Outline Curriculum on Pain for Schools of Occupational Therapy and Physical Therapy

Unruh A, et al. Prepared by the IASP ad hoc Subcommittee for Occupational Therapy/Physical Therapy Curriculum.  Pain curriculum for students in occupational therapy or physical therapy. IASP Newsletter 1994;3-8 (November/December).

Outline Summary
Introduction
A. Overview of roles and responsibilities
B. Overview of the interdisciplinary pain curriculum

Course Objectives
Course Outline
1. Introduction
2. Nature of pain
3. Pain across the life span
4. Assessment and measurement of pain
5. Management of pain
6. Common pain problems

References
Overviews
Information on specific issues

Introduction

A. Overview of roles and responsibilities of occupational therapists and physical therapists
Pain is a common problem for many of the clients/patients seen by occupational therapists and physical therapists. For these clients/patients, the primary therapeutic objectives are reduction of pain and associated disability, promotion of optimal function in everyday living, and enabling meaningful family and social relationships. Promotion of health and well-being through prevention of pain, and disability or handicap resulting from pain, are fundamental concerns. It is essential that occupational therapists and physical therapists take a holistic and collaborative view of the needs of the client/patient with pain. Therapists should be able to recognize the numerous misconceptions that prevail about pain and people with pain and be able to refute and challenge their existence.
The professions of occupational therapy and physical therapy vary in their underlying theoretical foundations and in their overall approach to pain.
Occupational therapists are primarily concerned with the psychosocial and environmental factors that contribute to pain and the impact of pain on the individual's everyday life. Their roles and responsibilities include:

1. Assessment of the impact of pain on occupational performance in the areas of self-care, paid and unpaid work, interests and leisure pursuits, customary habits and routines, and family relationships. Assessment will include evaluation of psychosocial and environmental factors aggravating pain in the home and workplace.

2. In collaboration with the client/patient, development of an occupational therapy program to increase self-esteem, restore self-efficacy, and promote optimal occupational function despite pain. Intervention strategies may include assistive devices and adaptive equipment, purposeful and productive occupations/activities, and vocational rehabilitation or work hardening to improve endurance and work skills and reestablish roles, habits, and routines of everyday life. Education about pain and supportive individual, family, or group counseling are utilized as needed.

3. Liaison and referral within an interdisciplinary team approach.

Physical therapists apply a wide range of physical and behavioral treatments to reduce pain and prevent dysfunction. Their roles and responsibilities include:
1. Assessment of the primary and secondary chemical (infection/inflammation), biomechanical (stress/strain), and behavioral factors that contribute to pain, the pain-activity cycle, and overall function.
2. In collaboration with the client/patient, development of a physical therapy program directed at modifying the effect of primary and secondary contributors to pain, promotion of tissue healing, and reduction of the factors that may lead to the recurrence of pain and dysfunction. Intervention may include education, exercise, manual therapy, movement facilitation techniques, and application of electro/physical agents based on thermal/mechanical/electrical/-phototherapeutic modalities. Education is focused on understanding pain and on improved posture, body mechanics, and gait. Exercise is directed toward the strengthening of specific muscle groups as well as counteracting the effects of generalized deconditioning. Movement is used as a mechanism to control and decrease pain and to increase mobility.
3. Liaison and referral within an interdisciplinary team approach.

Cognitive-behavioral strategies and supportive/educational approaches for pain management may be implemented to reduce pain and improve function and overall quality of life by occupational therapists and by physical therapists. Therapists from either profession have a common commitment to person-centered care, the promotion of health and well-being, and the prevention of long term disability and handicap resulting from pain. Family education is an integral component of therapeutic programs.

To carry out professional responsibilities for clients with pain, occupational therapists and physical therapists must have an understanding of the physiological basis and the psychological and environmental components of pain and their impact on pain experience across the life span. Therapists should be familiar with pain assessment and measurement approaches and should be able to implement a broad variety of management strategies from their specific professional orientations. While neither occupational therapists nor physical therapists are responsible for pharmacological management, they should have sufficient knowledge about pharmacological agents and their side effects to act as advocates for optimal pharmacological management and to support proper usage of medication by clients/patients.

