STANDARDS FOR PHYSIOTHERAPISTS

WORKING IN PAIN MANAGEMENT PROGRAMMES

CONTENTS
Introduction

Pain management programmes

Core skills of the physiotherapist

STANDARDS
1. Communication

2. Assessment

3. Intervention

4. Documentation

5. Health education

6. Quality Assurance

7. Health and safety

References
INTRODUCTION
The Physiotherapy Pain Association (PPA) was set up in 1994 for Chartered
Physiotherapists with an interest in pain. It was recognised as a Clinical Interest
Group of the Chartered Society of Physiotherapy (CSP) in 1996. Its objectives
include the promotion of relevant research, effective treatments and education and
training in pain and its management.

These standards appertain to physiotherapy practice within interdisciplinary Pain

Management Programmes (PMPs). This is a rapidly developing area of clinical practice.
The background knowledge and practical skills required for this speciality are not taught
systematically at undergraduate level in physiotherapy education, neither is there a
recognised route to gaining these competencies either during pre-qualifying or post-
qualifying education.

It was therefore necessary to develop standards of practice for physiotherapists working in

this speciality in order to ensure best practice and to assist in the identification of training
needs to achieve this. Due to the rapid proliferation of PMPs and the fact that treatment is
based on a psychological rather than a medical model it was felt that it would be helpful to
have unidisciplinary standards whilst continuing to recognise the importance of
interdisciplinary team standards.

The physiotherapist is a core member of the interdisciplinary team (Pain Society, 1996),
having competencies key to this type of rehabilitation. This specific role in pain
management and within the pain management team has continued to develop.

These standards should be read in conjunction with the CSP Standards of Physiotherapy
Practice (CSP, 1993) and other relevant speciality standards and Directives. They will be
reviewed in 1999.

The standards have been developed by a working party of the Physiotherapy Pain
Association, who are grateful for the help and support of Judy Mead MCSP, Senior
Professional Advisor, CSP.

Working Party Members:

Heather Muncey – Chair, Physiotherapy Pain Association, Frenchay and Southmead

PMP, Bristol
Frances Giles – Frenchay and Southmead PMP, Bristol
Babs Harper – Royal National Hospital for Rheumatic Diseases PMP, Bath
Stephanie Murfitt – Gloucester Royal Hospital PMP, Gloucester
Helen Chubb – St Peters Hospital, Chertsey
PAIN MANAGEMENT PROGRAMMES
BACKGROUND
It has been argued that interventions based on a medical model have had a limited effect
in the management of chronic pain and its consequences (Waddell, 1992). One of the
problems, for example, has been the failure to differentiate acute and chronic pain, pain
often being viewed as a symptom of tissue damage. Use of a multidimensional model
acknowledging the complexity of the development of pain and its presentation has proved
to be a more appropriate model in many circumstances (Waddell, 1992). In 1976 Wilbert
Fordyce used the behavioural model as a basis to explain the development of pain
disability and put forward a therapeutic approach to the behavioural management of pain.
Denis Turk applied cognitive principles in 1983 and subsequently the cognitive-behavioural
approach has been the basis of the main development in pain management. Although
programmes may differ in content depending on staff and time available, they are mostly
similar in their statement of aims. The cognitive-behavioural approach has been used in
the United Kingdom since the early 1980s and in particular over the last ten years has
become widely used and evaluated (Williams at al, 1994).

DEFINITION
Pain management within PMPs is described here as the use of a multidimensional
cognitive behavioural approach to manage pain and its consequences.

The PMP is delivered in a group setting by an interdisciplinary team, the core members of
which are a clinical psychologist, a physiotherapist and a medical practitioner specialising
in pain (Pain Society, 1996). Other professionals may be included in the team, such as an
occupational therapist or nurse.

Cognitive-behavioural PMPs use the normal rather than disease model of human
behaviour as a working hypothesis about the origin of some behaviours, and to identify
important maintaining variables (Harding & Williams, 1995).

AIMS OF PAIN MANAGEMENT PROGRAMMES

• Improve fitness, mobility and posture and counteract the effects the disuse
• Return to more normal and satisfying activities
• Counteract unhelpful beliefs and improve mood and confidence
• Avoid adverse drug effects and reduce unhelpful drugs
• Improve stress management and sleep
• Reduce effects of pain on family and improve social relationships
• Independence and maintenance of treatment gains
(From Harding & Williams, 1995)
CORE SKILLS OF THE PHYSIOTHERAPIST
The physiotherapist brings unique core skills to a PMP team that are part of
physiotherapy pre-qualifying and post-qualifying education, these being the use of
manual therapy, therapeutic exercise and electrophysical modalities (Curriculum
Framework, 1996). These will be integrated into the PMP utilising cognitive-
behavioural principles and other skills for which the physiotherapist requires
additional training.

TRAINING
As a PMP team member the physiotherapist will develop skills common to all disciplines:
• Cognitive-behavioural theoretical principles
• All aspects of the PMP, including other disciplines’ roles, to facilitate integration of
the team approach
• Approach to some common situations occurring with patients on PMPs using
cognitive-behavioural principles
• Interdisciplinary team working
• Education/teaching skills including working with groups of patients.

