pain catastrophizing thoughts were higher in those experiencing higher levels of self-stigma, which may be important to understand in the assessment and treatment of clients with FM.

Self–efficacy

Self–efficacy signifies a person’s confidence in their ability to complete a specific task or engage in a situation. It also affects the person’s consistent participation in that task or situation (Bandura, 1977); “The strength of people’s convictions in their own effectiveness is likely to affect whether they will even try to cope with given situations” (Bandura, 1977, p. 193). If self–efficacy is low, a person may be diffident about completing a task or avoid the task altogether. If self–efficacy is high, a person may persist through the task or situation despite limiting factors. Successful performance strengthens self–efficacy beliefs; however, unsuccessful attempts leading to unfinished tasks diminish them (Artino, 2012).

According to Bandura (1977), a person’s self–efficacy can influence their choice and participation in activities. Therefore, it is important that OTs address self–efficacy, in order to improve clients’ occupational performance. Studies suggest that the experience of chronic pain has significant effects on a person’s life roles and routines, forcing changes in the person’s everyday life (McParland et al., 2011). Moreover, an individual’s beliefs are significant in these altered life roles and routines. If a person with pain feels unsure of an activity’s effect on their symptoms, they may become fearful and avoid the desired activity.

Pain neuroscience education

Some healthcare professionals may have a poor understanding of the multi-factorial pain experience which can cause decreased confidence in their ability to treat chronic pain. Focusing only on the biomedical perspective is not sufficient to effectively treat chronic pain, and knowledge regarding approaches that address all aspects of the chronic pain experience is necessary (Johnson, 2019). The Australian National Pain Strategy (NPS) recommends education and training in treating pain and encourages practitioners to recognize stigmatization as well as help clients achieve societal validation by including “neurobiological insights into the nature of empathy” (Cohen et al., 2011, p. 1641). The World Health Organization encourages health care providers to work as a team with their clients to address pain (Kumar, 2007). Johnson (2019) included the recommendation for care providers to work together “to co-create explanations about pain and construct care plans that empower individuals to be active participants in their treatment because it creates self–efficacy” (p. 6).

Pain neuroscience education (PNE) is an educational strategy that helps clients, health care providers, and society at large to understand the biology and physiology of the pain experience (Louw et al., 2016). Louw et al. (2016) conducted a systematic review and found that PNE influences multiple factors. It can reduce the pain experience, catastrophizing thoughts, and negative psychosocial factors, among others. Watson et al. (2019) studied patients with musculoskeletal trauma who were preparing for surgery and found that PNE helped reduce pain and anxiety, and also increased self–efficacy.

Methods

Occupational profile

June is a 62–year–old woman who participated in occupational therapy over the course of 5 months and 21 days (April 2019–October 2019), with a total of eight visits. She was referred to occupational therapy by her rheumatologist because of functional deficits associated with FM. During occupational therapy treatment, she received interventions from a multidisciplinary team comprising members from the Physical Therapy, Psychiatry, Psychology, Podiatry, Pulmonology, and Rheumatology departments.

June was diagnosed with FM 10 years ago and had a significant surgical history, including a surgery to relieve bilateral carpal tunnel syndrome and right shoulder rotator cuff surgery. Her medical history includes lumbar spine degenerative disk disease, hypertension, obstructive sleep apnea, and chronic lower back pain. She had tested positive for Lyme’s Disease three times in the last 8 months and was treated with a course of antibiotics.

Her reported symptoms include severe fatigue; joint, muscle, and ligament pain; periods of forgetfulness; brain fog; anxiety; and depression. Episodes of dizziness due to specific movements such as stooping to pick up items; and numbness as well as tingling in hands, feet, and neck limit her ability to engage in daily life tasks. She mentions a poor sleep routine and considers morning her worst time of the day.

A complete occupational profile reveals that June was previously widowed, and currently lives in a large, old farmhouse with her supportive fiancé, who is also disabled. June’s valued occupational roles previously included that of a bus driver. Childhood trauma associated with her father’s death when she was 12 years old, made her feel responsible for caring for her 10 siblings, and later, being the primary caregiver for her mother. She describes multiple traumas associated with her birth family, including the destruction of a family home in a tornado and the loss of 10 family members in a single year.

