IASP Curriculum Outline on Pain for Occupational Therapy

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Task Force Members

Jenny Strong (chair), Cary Brown, Derek Jones

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 widespread prevalence of pain demonstrates the need for comprehensive pain education for all health-care professionals. Yet not all require the same type of pain-related knowledge and skills. IASP encourages all Occupational Therapy programs to utilize the following curriculum outline to embed pain education and training. As with other health professions, an objective of curricula is to instill the knowledge and skills necessary to advance the science and management of pain as part of an interprofessional team. The desired outcomes of education emphasize critical competencies that support the humanistic aspects of health care and the learner’s capacity to carry out tasks successfully in the real world. The fundamental concepts and complexity of pain include how pain is observed and assessed, collaborative approaches to treatment options, and application of pain competencies across the lifespan in the context of various settings, populations, and care-team models.

The Occupational Therapy Pain Curriculum aims to produce occupational therapy practitioners who are competent to work with clients with chronic pain and who can identify and address the impact of the pain experience on the client’s occupational performance and participation in meaningful everyday activities. To be able to do this, the occupational therapist needs to be aware of 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 lifespan. In addition, pain is a wider social issue, and other conceptual models (for example, here and here) also apply to persistent (chronic) pain as a persistent community and global health problem. Notably, in 2010, IASP members overwhelmingly supported framing access to pain management as a fundamental human right and issued a call to action.

Considerable variation exists from country to country in both the academic structure of professional education programs for occupational therapy and in the professional expectations of the entry-level therapist. Depending on political jurisdiction, the entry-level degree may be at the graduate or undergraduate level. Faculty should incorporate the specific content of this pain curriculum within their programs using the most appropriate structural and educational approaches to meet local professional 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. ISAP defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Effective pain intervention requires a nuanced understanding of this definition that recognizes the important role of the social determinants of health and the lived experience.
  2. Pain is a complex phenomenon and a multidimensional experience.
  3. People can experience pain at any stage of life.
  4. Assessment and intervention plans to manage pain need to be collaborative between patient and therapist to ensure that the patient’s goals for intervention are identified, and the strengths of the patient are recognized.
  5. The impact of pain on a client’s daily life needs to be considered in terms not only of physical limitations but also emotional and social influences on health and client-defined well-being. Activity analysis to determine the impact of pain on a client’s occupational performance (engagement in activities) needs to be considered from different stakeholders’ perspectives. Factors that should be considered include biological, psychological/spiritual, sociopolitical, and environmental influences that contribute to actual (or potential) challenges in the client’s everyday life.
  6. Cultural aspects relevant to pain expression and the pain experience need to be considered with all clients.
  7. Occupational therapy assessment and management must be based on best available research evidence.
  8. Self-management strategies need to focus on scheduling and adapting activities so that the person’s energy is maintained and pain is minimized.
  9. Pain is a public health problem with personal, social, ethical, and economic considerations.
  10. 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 of occupational restrictions.
  2. Recognize the inherent invisibility of chronic pain, and the resulting stigma that many clients face in their daily lives.
  3. Recognize the differences between acute and chronic pain and the implications for assessment and management of daily life.
  4. Understand how age, sex/gender, family background, culture, spirituality, 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.
  5. Be able to collect meaningful data relevant to the pain experience, pain-related loss of function, approach to activities, and resulting therapeutic needs for a client according to an occupational therapy framework.
  6. Be aware of the reliability, validity, benefits, and limitations of self-report, observational, behavioral, and physiological measures to assess and measure pain, the pain experience, and interference of pain in everyday life.
  7. Be able to combine assessment, an awareness of the social determinants of health, and self-efficacy theory, with client-identified activity goals and understand the importance of reevaluation of these goals on a short and long-term basis.
  8. Critically appraise pain-assessment tools, 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.