The physiotherapist also has specific training needs:

• Application of cognitive-behavioural principles to improving fitness.

The physiotherapist has a programme development and staff training role within the PMP
team:
• Developing the exercise component of the programme
• Developing the information/education part of the programme on
neuromusculoskeletal issues eg the healing process, acute versus chronic pain,
pain mechanisms, joint health, effects of inactivity
• Teaching other disciplines about the physiotherapist’s role and the role of fitness in
PMPs
• Teaching other disciplines about the management of common pathologies and
treatments that may occur in PMPs.

It is recognised that further work is required concerning competencies and training for
physiotherapists working in PMPs.

PEER SUPERVISION
In order that skills remain focused, physiotherapists should receive regular peer
supervision from a physiotherapist and a clinical psychologist. Physiotherapists should
also be active participants in the interdisciplinary teams’ clinical audit programme.
The CSP Standards of Physiotherapy Practice (1993) apply to physiotherapists
working with any patients in any setting and therefore underpin the following
standards for PMPs.

1. COMMUNICATION

PMP STANDARD 1

Communication between the physiotherapist and other members of the

interdisciplinary pain management team ensures a consistent approach to the
management of the patient.

CRITERIA

1.1 There is a system which allows effective verbal communication for the transfer of
information between team members.

1.2 There is a system for written communication with other members of the
Interdisciplinary team.

1.3 Physiotherapy records are kept in an area accessible to all members of the pain
management team.

1.4 There is evidence that physiotherapists participate in

• Patient programming meetings

• Collaborative patient records

• Writing the discharge summary.

1.5 There is a system in place for physiotherapists to contribute to decisions about

• Cross-referral to other professionals in the team

• Discharge

• Transfer of patients.

AUDIT TOOLS
Documentation
Team procedure/protocol files
Observation
PMP STANDARD 2

Information about the approach used in PMPs is communicated to non-clinical team

members of the service who come into contact with patients in the treatment
environment eg: reception staff, domestic staff.

CRITERIA

2.1 There is evidence of an induction process for non-clinical staff by the team.

AUDIT TOOL
Training records
2. ASSESSMENT

PMP STANDARD 3
A physiotherapist trained in PMPs shall carry out an assessment of the patient to
establish baseline data as part of the interdisciplinary team selection process for
the programme, an individual management plan and evaluation process, using
standardised, sensitive, reliable and valid measures where possible.

CRITERIA

3.1 The patient is assessed by the physiotherapist prior to the start of a PMP.

3.2 There is written evidence that baseline data comprises subjective and objective
findings, including
• Measures of functional ability eg activities of daily living and vocational status

• Exercise and activity levels

• Patients’ attitudes and beliefs towards physical activity

• Fulfilment of physical criteria for entry into the PMP.

3.3 There is written evidence that individual goals are agreed with the patient and
incorporated into the overall management plan.

3.4 There is written evidence that measures of functional ability are reassessed on
completion of the programme.

AUDIT TOOL
Documentation
3. INTERVENTION

PMP STANDARD 4

The PMP will include an element to optimise physical fitness, posture and
movement and counteract the effects of disuse.

CRITERIA

4.1 There is evidence that

• A fitness programme is agreed with the patient

• Pacing takes place in the fitness programme

• Goal setting is applied to physical activities

• Goal setting includes the reduction of use of aids and appliances.

4.2 Written and verbal information is provided to patients and relatives/significant others
regarding the effects of disuse.

AUDIT TOOL
Documentation

PMP STANDARD 5

The PMP will contain an element to increase confidence with exercise and physical
activities.

CRITERIA

5.1 Written and verbal information is provided to the patient relating to pain and factors
which influence pain.

5.2 There is evidence that the individual management plan includes managing identified
fear of movement, exercise and physical activity.

5.3 There is evidence of use of graded exposure to improve confidence with exercise
and physical activities.

AUDIT TOOLS
Documentation
Observation/Peer review
PMP STANDARD 6
The physiotherapist participates with other interdisciplinary team members to
provide support and advice to the patient and relatives/significant others.

CRITERIA

6.1 Sessions allow time for discussion and problem solving.

6.2 Time is allocated during the PMP for discussion with the patients’
relatives/significant others that the physiotherapist can contribute to.

AUDIT TOOLS
Documentation
Observation/Peer review

PMP STANDARD 7
The physiotherapist ensures that the intervention equips the patient with the
knowledge and skills to enable them to maintain and develop pain management
strategies after completion of the PMP.

CRITERIA

7.1 An individual flare-up/set-back plan is agreed with the patient.

7.2 The patient is provided with written and verbal information advising on flare-up/set-
back plans.

7.3 It is documented that the patient is invited to attend at least one follow-up session
after completion of PMP.

7.4 The patient’s maintenance plans are included in the interdisciplinary discharge
report forwarded to agreed health care professionals.

AUDIT TOOL
Documentation
4. DOCUMENTATION

PMP STANDARD 8

There is clear and accurate documentation of assessment findings, all interventions

and contact with each patient to facilitate optimum patient care.