June reports that she is unable to care for her home, either physically or financially, and describes many environmental challenges associated with living in a large, old farmhouse. The water heater is damaged, and water needs to be heated on a stove. Cooking and cleaning are difficult and constricted by a decreased tolerance to standing. She struggles with dressing herself and is afraid of falling while bathing and showering. She describes vacillating from feeling emotionally numb to constantly crying.

If her symptoms were reduced, June wishes to resume caring for her flower bed and vegetable garden. She wishes to go fishing, which she has not done since her husband committed suicide six years ago. Her strengths include support from her fiancé, her desire to complete tasks such as gardening, cooking, and fishing, as well as loving and caring for her three dogs. She was expressive during the occupational therapy evaluation process and hopeful about occupational therapy helping her to meet her goals.

Data were gathered through semi-structured interviews, observations of movement patterns including ease of movement with transfers, posture, and stiffness when completing reaching and other functional movements and four standardized measures. Measures were chosen based on information gathered in the subjective portion of the initial evaluation and based on measures used with those who experience pain to gain a better understanding of their pain experience. The retrospective single-subject case study design underwent review from the Baylor University human research ethics committee (IRB Reference #1919834). The committee determined that the case study did not meet the definition of human subject research according to the federal regulations 45 CFR 46.102€& (1). June provided written consent for participation.

The Canadian Occupational Performance Measure (COPM) (Law et al., 1990, 2014) was applied to identify needs in the areas of self-care, productivity as well as leisure and to develop goals accordingly. The COPM is a client–centered and individualized outcome measure administered in a semi–structured interview format which is used to identify occupational performance concerns (Law et al., 1990, 2014). Clients rate their perceived performance with respect to desired activities and their satisfaction with their performance in these activities. The ratings for performance and satisfaction range from 1 to 10 with 1 indicating “not able to do at all” or “not satisfied at all,” and 10 indicating “able to do extremely well” or “extremely satisfied.” Ratings with higher numbers indicate higher performance and satisfaction. The activities identified as important to the client became the client’s goals for occupational therapy intervention.

The QuickDASH (Beaton et al., 2005) is an 11–question outcome measure that gauges a client’s perception of their function and symptoms related to upper limb musculoskeletal conditions. Although the QuickDASH is typically used to assess upper limb conditions, it helps understand quality of life for clients with FM (Ataoğlu et al., 2018). It also includes optional modules with four questions each comprising a work module and a sport/performing arts module. Clients rate each question on a 5–point scale with 1 indicating “no difficulty or limitation” and 5 indicating “inability” or “extreme difficulty.” Ratings with higher numbers indicate higher disability/symptoms.

The Pain Catastrophizing Scale (PCS) (Sullivan et al., 1995) is a 13-statement measure which is used to gauge a client’s catastrophizing thoughts and feelings regarding past pain experiences. The PCS considers three different areas of catastrophizing thoughts including rumination, magnification, and helplessness. Clients rate statements from 0- not at all to 4—all the time, with a total possible score of 52. The higher the total score, the more the client is catastrophizing the pain experience. Clients with a score of 30 present a clinically relevant level of catastrophizing (Sullivan et al., 1995).

The Pain Self-Efficacy Questionnaire 2 (PSEQ-2) (Nicholas et al., 2015) is a two-statement self-rated measure indicating the client’s confidence in their ability to work and lead a normal life despite their pain experiences. Each statement is rated on a Likert scale from 0—“not confident at all” to 6—“completely confident.” Higher scores indicate higher pain self-efficacy. Assessing self-efficacy is important to understand how a client is coping with their pain.

Intervention

Pain neuroscience education

The decision to adopt PNE for this client aligns with the Occupational Therapy Practice Framework: Domain and Process (Framework) (AOTA, 2020), which recommends using an educational approach to support the participant’s progress. According to the Framework (AOTA, 2020), occupational therapy must promote health and wellness through treatment interventions that may restore, adapt, and promote participation in daily life roles and routines. The use of PNE as an educational strategy is within the scope of occupational therapy practices. Additional strategies used with June included addressing sensory concerns, relaxation, energy conservation, work simplification, pacing, and graded exposure. June also participated in movement-based strategies including Blomberg Rhythmic Movement Training ^® (BRMT), primitive reflex integration and neurodynamics of the upper extremities to calm the nervous system, and she was properly instructed to complete these in a home exercise/management program. PNE was included along with these other interventions, and it allowed June to better understand her pain and adopt required actions to address her symptoms.

