IASP Curriculum Outline on Pain for Physical Therapy
Task Force Members: Helen Slater, Kathleen Sluka, Anne
Söderlund, Paul J. Watson (Chair)
Curriculum Content Outline
I. Multidimensional Nature of Pain
II. Pain Assessment and Measurement
III. Management of Pain
IV. Clinical Conditions
Pain is a common problem and the primary therapeutic objectives of
physical therapists working with people in pain are the reduction of
pain and associated disability, the improvement of function, and
promotion of health and well-being in everyday living.
For the most effective management of pain, physical therapists must
have an understanding of the biological basis, the psychosocial and
environmental components of pain and their impact on the 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 evidence-based pain management strategies. The key focus is
to encourage early engagement of the patient in appropriate active pain
management strategies (what the patient can do) rather than focus on
passive interventions (what you do to the patient). In this regard,
treatment interventions are designed to form part of an overall pain
management approach which should also incorporate self-management.
While physical therapists are not responsible for pharmacological
management, they should have sufficient knowledge about pharmacological
agents and their side effects and be able to optimise the 'therapeutic
window' offered by pharmaceutical agents to encourage the use of active
management strategies as appropriate for each individual patient. It is
essential to take a patient-centred holistic and collaborative view of
the needs of the client/patient with pain and disability.
Considerable variation exists from country to country in the academic
structure of professional programs for physical therapy and in the
professional expectations that are made of an entry-level therapist. The
specific content of this pain curriculum can be integrated within
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 science, and the majority of their professional
therapeutics courses. We recommend that physical therapy pain management
should be taught independently in the curriculum from other traditional
courses such as orthopedics, manual therapy, or physical agents.
The following principles guide the curriculum development for
entry-level physical therapists and draw from the Declaration of Montréal (IASP 2010):
Article 1. The right of all people to have access to pain
management without discrimination
Article 2. The right of people in pain to acknowledgment of
their pain and to be informed about how it can be assessed and
Article 3. The right of all people with pain to have access
to appropriate assessment and treatment of the pain by adequately
trained health care professionals
- Pain is viewed as a biopsychosocial experience that includes
sensory, emotional, cognitive, developmental, behavioral, spiritual and
- Pain may be acute, persistent, or both and pain duration will guide
the development of the pain management plan.
- Pain must be assessed in a comprehensive and consistent manner using
valid and reliable assessment tools.
- Patients have a right to the best possible pain management. Pain
assessment and management are integral aspects of physical therapy
management and should involve patients and their family members.
- Pain assessment and management should be recorded in a clear and
readily accessible manner.
- Patient and family education about pain and its (self) management
are essential components of a physical therapy management plan.
- The physical therapist is an essential member of the pain management
Students should be familiar with the theoretical models behind
interventions as well as the empirical evidence for effectiveness of
these interventions. Course instructors are encouraged to adopt a
critical appraisal perspective as a basis for decision making when
reviewing the benefits and limitations of interventions.
Upon completion of this pain curriculum the entry-level physical
therapist will be able to:
- Apply knowledge of basic science of pain to the assessment and
management of people with pain.
- Promote health and well-being through prevention of pain and
- Assess and measure the biological and psychosocial factors that
contribute to pain, physical dysfunction and disability using valid and
reliable assessment tools.
- Identify professional, system, patient, family and community
barriers to effective pain assessment and management.
- Develop an evidence-informed physical therapy management program in
collaboration with the client/patient, directed at modifying pain,
promoting tissue healing, improving function and reducing disability.
- Implement management that includes patient education, active
approaches such as functionally oriented behavioural movement
re-education approaches and exercise (including pacing), and passive
approaches such as manual therapy, and application of electrophysical
agents as relevant.
- Demonstrate an awareness of their scope of practice to evaluate and
manage patients experiencing pain using evidenced-based practice
strategies for clinical decision-making.
- When appropriate, refer patients in a timely manner for additional
care to practitioners with expertise such as medical and surgical,
behavioral and psychological, or pharmacological interventions.
- Recognize individuals who are at risk for under-treatment of their
pain (e.g., individuals who are unable to self-report pain, neonates,
- Practice in accordance with an ethical code that recognizes human
rights, diversity, and the requirement to "do no harm."
- Reflect critically on effective ways to work with and improve care
for people with pain.
- Regularly update personal knowledge on pain and its management.
Curriculum Content Outline
I. Multidimensional Nature of Pain
A. Magnitude of the problem: epidemiology of pain as a public health
problem with social, ethical, and economic considerations
B. Current theories of the anatomical, physiological, and
psychological basis of pain and pain relief.
