IASP Curriculum Outline on Pain for Occupational Therapy

Task Force Members: Cary Brown, Joyce Engel, Liisa Holsti, Derek Jones, Gunilla Liedberg, Lena Martensson, Kate Miller, Jenny Strong, Anita Unruh (Chair)

Outline Summary

Introduction
Principles
Objectives
Curriculum Content Outline
 I. Multidimensional Nature of Pain
 II. Pain Assessment and Management
 III. Management of Pain
 IV. Clinical Conditions
References

Introduction

The occupational therapy (OT) pain curriculum aims to produce practitioners able to address the impact of pain experienced by the client on his or her every day occupations (function or activity), including physiological, psychosocial, and environmental components of that pain experience. To carry out professional responsibilities for clients with pain and their pain related loss of function, occupational therapists must have an understanding of explanatory models of pain (across the life span). In addition, pain is a wider social issue and other conceptual models also apply to persistent (chronic) pain as a community and global persistent health problem (e.g. http://www.who.int/classifications/icf/en/index.html, http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf)

Considerable variation exists from country to country in the academic structure of professional programs for occupational therapy and in the professional expectations that are made of an entry-level therapist; the entry-level degree may be at graduate or undergraduate level. Faculty should incorporate the specific content of this pain curriculum within their programs using structural and educational approaches most appropriate to meet local professional and program needs. This curriculum is designed to be most appropriate for students who have previously completed education covering anatomy and physiology, sociology, psychology, activity analysis, functional assessment and the majority of their professional therapeutics courses. In a traditional curriculum format, completion of this curriculum as constructed would require one semester in the last year of study.

Principles

The following principles guide the pain curriculum for entry level occupational therapists:

1. Pain is a complex phenomenon and a multidimensional experience.
2. Pain is a public health problem with social, ethical, and economic considerations.
3. People can experience pain at any stage of life and from any cause (identified or not).
4. The impact of pain on daily life and degree of impairment, developmental delay or psychological distress are critical components of comprehensive assessment
5. Activity analysis to explore the impact of pain on occupational performance (engagement in activities) needs to be considered from different perspectives, including factors (biological, psychological/spiritual, social/environmental) that contribute to actual (or potential) challenges in the individual's everyday life.
6. Prevention strategies need to focus on scheduling and adapting activities so that the person' energy is maintained and pain is minimized.
7. Assessment and intervention plans to manage pain need to be collaborative between client and therapist to ensure that the client's goals for intervention are identified, and the strengths of the client are recognized.
8. Prevention and intervention needs to be addressed at both micro (individual) and macro (socio-political) levels.

Objectives

Upon completion of this course, the entry-level occupational therapist will:

1. Understand current theories of the anatomical, neurological, physiological, developmental, social, psychological, cultural, and spiritual components of pain, pain related functional interference and management of daily life, and the ramifications for activity restrictions.
2. Recognize the differences between acute and persistent pain and their implications for assessment and management of daily life.
3. Understand how age, sex/gender, family, culture, spirituality, the environment and social determinants of health contribute to the pain experience and the consideration of these aspects in assessment and management of pain and pain related loss of function.
4. Be able to assess the pain experience, pain related loss of function, and resulting therapeutic needs for an individual according to an occupational therapy framework
5. Be familiar with the reliability, validity, benefits, and limitations of self-report, behavioral, and physiological measures to assess and measure pain, pain experience, and interference of pain in everyday life.
6. Be able to combine assessment and an awareness of the social determinants of health with client identified activity goals, and understand the importance of re-evaluation of these goals on a short and long term basis.
7. Critically appraise pain assessment tools, intervention strategies, and outcome measures.
8. Understand the prevention of pain problems in the home and workplace within a framework of health promotion and illness prevention.
9. Be familiar with the roles and responsibilities of other health care professionals in the area of pain management and the merits of interdisciplinary collaboration.

