Publications
APS Bulletin • Volume 10, Number 1, January/February 2000
Pain Clinic Perspectives
Steven H. Sanders, PhD, Department Editor
Occupational and Physical Therapists’ Knowledge and Attitudes Regarding Pain: A Survey
Deborah L. Rochman, MS OTR/L; Penelope Herbert, MS PT, cochairs, APS Rehabilitation Subcommittee
Department editor’s note: In assuming the department editorship for Pain Clinic Perspectives, I would like to thank former department editor Ronald Kulich for providing the following article by Deborah Rochman and Penelope Herbert. I would also like to express my appreciation to Ron for his excellent work as editor over the last several years. His focus and selection of articles have been very timely and informative. I shall do my best to carry on his tradition.
—Steven H. Sanders, PhD
While many may lament the decreased role of rehabilitation in pain, occupational therapists (OTs) and physical therapists (PTs) often are the forefront clinicians for most patients with noncancer-related chronic pain. Such therapists gain beliefs and knowledge about treating pain from many different sources. Professional education in these disciplines has given low priority to the study of pain (Nelson, Cash, & Bauer, 1990; Simmonds, 1999; Unruh, 1995a), and there is evidence that deficiencies in knowledge and attitudes about pain exist among therapists (Turnquist & Engel, 1994; Wolff, Michel, Krebs, &Watts, 1991) and students (Rochman, 1998; Unruh, 1995a).
In 1996, APS formed a task force to investigate the status of pain education and training of pain clinicians. The task force, now known as the APSTraining and Education Committee, consists of a multidisciplinary group of APS members that includes physicians, nurses, psychologists, PTs, and OTs. Subcommittees, representing the various disciplines, have been formed. Consistent with the interdisciplinary nature of pain management, the APS Rehabilitation Subcommittee includes OTs and PTs.
The subcommittee’s first goal is to develop an instrument to assess OTs’ and PTs’ knowledge and beliefs about pain. This tool could be used in educational and clinical settings. The second goal is to use the tool to illustrate the contrast in the pain knowledge and attitudes of a sample of OTs and PTs. Although pain-knowledge surveys had been conducted previously with PTs (Battie, Cherkin, Dunn, Ciol, & Wheeler, 1994; Wolff, Michel, Krebs, & Watts, 1991) and OTs (Rochman, 1998; Turnquist & Engel, 1994; Unruh, 1995b), none of the surveys had an interdisciplinary focus. The City of Boston Rehabilitation Professionals’ Knowledge and Attitudes Survey Regarding Pain (COBS) (Rochman & Herbert, 1999) was developed as an interdisciplinary instrument based on the International Association for the Study of Pain’s (IASP’s) Pain Curriculum for Students in Occupational or Physical Therapy (IASP Subcommittee for Occupational Therapy/Physical Therapy Curriculum, 1994).
The Pain Curriculum for Students in Occupational or Physical Therapy (IASP Subcommittee for Occupational Therapy/Physical Therapy Curriculum, 1994), developed by an international and multidisciplinary group of pain experts, attempted to address the problem of nonstandardized knowledge about pain. While acknowledging the two disciplines’ different theoretical bases and approaches to pain, the curriculum defined areas of pain knowledge required of PTs and OTs and supported and encouraged professional collaboration. The curriculum included 11 course objectives aimed at measuring the effectiveness of pain education. For example, the objectives addressed the need to understand current theories of pain and pain relief, differences between acute and chronic pain, the psychosocial, cultural, and environmental factors that contribute to the pain experience, and the need for objective evaluation using reliable and valid assessments and interventions. The COBS was designed to test the main objectives of this interdisciplinary curriculum.
Methods used for development of COBS
Using the IASP curriculum as a framework, learning objectives were developed through literature review and the consensus of eight clinical experts on pain, four from each discipline (see Table 1). Design of the survey involved the following:
Using an existing instrument with established reliability and validity (City of Hope National Medical Center, 1987)
Submitting the instrument to clinical experts for selection of questions appropriate for rehabilitation therapists
Using questions that more than 75% of the experts agreed should be used
Adding additional questions to include discipline-specific content
Creating case studies to address objectives not already met
Resubmitting the COBS to the eight clinical experts and the chairs of the training and education committee
Matching the survey objectives to the questions
Pilot testing using 30 therapists in an acute-care facility
Administering the COBS to the clinical experts with 97.5% agreement on the answers to the questions
TABLE 1. Learning Objectives of the COBS SurveyPhysical therapists and occupational therapists should be able to
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The final survey consisted of 36 items: 26 true-or-false questions, 5 multiple-choice questions and 4 case studies involving 5 questions. Demographic questions were added and included clinical setting, specialty area, years of experience, academic degree(s) earned, and region of training (Rochman & Herbert, 1999).
Administration and results
The survey was administered to a sample of OTs and PTs distributed across the United States. Three hundred and four surveys were returned with 180 surveys meeting criteria for inclusion in the study. Total scores (see Figure 1) indicated that
OTs working in the area of neurology had a statistically higher knowledge score than PTs with respect to the neurophysiological theories of pain through the life cycle.
PTs with bachelor’s degrees were more likely to select the appropriate form of nondrug intervention (e.g., heat or ice) than OTs with bachelor’s degrees.