CRITERIA

8.1 Contact and communication with relatives/significant other is recorded.

8.2 Subjective and objective findings are recorded at reassessment at the end of a
PMP to include
• Measures of functional ability

• Patients’ attitudes and beliefs towards physical activity.

8.3 Maintenance and development plans are recorded.

AUDIT TOOL
Documentation
5. HEALTH EDUCATION

PMP STANDARD 9

Education and information on pain and its consequences and the PMP is provided
to patients and relatives/significant others.

CRITERIA

9.1 Written information on pain and its consequences and the PMP is available.

9.2 Sources of further information are indicated eg self-help groups, charities.

AUDIT TOOLS
Documentation
Resource files

PMP STANDARD 10
Physiotherapists promote the role of physical fitness and a healthy lifestyle within
the management and prevention of pain.

CRITERIA

10.1 Information, education and advice are provided to patients, their relatives/significant
others and other healthcare workers on
• The role of exercise

• Maintenance of maximal health by applying improved fitness

• Pain and healthy use of the body

• Positive attitudes to health.

10.2 Sources of further information are indicated.

AUDIT TOOLS
Documentation
Resource files
PMP STANDARD 11

Education and information about the PMP is provided to healthcare workers in

primary and secondary care settings to promote the approach used to manage pain.

CRITERIA

11.1 Information is provided on the approach used in PMPs.

11.2 Training programmes and courses on pain management will be facilitated.

11.3 Information in the prevention of pain is provided.

AUDIT TOOLS
Information packs/files
Training records

PMP STANDARD 12

Information about approaches to pain management and the delivery of services is

provided to managers, purchasers, policymakers and the general public to promote
the approach to the management of pain and prevention of chronicity.

CRITERIA

12.1 Information is provided on the role of pain management in health care.

AUDIT TOOL
Organisational records
6. QUALITY ASSURANCE

PMP STANDRD 13

Physiotherapists participate in programmes to evaluate practice and improve

quality.

CRITERIA

13.1 There is evidence of physiotherapists’ involvement in unidisciplinary and team audit

programmes.

13.2 Any protocols are subjected to at least bi-annual audit.

AUDIT TOOL
Documentation

7. HEALTH AND SAFETY

PMP STANDARD 14
The environment facilitates the safe operation of the PMP.

CRITERIA

14.1 The area is an appropriate size and type for the PMP to take place (Health
Buildings Note 8, 1991).

14.2 The minimum staff level is one physiotherapist and one other suitably trained
person eg therapy assistance or member of staff, to be readily available in case of
an emergency.

AUDIT TOOL
Observation
PMP STANDARD 15

Equipment is available to meet the needs of patients attending the PMP.

CRITERIA

15.1 Equipment is inspected prior to use on each occasion.

15.2 Faulty equipment is taken out of use immediately.

15.3 The repair of faulty equipment is actioned.

15.4 Equipment is replaced as necessary.

15.5 Equipment is kept clean.

15.6 Equipment is kept in working order.

15.7 Safe storage areas are provided for equipment and other materials.

15.8 There is evidence of staff training in the use of equipment, its hazards and dangers,
prior to use.

15.9 New equipment conforms to local policy requirements.

15.10 The physiotherapist checks for any contra-indications for each patient prior to use.

15.11 Warnings and instructions regarding equipment and its use are given to patients at
a pace and in a manner appropriate to their level of understanding.

15.12 Risk assessments are carried out for procedures identified as carrying a risk.

AUDIT TOOLS
Documentation
Observation/Peer review
Training records
REFERENCES

Chartered Society of Physiotherapy (1993). Standards of Physiotherapy Practice. 2nd

Edition. Chartered Society of Physiotherapy, London.

Chartered Society of Physiotherapy and The Council for Professions Supplementary

to Medicine (1996). The Curriculum Framework. Chartered Society of Physiotherapy,
London.

Fordyce WE (1976). Behavioural Methods for Chronic Pain and Illness. CV Mosby, St
Louis, MO.

Harding VR and Williams AcdeC (1995). Extending Physiotherapy Skills Using a

Psychological Approach: Cognitive-Behavioural Management of Chronic Pain.
Physiotherapy, 81, 11, 681-688.

Health and Safety Executive (1992). Manual Handling. Guidance on Regulations. The
Stationary Office, London.

NHS Estates (1991). Health Buildings Note 8: Rehabilitation: Accommodation for

Physiotherapy, Occupational Therapy and Speech Therapy. The Stationary Office,
London.

Pain Society (1996). Desirable Criteria for Pain Management Programmes: a Report of a
Working Party of the Pain Society. J Pain Soc 12(1&2), 12-15.

Turk DC, Meichenbaum D and Genest M (1983). Pain and Behavioural Medicine: the
Cognitive-Behavioural Approach. Guildford Press, New York.

Williams AcdeC, Nicholas MK, Richardson PGH et al (1993). Evaluation of a

Cognitive-Behavioural Programme for Rehabilitating Patients with Chronic Pain. British
Journal of General Practitioners. 43:513-517.

Waddell G (1992). Biopsychosocial Analysis of Low Back Pain in Clinical Rheumatology.

Vol 6 (3) 5523-57 Balliere.