The therapist provided PNE using stories and metaphors and the “Why You Hurt: Therapeutic Neuroscience Education System” (Louw, 2014) visual cards. The stories and metaphors chosen for instruction were related to June’s reported experiences shared during the subjective portion of the treatment session and prior knowledge from previous education provided before intervention. Next, the therapist helped June make connections between the education provided during the session and the effects of the intervention at the end of the session. Both client-directed questions by the therapist and therapist-directed questions by June allowed the therapist to understand if June could integrate the content and relate this information to her own life. The knowledge was distributed in small amounts, during sessions that were 10–15 min long, to allow June to grasp the information, relate the learning to other treatment interventions, and build on concepts she had learned in previous sessions.

Example of pain neuroscience education in an occupational therapy session

June was engaged in occupational therapy evaluation and treatment in the outpatient hospital-based setting. At the beginning of the session, June provided subjective information regarding her status and areas of concern and limitation, identified helpful strategies, and asked follow-up questions as they arose. The therapist provided June with a metaphor describing the nervous system as a living alarm (Louw et al., 2015) using the “Why You Hurt: Therapeutic Neuroscience Education System” (Louw, 2014) visual cards to apprize June regarding the nervous system’s function while relating it to her life based on the symptoms and experiences she shared during the session. June and the therapist then explored calming activities such as rocking and manipulating a soft, slightly resistive fidget. These activities included her stated sensory preferences and movement-based therapies to provide preparatory activities through body awareness and calming input. These activities were meant to allow her to return home to complete her daily occupations with lesser influence of her symptoms by being aware of the activities she could engage in as symptoms increased or decreased before, during, and after task completion. We discussed the best times to perform the activities in her daily schedule to help ease her symptoms and allow her to complete more tasks that she wants to complete. At the end of the session, June and the therapist connected the self-identified helpful interventions to the education and developed a home activity program to support continued occupational performance based on her expressed needs and goals. The home activity program included recommendations on when, what, and how to implement calming strategies throughout her day, and calming BRMT^® movements that June identified as calming and helpful to her during the session. June incorporated positive phrases and mantras into her daily routine as part of her home activity program to further support the completion of home activities.

Future sessions were built upon the education from the initial intervention session, and additional stories and metaphors were provided to illustrate necessary concepts related to her pain and symptoms in order to improve occupational performance. June adopted other calming strategies including visualization with breathing techniques, and movement-based therapies such as BRMT^® and upper extremity neurodynamics. In addition, June employed energy conservation and positioning techniques to maximize daily activities such as washing dishes, laundry, meal preparation, vacuuming, and removing items from the dishwasher, as well as addressing important personal goals that she had established.

Results

A retrospective single-case study design including pretest and post-test outcome measures was employed to assess June’s progress along with qualitative reflections of her overall improvement. The results were calculated by changes in point scores and percentages as they are related to clinically significant changes in the outcome measures. After June’s discharge, she provided final ratings regarding her occupational performance and satisfaction, upper extremity disability, pain catastrophizing thoughts, and pain self-efficacy. These results were compared with initial visit scores to gauge progress. The COPM was completed at the initial occupational therapy visit, the fifth visit, and then again upon discharge. Overall, June’s COPM scores improved by 3.8 points in performance and 6.6 points in satisfaction, as rated on her final visit (Table 1) (Davis & Gillard, 2021).

Table 1. Canadian Occupational Performance Measure (COPM).

COPM	Performance/Satisfaction	Performance/Satisfaction	Performance/Satisfaction
	Visit 1	Visit 5	Visit 8
Cast a fishing rod	1/1	5/3	6/8
Stir-fry food	2/2	2/1	5/8
Gardening vegetables	1/1	4/4	4/8
Walk ¼ mile for leisure	3/2	2/1	8/8
Bathing dogs in the bathtub	1/1	2/1	4/8
Mean value	1.6/1.4	3/2	5.4/8
Changes from Visits 1 to 8			3.8/6.6

Note. Source: Authors.