OTs with master’s degrees demonstrated superior understanding of both the impact of the psychological, cultural, and emotional influences that act as environmental reinforcers (e.g., religious beliefs, distraction, oversolicitous or “enabling” behaviors on the part of family members) on the pain experience, as well as the uses of a self-report scale.
In relation to clinical settings and pain knowledge and beliefs:
Outpatient therapists were better able than inpatient therapists to differentiate between acute and chronic pain and the different responses and behaviors of patients with pain.
Outpatient therapists were more likely than inpatient therapists to be able to identify current myths and misconceptions about pain.
There was a positive relationship between knowledge scores and years of clinical experience. (Patients are our best teachers!)
Total scores did not correlate with higher academic degrees, but more advanced degrees correlated with more knowledge about pharmacology and placebo.
FIGURE 1. Total Frequency of Scores of Physical Therapy and Occupational Therapy Combined (N = 180).(Scores of 30 or more were considered adequate for pain knowledge. 48% of respondents met the standard.) 
Note. From A Rehabilitation Professionals' Knowledge and Attitudes Survey Regarding Pain: Development of the City of Boston Survey, by D.L. Rochman and P. Herbert. Poster session presented at the 9th World Congress of Pain, Vienna, Austria, August, 1999. |
Discussion
The results of this study indicate that OTs’ and PTs’ knowledge about pain increases with years of practice and does not correlate with the therapists’ educational levels. Therapists’ scores demonstrated low accuracy in beliefs about addiction, acceptance of patients’ reports of pain, and current myths and misconceptions about pain. These findings highlight the problems of misinformation and misconception about pain and the impact of these perceptions on clinical reasoning and practice patterns. Educational curricula should include sufficient content to prepare clinicians to assess and manage pain effectively (U.S. Department of Health and Human Services, 1994). Improving the pain knowledge of faculty or having faculty members with pain expertise may provide a viable solution (McCaffery & Ferrell, 1996).
Inconsistent pain management practices and negative attitudes and judgments about patients with pain also were demonstrated in this study. Low accuracy was most consistently demonstrated in the case study portion of the survey, suggesting not only a deficiency in fundamental pain neurophysiology, but also a need to directly confront commonly held beliefs when educating clinicians on effective pain interventions. In addition to being given current and factual information about pain and pain relief, students and therapists should be encouraged to discuss their own or family members’ experiences with pain as a means of exploring their personal beliefs and attitudes regarding pain. To influence not just what therapists can do, but also what they will do, using the IASP core pain curriculums for professional education during ongoing interdisciplinary teaching rounds may be a more inclusive way of converting knowledge to behavior.
References
Battie, M., Cherkin, D., Dunn, R., Ciol, M., & Wheeler, K. (1994). Managing low back pain: Attitudes and treatment preferences of physical therapists. Physical Therapy, 74, 219-226.
City of Hope National Medical Center. (1987). Nurses’ knowledge and attitudes survey regarding pain. An instrument developed by Betty Ferrell and Margo McCaffery.
International Association for the Study of Pain Subcommittee for Occupational Therapy/ Physical Therapy Curriculum. (1994, November/December). Pain curriculum for students in occupational therapy or physical therapy. IASP Newsletter, 3-8.
McCaffery, M., & Ferrell, B. (1996). Correcting misconceptions about pain assessment and use of opioid analgesics: Educational strategies aimed at public concerns. Nursing Outlook, 44, 84-90.
Nelson, C., Cash, S., & Bauer, D. (1990). Adult physical dysfunction content in professional curricula. American Journal of Occupational Therapy, 44, 1079-1087.
Rochman, D. (1998). Students’ knowledge of pain: A survey of four schools. Occupational Therapy International, 5(2), 140-154.
Rochman, D., & Herbert, P. (1999, August). A rehabilitation professionals’ knowledge and attitudes survey regarding pain: Development of the City of Boston Survey. Poster session presented at the 9th World Congress of Pain, Vienna, Austria.
Simmonds, M. (1999, August). Pain in physiotherapy curricula: An international faculty survey. Poster session presented at the 9th World Congress of Pain, Vienna, Austria.
Turnquist, K., & Engel, J. (1994). Occupational therapists’ experiences and knowledge of pain in children. Physical and Occupational Therapy in Pediatrics, 14, 35-51.
Unruh, A. (1995a). Pain knowledge and attitudes questionnaire. Unpublished questionnaire. School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia.
Unruh, A. (1995b). Teaching student occupational therapists about pain: A course evaluation. Canadian Journal of Occupational Therapy, 62(1), 30-36.
U.S. Department of Health and Human Services. (1994). Management of cancer pain. [Clinical practice guideline]. (AHCPR Publication No. 94-0592). Rockville, MD: Author.
Wolff, M., Michel, T., Krebs, D., & Watts, N. (1991). Chronic pain: Assessment of orthopedic physical therapists’ knowledge and attitudes. Physical Therapy, 71, 207-214.
Authors’ note: The COBS survey is available from the City of Hope National Medical Center and Beckman Research Institute in Duarte, CA, or through its Web site (http–//mayday.coh.org) under “Instruments.” Deborah L. Rochman is a lecturer at Tufts University, Boston School of Occupational Therapy, Medford, MA, and clinical instructor, Gelb Orofacial Pain Center, Tufts University, School of Dental Medicine, Boston. Penelope Herbert is a program director at Spaulding Rehabilitation Hospital in Boston and rehabilitation consultant to the Massachusetts General Hospital Pain Service in Boston.