B. Overview of the interdisciplinary pain curriculum for students in occupational therapy or physical therapy
This pain curriculum is designed as an interdisciplinary course of study to support and encourage professional collaboration. The focus of the course is on the pain experience of clients/patients and the physiological, psychosocial, and environmental components of that experience, with an application of profession-specific theoretical frameworks to assess and manage pain and the impact of pain on everyday life. In this respect, this course presents new knowledge that will be applicable to students in either occupational therapy or physical therapy. However, in some educational programs, it may not be feasible or practical to offer this course in an interdisciplinary framework.

Inclusion of specific management strategies, as detailed in this curriculum, may depend on whether these strategies have been previously examined in other course work. Review of interventions rather than detailed instruction of each management strategy is expected in this course. Course instructors should modify management strategies where necessary if this curriculum is presented as a profession-specific course.

Students should be familiar with the theoretical models behind interventions as well as the empirical evidence of effectiveness of any management strategies. Course instructors are encouraged to adopt a critical appraisal perspective as a basis for decision making when reviewing the benefits and limitations of interventions.

Occupational therapy and physical therapy programs have different clinical areas of priority for student education. A suggested list of common pain problems for discussion according to definition, prevalence, clinical features, and possible interventions is included. The relevance of these pain problems within the curriculum should be decided by individual course instructors. All pain terminology and definitions used in this course should be consistent with Merskey and Bogduk (1994), Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definition of Pain Terms.

Considerable variation exists from country to country in the academic structure of professional programs for occupational therapy or physical therapy and in the professional expectations that are made of an entry-level therapist. Faculty in occupational therapy and physical therapy programs should incorporate the specific content of this pain curriculum within their programs using whatever structural and educational approaches would be the most appropriate to meet local professional and program needs. However, this curriculum is designed to be most appropriate for students who have previously completed courses in anatomy, physiology, and kinesiology or movement, and the majority of their professional therapeutics courses. In a traditional curriculum format, completion of this curriculum as constructed would require two semesters in a senior year and would be the approximate equivalent of a four to six credit-hour course.

Course Objectives

Upon completion of this course, the occupational therapy or physical therapy student will:
1. Understand the current theories of the anatomical, physiological, and psychological basis of pain and pain relief.
2. Recognize how age, gender, family, culture, spirituality, and the environment contribute to the pain experience and must be considered in assessment and management of pain.
3. Be able to assess the pain experience and resulting therapeutic needs for an individual according to an occupational therapy or physical therapy framework.
4. Recognize the differences between acute and chronic pain and their implications for assessment and management of pain.
5. Emphasize performance of a comprehensive evaluation and treatment in the acute pain phase to prevent the onset of chronicity.
6. Be familiar with the reliability, validity, benefits, and limitations of self-report, behavioral, and physiological measures to assess and measure pain, pain experience, and impact of pain on everyday life.
7. Use a person-centered perspective to formulate collaborative intervention strategies consistent with an occupational therapy or physical therapy perspective.
8. Adopt a critical appraisal perspective toward the use of assessment and intervention strategies and outcome measures.
9. Understand the prevention of pain problems in the home and workplace within a framework of health promotion and illness prevention.
10. Be familiar with the roles and responsibilities of other health care professionals in the area of pain management and the merits of interdisciplinary collaboration.