June completed the QuickDASH on the initial visit and after her discharge. She scored 88.64% on the QuickDASH and 100% on the Sports/Performing Arts Module in terms of Fishing/Gardening on the initial visit, and she scored 45.45% on the QuickDASH and 37.5% on the Sports/Performing Arts Module after discharge. She demonstrated a U/E disability rating improvement of 43.19% on the QuickDASH and 62.5% improvement on the Sports/Performing Arts Module from initial visit to discharge (Figure 1) (Davis & Gillard, 2021).

Figure 1. QuickDASH.

Note. Source: Authors.

June initially scored 36 on the PCS, and then scored 14 after the discharge, rating catastrophizing thoughts less by 22 points (Figure 2).

Figure 2. Pain Catastrophizing Scale (PCS).

Note. Source: Authors.

June’s initial score on the PSEQ-2 was three out of 12, indicating low confidence in her ability to complete some form of work and live a normal lifestyle despite her pain. After her discharge, June showed higher self-efficacy on the PSEQ-2 as demonstrated by a score of 11 out of 12 (Figure 3).

Figure 3. Pain Self-Efficacy Questionnaire 2 (PSEQ-2).

Note. Source: Authors.

While discussing her experience with social engagement and chronic pain, June mentioned that people “judge you terribly.” She reported how people would be rude to her and glare at her when she would use a scooter at the grocery store. She found asking for help from others difficult and stated, “Asking for help is like swallowing dirt.” June shared about feeling judged by her family as they stopped inviting her to family social events. She stated that medical providers generally never took her seriously thinking that she was looking for drugs. June felt unheard.

After receiving occupational therapy treatment, June felt more confident and stated, “I feel like I have woken up” (Davis & Gillard, 2021). She mentions feeling more aware of being unable to perform simple tasks and how this affected her (Davis & Gillard, 2021). She socializes more, takes the dogs outside frequently, and she can walk to the mailbox to collect the mail. Her self-efficacy improvement was noted by the increased confidence to complete meaningful daily activities.

As June’s confidence improved, so did her ability to communicate her symptoms and emotions. Her health care team’s trust in her story and their ability to assist her in vocalizing and understanding her condition decreased the stigma she felt with past providers and in turn, decreased the self-stigma she noted to experience. She mentioned that her loved ones have a deeper understanding and appreciation of her condition beyond society’s expectations, which increased her confidence with socialization and when completing tasks outside of the home.

During our final meeting, June appeared different from her initial disposition. She was no longer tearful and was smiling. She was well-groomed and nicely dressed for her appointment, wearing a bright scarf that she had not previously worn to therapy. She appeared no longer fearful or avoidant of participating in her own health care decision making, which also indicated improved self-efficacy.

Discussion

Our findings identify PNE as an occupational therapy intervention that may ameliorate self-stigma and occupational performance. This study extends the literature discussing the need to reduce the stigma of chronic pain by educating healthcare professionals on biological, physiological, and psychosocial contributors to the chronic pain experience (De Ruddere & Craig, 2016; Nielsen, 2012). With new understandings of the chronic pain experience, healthcare providers can educate their clients, clients’ families, and the community on chronic pain, thereby decreasing associated stigma.

Education and training are common interventions used in occupational therapy practice along with other interventions to promote participation in desired and needed occupations. This aligns with the AOTA’s (2021) position statement on the Role of Occupational Therapy in Pain Management, highlighting PNE as an intervention strategy used within an occupational therapy case example to support the achievement of a client’s occupational therapy goals.

Education can improve the understanding of all factors that influence a person’s participation in certain occupations. This education may contribute to decreasing social stigma and self-stigma by equipping health care providers, clients, and communities with knowledge on how pain limits individuals, even when it is undetected and without a physical explanation. Education can encourage participation because the factors influencing the pain experience are better understood. Pain is complex, and education specific to the chronic pain experience can enhance participation in desired occupations. June reflected on how understanding activity patterns influenced her pain experience and allowed her to increase her occupational performance and satisfaction. She became confident in completing tasks and in reporting her needs to others. She knew what to expect and how to respond to her symptoms based on the education and problem-solving skills acquired through the therapeutic process.