Curriculum Content Outline

I. Multidimensional Nature of Pain

A. Introduction

1. Definition of pain as a complex phenomenon and a multidimensional experience
2. Epidemiology of pain as a public health problem with social, ethical, and economic considerations
3. Barriers affecting occupational performance and activities in daily life, and impacting participation due to living with pain
4. Ethical and legal standards in pain rehabilitation, prevention and advocacy

B. Historical theories

1. Descartes' theory of pain
2. Gate Control Theory of pain
3. Neuromatrix
4. Biopsychosocial Model of Pain

C. Physiological basis of pain

1. Peripheral and central mechanisms of pain (including nociceptive events, ascending and descending pathways, effects of inflammation and tissue damage on nociceptors, nerve trauma and entrapment, central and peripheral sensitization, referred pain)
2. Physiological and pathological effects of unrelieved pain
3. Postural and ergonomic components (in home, work and leisure contexts)
4. Impact of co-morbidities
5. Fatigue

D. Distinction among acute, breakthrough, and persistent pain

1. Definitions and classifications
2. Impact on physiology of pain and psychological response to pain
3. Pain threshold, pain tolerance, and pain endurance

E. Psychological, behavioral, social and spiritual components of the pain experience, their relation to daily life activities and relationship to acute or chronic nature of pain

1. Anxiety, avoidance, crisis reactions, stress, catastrophizing, life adjustment process
2. Impact on spirituality and meaningfulness, hope and hopelessness and its consequences for daily life
3. Psychological effect of unrelieved pain on perceptions of control and self-efficacy
4. Depression, wish to die, suicidal risks
5. Impact of persistent pain on occupational performance (function and activity) and quality of life
6. Barriers to effective pain communication
7. Suffering and pain

F. Social Determinants of Health and Pain

1. Economic factors
2. Educational factors
3. Work environments
4. Ethnicity and cultural factors
5. Sex and gender influences on pain experience
6. Pain management as an economic commodity

G. Pain across the lifespan

1. Pain in infancy, childhood, and adolescence
2. Pain in the older people
3. Pain in people with profound and multiple impairments
4. Family influences

H. Health care environments and pain experience

1. Person-centred care
2. Encounters in health care and consequences for the client

I. Interaction of physiological basis of pain with psychological and environmental components

1. Impact on pain perception, communication, meaning construction and pain response

II. Pain Assessment and Measurement

A. Occupational therapy assessment of pain impact on daily life and quality of life

1. activity patterns
2. time use
3. goal fulfillment
4. changes in routines
5. habits
6. roles
7. skills related to goal-fulfillment

B. Assessment and measurement appropriate to client with communication problems due to age, language, or physical/cognitive difficulties

C. Use of International Classification of Functioning, Disability and Health

D. Evaluation of utility, reliability, and validity of measures of pain and related function.

E. Recognition of self-report measures as the gold standard:

1. pain intensity
2. location
3. quality
4. temporal variation
5. chronology of pain
6. relieving or aggravating factors

F. Use of behavioral and physiological measures of pain

G. Use of standardized baseline and repeat measures of pain related interference with function and quality of life

III. Management of Pain

A. Conduct person-centered intervention through collaborative activity goal setting using concepts and strategies from clinical reasoning

B. Utilize principles of critical research appraisal and application to clinical decision making

C. Consider principles of a therapeutic milieu to promote optimal quality of life based on:

1. relationship of trust, respect for client's meaning and construction of pain
2. patient's goals and shared decision making
3. focus on self-efficacy and personal autonomy
4. facilitation of active coping

D. Develop a daily routine to support readjustment of habits and roles considering individual capacity, goals and life situation

1. modify physical and psychosocial factors that contribute to pain related loss of function or negative consequences of pain on daily life
2. structure psychosocial and physical environments to facilitate goal attainment
3. involve family members and significant others
4. encourage active versus passive participation
5. facilitate pain health literacy (including communication and expression strategies)
6. provide the patient with skills for health system navigation

E. Conceptualize service delivery as an interdisciplinary team process within the biopsychosocial and persistent disease management models.