Course Outline

1. Introduction
a. Definition of pain as a multidimensional experience
b. The epidemiology of pain as a public health problem with social, ethical, and economic considerations
c. Barriers to pain assessment and management
d. Role of occupational therapy and physical therapy in pain care--complementary roles

2. Nature of pain
a. Historical theories
  i. Descartes' theory of pain
  ii. Gate Control Theory of pain
b. Physiological basis of pain
  i. peripheral and central mechanisms (including nociceptive events, ascending and descending pathways, effects of inflammation and tissue damage on nociceptors, nerve trauma and entrapment, central and peripheral sensitization)
  ii. biochemical and biomechanical nociception
  iii. sympathetic nervous system mechanisms in pain
  iv. tonic and phasic pain
  v. referred pain (visceral and somatic pain)
  vi. physiological and pathological effects of unrelieved pain
  vii. trigger point mechanisms (e.g., myofascial pain)
  viii. postural components (home and work)
c. Distinction among acute, recurrent, and chronic pains
  i. definition and classifications of acute and chronic pains
  ii. impact on physiology of pain
  iii. impact on psychological response to pain
  iv. specific pain definitions including pain threshold, pain tolerance, and pain endurance
d. Psychological and behavioral components of pain experience and relationship to acute or chronic nature of pain
  i. anxiety, fear, crisis reactions, stress
  ii. impact on spirituality and meaningfulness, hope and hopelessness
  iii. psychological effect of unrelieved pain on perceptions of control and self-efficacy
  iv. depression, wish to die, suicidal risks
  v. impact of persistent pain on habits, roles, occupational performance, and future quality of life
  vi. personality and gender influences on pain experience
e. Environmental components of pain experience
  i. family and social influences
  ii. ethnic and cultural considerations
f. Interaction of physiological basis of pain with psychological and environmental components and their impact on pain perception and pain response

3. Pain across the life span (physiological and psycho-social factors, implications for assessment, measurement, and intervention)
a. Pain in infancy, childhood, and adolescence
b. Pain in the elderly

4. Assessment and measurement of pain
a. Application of professional models to assessment of pain (in occupational therapy, e.g., the models of human occupation and occupational performance; in physical therapy, e.g., the orthopedic model, the acute pain model, and movement theory)
b. WHO model of impairment, disability, and handicap
c. Utility, reliability, and validity of pain measures
d. Self-report measures as the gold standard of measurement for pain intensity, location, quality, temporal variation, chronology of pain, and factors that increase or decrease pain
e. Behavioral and physiological measures
f. Benefits and limitations of measurement strategies for acute, recurrent, or chronic pain
g. Assessment of pain impact on daily life and quality of life
  i. using daily diary recording of pain, activity level (including self-care, work, leisure activities, exercise)
  ii. changes in routines, roles, and skills
h. Meaning of pain behavior considering age of the individual, nature of pain, and contextual characteristics of the pain
i. Assessment and measurement of pain when the client has communication problems due to age, language, or physical/cognitive difficulties
j. Outcome measures