Curriculum Content Outline

  1. Multidimensional Nature of Pain
    1. 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
    2. Historical theories
      1. Descartes’ Theory of Pain
      2. Gate Control Theory of Pain
      3. Neuromatrix Theory
      4. Biopsychosocial Model of Pain
    3. 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, neuroplasticity, sensory sensitivity)
      2. Physiological and pathological effects of unrelieved pain
      3. Postural and ergonomic components (in home, work, and leisure contexts)
      4. Impact of comorbidities
      5. Fatigue/sleep deficiency
    4. 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
    5. 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 their consequences for daily life
      3. Psychological effect of unrelieved pain on perceptions of control and self-efficacy
      4. Depression, rumination, suicidality, grief
      5. Impact of persistent pain on occupational performance (function and activity) and quality of life
      6. Barriers to effective pain communication (with particular attention to those with nonverbal communication, such as infants and persons with dementia)
      7. Suffering and pain
    6. 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
    7. Pain across the lifespan
      1. Pain in infancy, childhood, and adolescence
      2. Pain in the middle years
      3. Pain in older people
      4. Pain in people with profound and multiple impairments
    8. Health-care environments and pain experience
      1. Client-centered care
      2. Encounters in the health-care system and consequences for the client
    9. Interaction of physiological basis of pain with psychological and environmental components
      1. Impact on pain perception, communication, meaning construction, and pain response
    1. Occupational therapy assessment of pain impact on daily life and quality of life
      1. Activity patterns and approach to activity engagement
      2. Time use
      3. Goal fulfillment
      4. Changes in routines
      5. Habits
      6. Roles and self-image
      7. Skills related to goal fulfillment
    2. Assessment and measurement appropriate to clients with communication problems due to age, language, cultural, or physical/cognitive difficulties
    3. Use of International Classification of Functioning, Disability, and Health
    4. Evaluation of utility, reliability, and validity of measures of pain and related function
    5. 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
    6. Use of behavioral and physiological measures of pain
    7. Use of standardized baseline and repeat measures of pain-related interference with function and quality of life
    8. Familiarity with consensus-developed pain outcome-measurement tools, such as IMMPACT (in North America), ePPOC (in Australia and New Zealand), and PROMIS pain-interference assessment systems
  2. Pain Assessment and Measurement
    1. Occupational therapy assessment of pain impact on daily life and quality of life
      1. Activity patterns and approach to activity engagement
      2. Time use
      3. Goal fulfillment
      4. Changes in routines
      5. Habits
      6. Roles and self-image
      7. Skills related to goal fulfillment
    2. Assessment and measurement appropriate to clients with communication problems due to age, language, cultural, or physical/cognitive difficulties
    3. Use of International Classification of Functioning, Disability, and Health
    4. Evaluation of utility, reliability, and validity of measures of pain and related function
    5. 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
    6. Use of behavioral and physiological measures of pain
    7. Use of standardized baseline and repeat measures of pain-related interference with function and quality of life
    8. Familiarity with consensus-developed pain outcome-measurement tools, such as IMMPACT (in North America), ePPOC (in Australia and New Zealand), and PROMIS pain-interference assessment system
  3. Management of Pain
    1. Conduct client-centered intervention through collaborative activity goal setting, using concepts and strategies from clinical reasoning
    2. Utilize principles of critical research appraisal and application to clinical decision making
    3. 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. Client's goals and shared decision making
      3. Focus on the client’s self-efficacy and personal autonomy
      4. Facilitation of active coping
    4. Develop a daily routine to support readjustment of habits and roles considering individual capacity, goals, approach to activity, 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 client with skills for health system navigation (both physical and virtual)
    5. Conceptualize service delivery as an interdisciplinary team process within the biopsychosocial and persistent chronic conditions management models
    6. Promote the client and other stakeholders’ awareness of the social determinants of health and a macro analysis of chronic pain as a social public health issue that requires intervention and advocacy from all levels of stakeholders including client, health-care providers, policymakers, and funders
    7. Consider management strategies according to the nature of pain (acute, recurrent, or persistent) and the client’s needs and goals
    8. Utilize individual and group approaches for education, support, self-efficacy and advocacy
    9. Incorporate cognitive-behavioral interventions in the 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
    10. Utilize chronic conditions 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. Promote self-efficacy and role engagement/reengagement
      5. Address intimacy and sexuality
      6. Include pain-reduction strategies and modalities as relevant to the individual client’s condition
    11. Use an evidence-based approach to the use of assistive devices, adaptive equipment and splinting, considering joint protection, promotion of function, prevention of harm, and disability
    12. Develop plans for reintegration into work (paid and unpaid employment) using the client’s goals
    13. Encourage pain health-literacy education, including finding, accessing, and evaluating health resources required to assume and maintain an active role in health self-management
    14. Provide advocacy at the policy and service-delivery levels
  1. Clinical Conditions
    1. Migraine, tension, or mixed headache
    2. Musculoskeletal pains (e.g., low back pain, arthritis)
    3. Pain associated with burns and scars
    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

van Griensven, H., Strong, J. & Unruh, A.M. (Eds.) (2014). Pain: A textbook for health professionals. Second Edition. Edinburgh, UK: Churchill Livingstone. The publications below further elaborate theoretical frameworks and issues pertaining to occupational therapy and person-centered collaborative care. See also websites for occupational therapy associations such as www.caot.cawww.aota.org, and www.ausot.com.au.

Andrews, N., Meredith, P.J., Strong, J. & Donohue, G.F. (2014). Adult attachment and approaches to activity management in chronic pain. Pain Research and Management, 19, 317-327.

Andrews, N., Strong, J., & Meredith, P. (2012). Activity pacing, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis. Archives of Physical Medicine & Rehabilitation, 93, 2109-2121.

Andrews, N., Strong, J., & Meredith, P., Gordon, K., & Bagraith, K. (2015). “It’s very hard to change yourself”: An exploration of overactivity in people with chronic pain using interpretative phenomenological analysis. PAIN, 156, 1215-1231.

Bagraith, K.S., Hayes, J., & Strong, J. (2013). Mapping patient goals to the ICF: examining content validity and clinical utility of the low back pain core set,  Journal of Rehabilitation Medicine, 45, 481-487.

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.

Brown C, Green A. The relationship between sleep and pain (Chapter 16).  In
An Occupational Therapist's Guide to Sleep and Sleep Problems. A Green and C Brown (editors). London,UK: Jessica Kingsley Publishers, 2015.

Special issue on Pain Management and Occupational Therapy (2012).  Occupational Therapy Now, 14(5). 

Canadian Association of Occupational Therapists (2012). CAOT Position Statement: Occupational therapy and pain management.

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. 

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.

IASP. (2010) Declaration of Montréal; Declaration that Access to Pain Management Is a Fundamental Human Right.  International Association for the Study of Pain.

ICFDH. International Classification of Functioning, Disability and Health. Geneva, World Health Organization)

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.

Meredith, P.J., Rappel, G., Strong, J., & Bailey, K.J. (2015). Sensory sensitivity and strategies for coping with pain. American Journal of Occupational Therapy, 69, 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.

Strong, J., Mathews, T., Sussex, R., New, F., Hoey, S., & Mitchell, G. (2009). Pain language and gender differences when describing a past pain evenint, PAIN, 145, 86-95.

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