F. Promote the patient's awareness of the social determinants of health and a macro analysis of chronic pain as a social, public health issue that requires intervention at the patient, policy and advocacy levels

G. Consider management strategies according to nature of pain (acute, recurrent, or persistent) and the client's statement of needs/goal expectations

H. Utilize individual and group approaches for education, support, self-efficacy and advocacy.

I. Incorporate cognitive-behavioral interventions in client's occupations and activities

1. short and long-term goals
2. coping strategies and appraisal
3. cognitive restructuring
4. distraction
5. relaxation
6. visual imagery
7. mindfulness based strategies

J. Utilize persistent disease self-management programs

1. Use occupations and activities with meaning to the client
2. Incorporate activity tolerance, energy conservation, pacing, use of pain management strategies and therapeutic modalities to promote activity, relapse prevention and management)
3. Discuss sleep and sleep hygiene
4. Address intimacy and sexuality
5. Include back care

K. Evaluate the utility of various assistive devices, adaptive equipment and splinting considering joint protection, promotion of function, prevention of harm and disability

L. Develop plans for reintegration into work (paid and unpaid employment) using client's goals

M. Encourage pain health literacy education including finding, accessing, and evaluating health resources required to assume an active role in health self-management

N. Provide advocacy at the policy and service delivery level

IV. Clinical Conditions

1. Migraine, tension or mixed headache
2. Musculoskeletal pains (e.g low back pain, arthritis)
3. Pain associated with burns
4. Pain in progressive disease, terminal illness (cancer), palliative care
5. Pain associated with neurological conditions
6. Complex regional pain syndrome, myofascial pain syndrome, fibryomyalgia
7. Phantom limb pain

References

Strong, J., van Grievensen, H., & Unruh, A.M. (Eds.) (in press). Pain: A textbook for health professionals. Edinburgh, UK: Churchill Livingstone. (release expected in 2013). This book is a second edition of an earlier textbook by Strong et al. (2002).

The publications below further elaborate theoretical frameworks and issues pertaining to occupational therapy and person-centred collaborative care. See also websites for occupational therapy association websites such as www.caot.ca, www.aota.org, and www.ausot.om.au.

• Borell, L, Asaba, E., Rosenberg, L., Schult, M. L., & Townsend, E.A. (2006). Exploring experiences of ‘participation' among individuals living with chronic pain. Scandinavian Journal of Occupational Therapy, 13, 76-85.
• CAOT (in press). CAOT Position Statement: Occupational therapy and pain management. Canadian Journal of Occupational Therapy.
• CHSD (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social determinants of Health. Geneva, World Health Organization. http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf
• Engel, J. (2013). Evaluation and pain management. In Pendleton, H.M., & Schultz-Krohn, W. (Eds.). Pedretti's occupational therapy for physical dysfunction, 7th edition (pp. 718-728). St. Louis: Mosby Elsevier.
• ICFDH. International Classification of Functioning, Disability and Health. Geneva, World health Organization) http://www.who.int/classifications/icf/en/index.html
• Hand, C., Law, M., & McColl, M. A. (2011). Occupational therapy interventions for chronic diseases: A scoping review. American Journal of Occupational Therapy, 65, 428-436.
• Holsti, L., Backman, C., & Engel, J. (in press). Occupational therapy. In McGrath P, Stevens B, Walker S, Zempsky W (Eds). Oxford Textbook of Pediatric Pain. Oxford University Press: Oxford, England.
• Keponen, R., & Kielhofner, G. (2006). Occupation and meaning in the lives of women with chronic pain. Scandinavian Journal of Occupational Therapy, 13, 211- 220.
• Mårtensson, L., Archenholtz, B., & Dahlin Ivanoff, S. (2006). The conceptions of pain and rehabilitation questionnaire (CPRQ): Development and test of face validity and stability over time. Scandinavian Journal of Occupational Therapy, 14, 1-10.
• Perneros, G., & Tropp, H. (2009). Development, validity, and reliability of the assessment of Pain and Occupational Performance (POP): A new instrument using two dimensions in the investigation of disability in back pain. Spine, 9, 486-498.
• Persson, D, Andersson, I, & Eklund, M. (2011). Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18, 188-197.
• Robinson, K., Kennedy, N., & Harmon, D. (2011). Is occupational therapy adequately meeting the needs of people with chronic pain? American Journal of Occupational Therapy, 65, 106-113.
• Skjutar, Å., Schult, M.L., Christensson, K., & Müllersdorf, M. (2010). Indicators of need for occupational therapy in patients with chronic pain: Occupational therapists' focus groups. Occupational Therapy International, 17, 93-103.