5. Management of pain and prevention of negative consequences of pain on everyday life occupations/activities
a. Person-centered intervention through collaborative goals
  i. using concepts and strategies from clinical reasoning to understand the experience and needs of a person with pain
b. Principles of critical research appraisal and application to clinical decision making
c. Principles of a therapeutic milieu to reduce pain and promote optimal function
  i. trust and honesty
  ii. control and predictability
  iii. anticipating pain when it may occur
  iv. using baseline and daily measures of pain and activity
  v. developing a daily routine to support readjustment of habits and roles according to individual capacity and life situation
  vi. modification of physical and psychosocial factors that promote pain or negative consequences of pain on daily life
  vii. involvement of family members and significant others
  viii. encouragement of active over passive participation
  ix. communication and team process
d. Using an interdisciplinary team approach
  i. roles and responsibilities of the health care team
e. Consideration of management strategies according to nature of pain (acute, recurrent, or chronic) and the client's statement of needs
f. Group approaches for education, support and encouragement
g. Cognitive-behavioral interventions
  i. setting short- and long-term goals
  ii. developing a daily routine
  iii. pacing of activities
  iv. coping strategies and appraisals
  v. distraction
  vi. relaxation
  vii. visual imagery
  viii. play and art
  ix. use of meaningful occupations/activities
h. Operant strategies to support effective coping strategies
i. Physical interventions
  i. movement to control pain
  ii. exercise to correct posture and improve strength
  iii. movement and exercise to improve self-esteem, restore self-efficacy, normalize body awareness, and promote optimal function
  iv. heat and cold
  v. massage
  vi. mobilizations/manipulation
  vii. TENS and other electrical protocols
  viii. biofeedback
  ix. laser
  x. acupuncture
  xi. spray and stretch
  xii. biomechanical therapies
  xiii. other interventions (ultrasound, Rolfing, shiatsu, pulsed electromagnetic fields, McKenzie's techniques, Alexander techniques, Trager, muscle energies, myofascial release and craniosacral techniques, mobilization of the nervous system)
j. Assistive devices and adaptive equipment
  i. benefits and limitations
k. Reintegration into work (paid and unpaid employment)
  i. work assessment, work hardening
  ii. application of ergonomic principles
  iii. reducing pain-producing hazards
  iv. work simplification
  v. using groups to support reintegration to work
  vi. litigation and compensation and possible medico-legal implications for clients/patients and therapists
l. Back care
  i. reducing hazards to good back care
  ii. posture in standing, sitting, and sleeping
  iii. strategies for bending, lifting, and reaching
  iv. building exercise and relaxation into daily life
m. Sleep
  i. alternatives to medication
  ii. creating a sleep environment for restorative sleep
  iii. readjusting the biological clock
  iv. sleep problems and relationship to somaticovisceral pain
n. Role of pharmacological approaches
  i. principles of administration
  ii. NSAIDs, opioids, adjunctive medications, and other alternatives
  iii. modes of administration
  iv. side effects
  v. tolerance, physical dependence, psychological dependence, and drug-seeking behavior
  vi. addiction risks
  vii. patient-controlled analgesia
  viii. role of occupational therapy and physical therapy in supporting optimal pharmacological strategies
o. Nutrition and diet
p. Intimacy and sexuality
q. Placebo effect of management strategies

6. Common pain problems (definition, prevalence, clinical features, possible interventions)
a. Migraine and headache
b. Back and neck pain
d. Neuralgias
e. Pain associated with burns
f. Pain associated with progressive disease, terminal illness (cancer), palliative care
g. Pain and psychiatric illness
h. Pain in AIDS
i. Pain due to health care procedures

7. Service delivery
a. Traditional pain management model, multidisciplinary pain treatment clinics and facilities, modality-specific practice
b. Ethical and legal standards of pain management

References

A suggested reference list for key issues is included with this curriculum, but course instructors are cautioned that current pain research will expand and change knowledge and practice issues. The reference list should be regularly updated. (An updated list of publications concerning occupational therapy and pain may be obtained from Anita Unruh, School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada B3H 3W4; e-mail: aunruh@ac.dal.ca)

The following texts provide comprehensive overviews of many components of this curriculum:
Bond, M.R., Pain: Its Nature, Analysis and Treatment, 2nd ed., Churchill Livingstone, New York, 1984.
Bonica, J.J. (Ed.), The Management of Pain, 2nd ed., Vols. I and II, Lea and Febiger, Philadelphia, 1990.

Fields, H.L., Pain, McGraw-Hill, New York, 1987.
Fordyce, W.E., Behavioral Methods for Chronic Pain and Illness, Mosby, St. Louis, 1976.

McCaffery, M. and Beebe, A., Pain: Clinical Manual for Nursing Practice, Mosby, St. Louis, 1989.
Melzack, R. and Wall, P.D., The Challenge of Pain, Penguin, Harmonds-worth, 1982.

Schechter, N.L., C.B. Berde and Y. Yaster (Eds.), Pain in Infants, Children, and Adolescents, Williams and Wilkins, Baltimore, 1993.
Sternbach, R.A. (Ed.), The Psychology of Pain, Raven Press, New York, 1986.