C. Definition of pain and the multidimensional nature of the pain
D. Impact of age, gender, family, culture, spirituality, and the
environment on the pain experience
E. Role and responsibilities of the physical therapist in pain
management and the integration of physical therapy into the
F. Roles and responsibilities of other health care professionals in
the area of pain management and the merits of interdisciplinary
G. Integration of physical therapy interventions into an holistic
management strategy in collaboration with other professions (health and
H. Pain across the life span (physiological and psycho-social
factors, implications for assessment, measurement, and intervention)
- Implications and assessment of pain in infancy, childhood, and
adolescence with reference to optimizing physical, psychological,
educational and social development and integrate these into the
- Specific problems faced by the elderly with painful conditions with
respect to the influence of co-morbidities, access to appropriate
services and maintenance of independence.
I. Basic science:
- Understand and describe nociceptors and the adequate stimuli to
activate nociceptors in different tissue types (i.e. skin, muscle,
joint, viscera). Explain the afferent innervations of the spinal cord
from different tissue types, and how pain from different tissues is
- Define and describe peripheral sensitization and how these changes
are associated with pain perception
- Describe neurogenic inflammation, the neurotransmitters involved in
this process, and how these neurotransmitters could contribute to
peripheral pain processing.
- Understand the changes and role of ion channels, excitatory
neurotransmitters, and inhibitory neurotransmitters in the peripheral
nervous system and in non-neuronal cells, and explain how these changes
are important in the processing of pain transmission.
- Describe animal models of pain. Understand what the models are
trying to mimic, and why one would use an animal model to study
- Describe the pain pathways involved in the sensory discriminative
and motivational affective component of pain.
- Describe and define central sensitization and how this is similar
and different from peripheral sensitization.
- Describe and understand the mechanisms that underlie pain behaviors:
referred pain, primary hyperalgesia, secondary hyperalgesia, allodynia.
- Understand the role of excitatory neurotransmitters, inhibitory
neurotransmitters, and glia in the central nervous system in enhancement
of pain transmission, and changes that occur as a result of tissue
- Describe the descending pathways that modulate pain transmission.
- Understand the differences between pain facilitation and pain
inhibition, brain sites, and neurotransmitters that play a role in this
process. In particular understand how these pathways can be activated by
- Understand the long-term consequences of chronic pain on the
- Understand neuroimaging tools and key brain regions underpinning the
experience of pain, and how this changes depending upon the context,
cognitive and emotional state of the individual.
- Compare and contrast two or more theories on the interactions
between pain and motor function (e.g. Vicious Cycle Theory and Pain
II. Pain Assessment and Measurement
A. Recognize the differences between acute and chronic pain and the
implications for assessment and management of the patient.
B. Emphasize performance of a comprehensive assessment using reliable
and validated tools in the acute pain phase to prevent the onset of
C. Use a biopsychosocial approach for assessment of pain and
disability as it accounts for the multidimensional nature of pain in
domains relevant to physical therapy practice.
D. Account for the multidimensional nature of pain by including
appropriate assessment measures for primary domains including:
E. Recognize strengths and limitations of commonly used measures for
different pain dimensions:
- Self-report measures as "accepted standard" not gold standard
- Physical performance measures including Functional Capacity
- Physiological/autonomic response measures
F. Modify pain assessment strategies to match inherent variability
associated with the patient's clinical presentation:
- Individual factors (e.g. age, sex, etc.)
- Sociocultural influences (e.g. spirituality, ethnicity, etc.)
- Clinical characteristics of pain (e.g. duration, anatomical
- Pain type and state (e.g. neuropathic pain, cancer pain, etc.)
- Vulnerable populations (e.g. communication barriers, cognitive
G. Interpret, critically appraise (reliability, validity, and
responsiveness), and implement available pain assessment instruments
- Screening for the development of chronic conditions
- Identifying accepted patient subgroups for application of treatment
- Determining clinical relevance and/or magnitude of patient outcomes
H. Understand the need to monitor and review the effectiveness of
treatment/management and modify treatment and management strategies
I. Understand the need to refer to relevant health professional as
appropriate and in a timely manner.
III. Management of Pain
A. Demonstrate an ability to integrate the patient assessment into an
appropriate management plan using the concepts and strategies of
B. Understand the principles of an effective therapeutic
patient/professional relationship to reduce pain, promote optimal
function and reduce disability through the use of active and where
appropriate, passive pain management approaches
C. Assist patients to develop a daily routine to support achievement
and, where necessary, readjustment of habits and roles according to
individual capacity and life situation
D. Understand the need to involve family members and significant
others including employers where appropriate.
E. Use a person-centered perspective to formulate collaborative
intervention strategies consistent with a physical therapy
F. Understand appropriate pharmacology
- Understand the principles of the pharmacology of medications used to
- non-opioid medications
- topical analgesics and local anaesthetics
- Understand the limitations of the pharmacological management of
chronic pain, the importance of combining pharmacological approaches
with non-pharmacological management of chronic pain and the use of such
strategies alongside appropriate evidence-based active self management
G. Patient education
- Recognise the impact of, and evidence for, the use of therapeutic
neuroscience education and self-management as a critical part of pain
- Design and apply appropriate educational strategies based on
- Identify the range of educational opportunities available across
therapeutic domains (eg, injury, disease, medical and post surgical
intervention) with consideration of age, culture and gender.