This case study highlights PNE as an occupational therapy intervention to decrease pain catastrophizing thoughts and increase self-efficacy, which in turn may decrease self-stigma and improve occupational performance. Internalized stigma impacts self-esteem, self-efficacy, and catastrophizing thoughts about pain (Waugh et al., 2014). Our results support this notion as June indicated she felt more confidence in her ability to complete tasks despite her pain and was less worried about how and when her symptoms may affect her.

June demonstrated significant positive clinical changes in her performance and satisfaction scores on the COPM and QuickDASH, thus meeting her goals in occupational therapy. These results indicate the potential of PNE when combined with other occupational therapy interventions to decrease self-stigma, increase self-efficacy, and reduce catastrophizing thoughts. Ryan et al. (2010) found short-term results for individual sessions of pain biology education, improving self-efficacy in persons with chronic low back pain more effectively than pain biology education in conjunction with group exercises for the same target group. When pain is discussed from a biological, physiological, and psychosocial perspective, it could help the client, healthcare providers, and the community reconceptualize the problem and subsequently increase the client’s confidence in their ability to complete tasks (Moseley, 2004). Moseley’s (2004) discussion on how pain beliefs could affect motor performance may be correlated with the findings of this study. June felt prepared for discharge from occupational therapy when her satisfaction of goal performance improved and exceeded her actual goal performance. Pain may continue to limit her performance, but her fear regarding the pain had decreased and she could complete goal activities more frequently with greater satisfaction.

De Ruddere and Craig (2016) discuss different intervention strategies to address stigma including educating the individual and the community and influencing legislative efforts to promote social environments and prevent occupational marginalization. PNE has the potential to help decrease self-stigma and may influence people to avoid others’ stigmatized and incorrect impressions of them. Teaching PNE in the community may help people understand their own or others’ pain experiences. PNE provided to middle school students has impacted their pain beliefs and improved their understanding of pain (Louw et al., 2018). OTs often provide community-based services and could effectively provide education on pain to reduce its consequent suffering and stigma. Addressing social stigma through legislation by advocating for increased understanding, support, and services provided for persons with FM and other pain conditions would promote the use of interventions that reduce stigma and occupational marginalization.

Implications for occupational science and occupational therapy

A larger research study would be beneficial to further understand how PNE influences self-stigma and occupational performance in chronic pain. This study provides insights to consider, including how improvement in occupational satisfaction can outpace one’s performance of the task itself, which may influence goal achievement, reduce perceived stigma, and help in the successful self-management of chronic pain conditions such as FM.

Limitations

This is a single-subject case study design; therefore, the authors are unable to generalize the results of this study in occupational science and occupational therapy. The study’s objectivity is limited as assessments and interventions were provided by the same therapist. As June simultaneously received services from multiple disciplines during this period, her results may not be the outcome of a single discipline’s intervention strategies.

Conclusion

To adopt occupational science and occupational therapy efforts to reduce self-stigma and improve occupational performance of persons with chronic pain, PNE should be considered as a potential intervention strategy to be used along with other occupational therapy interventions, as part of a biopsychosocial multidisciplinary approach. Through understanding June’s occupational history and implementing occupational therapy interventions including PNE, her occupational performance and satisfaction improved on the COPM. Other improvements included decreased upper extremity disability ratings on the QuickDASH, decreased pain catastrophizing scores on the PCS, and higher pain self-efficacy on the PSEQ-2. This retrospective case study highlights the potential of using a specific education strategy to decrease factors that may limit occupational performance for clients with FM, such as self-stigmatization and should be considered further in both occupational therapy practice and research.

Acknowledgments

The authors would like to thank June for her bravery in allowing us to tell her story, which will promote understanding and care for all people experiencing similar conditions. We would also like to thank Editage (www.editage.com) for English language editing. Lastly, we would like to thank Bridget Scheidler, EdD, OTR, CAPS for her thoughtful insights and encouragement during the writing process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article.