Wall, P.D. and R. Melzack (Eds.), Textbook of Pain, 3rd ed., Churchill Livingstone, Edinburgh, 1994.

The following papers, chapters, and books provide additional information on specific issues:
Abdel-Moty, E., Fishbain, D.A., Khalil, T.M., Sadek, S., Cutler, R., Rosomoff, R.S. and Rosomoff, H.L., Functional capacity and residual functional capacity and their utility in measuring work capacity, Clin. J. Pain, 9 (1993) 168-173.
Agerberg, G. and Carlsson, G.E., Symptoms of functional disturbances of the masticatory system, Acta Odontol. Scand., 33 (1975) 183-190.
Aronoff, G.M. (Ed.), Pain Centers: A Revolution in Health Care, Raven Press, New York, 1988.

Basmajian, J.V. and Nyberg, R., Rational Manual Therapies, Williams and Wilkins, Baltimore, 1993.
Bernstein, B.A. and Pachter, L.M., Cultural considerations in children's pain. In: N.L. Schechter, C.B. Berde and M. Yaster (Eds.), Pain in Infants, Children and Adolescents, Williams and Wilkins, Baltimore, 993, pp. 113-122.
Brattberg, G., Selecting patients for pain treatment: applying a model to epidemiological data, Clin. J. Pain, 6 (1990) 37-42.

Cailliet, R., Pain: Mechanisms and Management, F.A. Davis, Philadelphia, 1993.
Carr, D.B., Osgood, P.F. and Szyfelbein, S.K., Treatment of pain in acutely burned children. In: N.L. Schechter, C.B. Berde and M. Yaster (Eds.), Pain in Infants, Children, and Adolescents, Williams and Wilkins, Baltimore, 1993, pp. 495-504.
Choiniere, M., Pain of burns. In: P.D. Wall and R. Melzack (Eds.), Textbook of Pain, 3rd ed., Churchill Livingstone, Edinburgh, 1994, pp. 523-537.
Cousins, M. and Loeser, J., Desirable Characteristics for Pain Treatment Facilities, IASP Publications, Seattle, 1990.
Crook, J., Women and chronic pain. In: R. Roy and E. Tunks (Eds.), Chronic Pain: Psychosocial Factors in Rehabilitation, Williams and Wilkins, Baltimore, 1982, pp. 68-78.
Crook, J., Comparative experiences of men and women who have sustained a work related musculoskeletal injury. In: Abstracts: 7th World Congress on Pain, IASP Publications, Seattle, 1993, pp. 293-294.
Crook, J., Rideout, E. and Browne, G., The prevalence of pain complaints in a general population, Pain, 18 (1984) 299-314.
Deyo, R.A., Measuring the functional status of patients with low back pain, Arch. Phys. Med. Rehabil., 69 (1988) 1044-1053.
Donelson, R.G., Identifying appropriate exercises for your low back pain patient, J. Musculoskeletal Med., 8 (1991) 14-29.

Engel, J., Pain management. In: H.L. Hopkins and H.D. Smith (Eds.), Willard and Spackman's Occupational Therapy, 8th ed., J.B. Lippincott, Philadelphia, 1993, pp. 596-604.
Engel, J.M. and Rapoff, M.A., Biofeedback-assisted relaxation training for adult and pediatric headache disorders, Occup. Ther. J. Res., 10 (1990) 283-299.
Engel, J.M. and Rapoff, M.A., A component analysis of relaxation training for children with vascular, muscle contraction, and mixed headache disorders. In: D.C. Tyler and E.J. Krane (Eds.), Advances in Pain Research and Therapy, Vol. 15, Raven Press, New York, 1990, pp. 273-290.

Fleming, M.H., Aspects of clinical reasoning in occupational therapy. In: H.L. Hopkins and H.D. Smith (Eds.), Willard and Spackman's Occupational Therapy, 8th ed., J.B. Lippincott, Philadelphia, 1993, pp. 67-881.