- Consider the scope and evidence for/against various contemporary
therapeutic educational styles (e.g. biomedical, psychological,
neuroscience) and models (e.g stages of change theory) and service
delivery modes including face to face, web-based, group education.
- Identify key variables which may impact on knowledge outcomes for
the patient (eg self efficacy, health literacy, co-morbidities,
culture), the clinician (eg health professional's pain-related beliefs),
the message (e.g. use of multimedia), and the context (e.g. insurance
limitations; risk reduction; injury prevention)
H. Behavioral management
- Understand and apply functional behavioral analysis of pain
- Appraise the value of screening tools in the identification of
psychosocial factors predictive of persistent disability.
- Apply behavioural approaches (physical and cognitive behavioral
components) and evaluate the effects.
- Understand the parameters (i.e., mode, frequency, duration,
intensity) of therapeutic exercise for pain relief.
- Describe how to modify exercise parameters as they relate to the
pain condition, age, psychosocial factors, and patient's health
- Recognize the importance of implementing adjunct therapies to
address issues related to exercise prescription (i.e., biopsychosocial,
fear avoidance behaviour, catastrophizing, cognitive behavioural
- Understand the importance of patient education in prescribing
therapeutic exercise, including the concept of motivation, pacing) to
enhance overall treatment effectiveness and compliance.
J. Reintegration into work (paid and unpaid employment)
- Identify the factors associated with prolonged work loss and
integrate strategies to overcome barriers to return to work
- Understand the role of ergonomic principles, modified workplace
- Develop a management plan in co-ordination with employers and case
K. For the following interventions
- Manual Therapy (massage, manipulation, mobilization)
- Transcutaneous electrical nerve stimulation (TENS, IFC)
- Understand the proposed neurophysiological mechanisms and the
associated effects, and for manual therapy the biomechanical effects, of
each intervention as it pertains to pain management.
- Understand the principles of clinical application and current
evidence for the each intervention in the management of different pain
IV. Clinical Conditions
A. Understand the use of education, exercise and adjuvant physical
therapy interventions as they pertain to specific acute and chronic pain
conditions. The following is a list of different clinical conditions
commonly managed with physical therapy. Other conditions may also
warrant physical therapy interventions.
- Low back and neck pain
- Headache and Migraine
- Cancer pain
- Myofascial pain
- Neuropathic pain
- Complex regional pain syndromes
- Temporomandibular disorder
- Adhesive capsulitis
- Postoperative pain
- Pelvic floor pain
Sluka KA, Mechanisms and Management of Pain for the Physical
Therapist, IASP Press, 2009. This book provides a general overview
of the epidemiology, definitions, basic science mechanisms, assessment,
physical therapy management, interdisciplinary care, and pain syndromes.
It uses an evidence-based approach to pain management including
information on education, exercise, electrotherapy, manual therapy, and
Additional references listed below expand what is currently found in
the above text:
- Apkarian AV, Baliki MN, Geha PY. Towards a theory of chronic pain.
Prog Neurobiol. 2009 Feb;87(2):81-97. Epub 2008 Oct 5. Review.
- Engers AJ, Jellema P, Wensing M, van der Windt DAWM, Grol R, van
Tulder MW. Individual patient education for low back pain. Cochrane
Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004057. DOI:
- Foster G, Taylor SJC, Eldridge S, Ramsay J, Griffiths CJ.
Self-management education programmes by lay leaders for people with
chronic conditions. Cochrane Database of Systematic Reviews 2007, Issue
4. Art. No.: CD005108. DOI: 10.1002/14651858.CD005108.pub2. Publication
status and date: Edited (no change to conclusions), published in Issue
- Furlan AD, van TulderMW, CherkinD, Tsukayama H, Lao L, Koes BW,
Berman BM. Acupuncture and dry-needling for low back pain. Cochrane
Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI:
10.1002/14651858.CD001351.pub2. Publication status and date: Edited (no
change to conclusions), published in Issue 9, 2010.
- Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for
shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 2.
Art. No.: CD004258. DOI: 10.1002/14651858.CD004258. Publication status
and date: Edited (no change to conclusions), published in Issue 9,
- Kendall N, Burton K, Watson PJ, Main C. Tackling musculoskeletal
problems: a guide for clinic and workplace. TSO. London 2009.
- Moseley, G. L., Nicholas M K, et al. (2004). A randomized controlled
trial of intensive neurophysiology education in chronic low back pain."
Clin J Pain 20(5): 324-30.
- Persson A L, Veenhuizen H, Zachrison L, Gard G. Relaxation as
treatment for chronic musculoskeletal pain: a systematic review of
randomised controlled studies. Physical Therapy
- Trinh K, Graham N, Gross A, Goldsmith CH, Wang E, Cameron ID, Kay
TM, Cervical Overview Group. Acupuncture for neck disorders. Cochrane
Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004870. DOI:
10.1002/14651858.CD004870.pub3. Publication status and date: Edited (no
change to conclusions), published in Issue 3, 2010.