Guisch, L.R., Occupational therapy for chronic pain: a clinical application of the model of human occupation, Occup. Ther. Ment. Health, 4 (1984) 59-73.

Haker, E., Lateral epicondylalgia (tennis elbow): diagnosis, treatment and evaluation, Crit. Rev. Phys. Rehabil. Med., 5 (1993) 129-154.
Harkins, S.W., Proce, D.D., Bush, F.M. and Small, R., Geriatric pain. In: P.D. Wall and R. Melzack (Eds.), Textbook of Pain, 3rd ed., Churchill Livingstone, Edinburgh, USA, 1994, pp. 769-784.
Henriksson, C.M., Long term effects of fibromyalgia on everyday life: a study of 56 patients, Scand. J. Rheumatol., 23 (1994) 36-41.
Henriksson, C., Gundmark, I., Bengtsson, A. and Ek, A-C., Living with fibromyalgia: consequences for everyday life, Clin. J. Pain, 8 (1992) 138-144.
Herman, E. and Baptiste, S., Group therapy: a cognitive-behavioral model. In: E. Tunks, A. Bellissimo and R. Roy (Eds.), Chronic Pain: Psychosocial Factors in Rehabilitation, 2nd ed., Krieger, Melbourne, Fla., 1990, pp. 212-228.

James, F.R., Large, R.G., Bushnell, J.A. and Wells, J.F., Epidemiology of pain in New Zealand, Pain, 25 (1991) 53-68.

Leckie, R.S. and Warfield, C.A., Uses of acupuncture for pain relief, Hosp. Pract., 12 (1986) 36-41.
Lennane, K.J. and Lennane, R.J., Alleged psychogenic disorders in women: a possible manifestation of sexual prejudice, N. Engl. J. Med., 288 (1973) 288-292.
Low, J.L. and Reed, A., Electrotherapy Explained, Butterworth-Heinemann, Oxford, 1990.

Management of Cancer Pain Guideline Panel, Clinical Practice Guideline, no. 9, Management of Cancer Pain, AHCPR Publication no. 94-0592, U.S. Department of Health and Human Services, 1994.
Mannheimer, J.S., Nonmedicinal and non-invasive pain control techniques in the management of rheumatic disease and musculoskeletal disorders, J. Rheumatol., 14 (1987) 26-32.
Mannheimer, J.S., Prevention and restoration of abnormal upper quarter posture. In: H. Gelb and M. Gelb (Eds.), New Concepts in Craniomandibular and Chronic Pain Management, C.V. Mosby, St. Louis, 1994, pp. 93-161.
Mannheimer, J.S. and Dunn, J., Cervical pain: evaluation and relation to temporomandibular disorders. In: A.S. Kaplan and L.A. Assael (Eds.), Temporomandibular Disorders: Diagnosis and Treatment, W.B. Saunders, Philadelphia, 1991, 50-94.
Mannheimer, J.S. and Rosenthal, R.M., Acute and chronic postural abnormalities as related to craniofacial pain and temporomandibular disorders, Dent. Clin. North Am., 35 (1991) 185-208.
Matheson, L.N., Ogden, L.D., Violette, K. and Schultz, K., Work hardening: occupational therapy in industrial rehabilitation, Am. J. Occup. Ther., 39 (1985) 314-321.
Mathews, J.R., McGrath, P.J. and Pigeon, H., Assessment and measurement of pain in children. In: N.L. Schechter, C.B. Berde and M. Yaster (Eds.), Pain in Infants, Children and Adolescents, Williams and Wilkins, Baltimore, 1993, pp. 97-111.
McGrath, P.J., Finley, G.A. and Turner, C.J., Making Cancer Less Painful: A Handbook for Parents, Izaak Walton Killam Children's Hospital, Halifax, N.S., Canada, 1992.
McGrath, P.J., Ritchie, J. and Unruh, A.M., Nursing and children's pain. In: D. Carrol and D. Bowsher (Eds.), Nursing Aspects of Pain, Butterworth Heinemann, Oxford, 1993, pp. 100-123.
McGrath, P.J. and Unruh, A.M., Social and legal issues. In: K.J.S. Anand and P.J. McGrath (Eds.), Pain in Neonates, Elsevier, Amsterdam, 1994, pp. 275-294.
Melnik, M.S., Saunders, R. and Saunders, H.D., Managing Back Pain: A Self-Help Manual, Educational Opportunities, Edina, Minn., 1989.
Melzack, R. and Torgerson, W.S., On the language of pain, Anaesthesiology, 34 (1971) 50-59.
Merskey, H. and Bogduk, N., Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definition of Pain Terms, 2nd ed., IASP Press, Seattle, 1994.
Milne, J.M., The biopsychosocial model as applied to a multidisciplinary pain management programme, J. N.Z. Assoc. Occup. Ther., 36 (1983) 19-21.

Olesen, J., P. Tfelt-Hansen and K.M.A. Welch (Eds.), The Headaches, Raven Press, New York, 1993.

Richter, I., McGrath, P.J., Humphreys, P.J., Goodman, J.T., Firestone, P. and Keene, D., Cognitive and relaxation treatment of pediatric migraine, Pain, 25 (1986) 195-203.

Sackett, D.L., Haynes, R.B., Guyatt, G.H. and Tugwell, P., Clinical Epidemiology: A Basic Science for Clinical Medicine, 2nd ed., Little, Brown, Boston, 1991.
Saxon, S.V., Pain Management Techniques for Older Adults, C.C. Thomas, Springfield, Ill., 1991.
Somerville, M., Death of pain: pain, suffering, and ethics. In: G.F. Gebhart, D.L. Hammond and T.S. Jensen (Eds.), Proceedings of the 7th World Congress on Pain, Progress in Pain Research and anagement, Vol. 2, IASP Press, Seattle, 1994, pp. 41-58.
Sternbach, R.A., Survey of pain in the United States: The Nuprin Pain Report, Clin. J. Pain, 2 (1986) 49-53.
Strong, J., The occupational therapist's contribution to the management of chronic pain, Patient Management, 13 (1989) 43-50.

Teperi, J. and Rimpela, M., Menstrual pain, health and behaviour in girls, Soc. Sci. Med., 29 (1989) 163-169.
Townsend, E., Ryan, B. and Law, M., Using the World Health Organization's international classification of impairments, disabilities, and handicaps in occupational therapy, Can. J. Occup. Ther., 57 (1990) 16-5.
Turk, D. and Melzack, R., Handbook of Pain Assessment, Guilford Press, New York, 1992.
Turnquist, K.M. and Engel, J.M., Occupational therapists' experiences and knowledge about pain in children, Phys. Occup. Ther. Pediatr., 14 (1994) 35-51.
Twomey, L.T. and Taylor, J.R. (Eds.), Clinics in Physical Therapy of the Low Back, 2nd ed., Churchill Livingstone, Edinburgh, 1994.
Tyrer, S.P. (Ed.), Psychology, Psychiatry and Chronic Pain, Butterworth-Heinemann, Newton, Mass., 1993.
Tyson, R. and Strong, J., Adaptive equipment: its effectiveness for people with chronic lower back pain, Occup. Ther. J. Res., 10 (1990) 111-121.

Vasudevan, S.V., Rehabilitation of the patient with chronic pain: is it cost effective? Pain Digest, 2 (1992) 99-101.
Vasudevan, S.V., Pain centers: organization and outcome, West. J. Med., 154 (1991) 532-535.

White, J. and Strong, J., Objective measurement of activity levels in patients with chronic low back pain, Occup. Ther. J. Res., 12 (1992) 217-228.

IASP asks its members to encourage their specialty schools to consider adopting this curriculum outright, to modify it as necessary for local needs, or to translate it for local dissemination.