Chronic pain - assessment of orthopedic physical therapists' knowledge and attitudes.

Literature Review

The purposes of this study were to measure the knowledge of pain mechanisms and pain management among practicing orthopedic physical therapists and to describe the attitudes these therapists hold in regard to treating patients with benign chronic pain secondary to orthopedic disorders. We define benign chronic pain as pain of greater than 6 months' duration not attributable to malignancy. Patients with benign chronic pain are frequently seen in orthopedic physical therapy clinics. A majority of the studies cited in this article are oncology related. We believe the similarity between patients with pain of oncologic etiology and patients with benign chronic pain is in how the acute care model of pain mechanisms and management is incorrectly applied to both populations. The lack of knowledge of pain mechanisms and management, the detrimental effects of negative attitudes about treating patients, and the incorrect application of principles of pain management noted in the cancer literature are also characteristic of the literature on patients with benign chronic pain.

Education

The current medical model of pain mechanisms and management is acute care and disease oriented.(1,2) Pain is seen as a closed system. The cause is within the patient and can ultimately be resolved by treatment.(1-4) The core of the traditional medical model is the belief that disordered bodily states result from physical causes. Pain, therefore, is primarily a physical response to organic dysfunction.(5,6) The patient and the health care professional expect that, by the tenets of the traditional medical model, the patient will experience pain relief.(7) According to Bonica, as pain progresses from acute to chronic, "different fiber pathways are utilized, and diverse areas of the brain become involved in pain perception and modulation."8(pii)

One detrimental result of using this model is that benign chronic pain is then seen as an extension of acute pain having a specific physical cause. Many health care professionals, including physical therapists, evaluate pain using the acute care model, and treatment is based on the same model.(914) There is an apparent assumption that the etiology is the same for both acute and chronic pain, but that chronic pain is merely of longer duration. We believe that an understanding of the scope of chronic pain should make it apparent that

no matter how complete our understanding

of anatomical, physiological,

and chemical substrates of an individual

chronic pain state, our treatment

will not be successful without attention

to and treatment of the patient's suffering

and pain behaviors.(15(p577)

Attitudes The difficulties in treating patients with pain are compounded not just by a lack of knowledge but also by behaviors that are guided largely by attitudes.(16-18) The health care professional's treatment of pain is based on knowledge, experience with specific treatments, and personal attitudes about pain. Attitudinal studies(l9-2l) reported the nursing literature have shown that, when a clinician is unable to relieve pain and emotional distress, feelings of professional competence diminish and lead to avoidance of the situation, physically and intellectually. If clinical expectations are not fulfilled, the therapist may feel a sense of frustration.(22,23) Health care professionals are often aware that improvements in their patients with chronic pain are limited, yet they still expect positive changes similar to those achieved in patients with acute pain.(24) The relationship between knowledge and attitude among nurses caring for patients with cancer has been studied extensively.(16-18,25,28) These studies revealed that nurses, in general, have insufficient knowledge of the concepts of oncology and pain management, and this lack of knowledge contributes to poor attitudes. According to Reed-Ash, "The treatment of pain often depends upon the attitudes and mores of the health professionals rather than the patient's perception of pain."(29(P179)) Increasing knowledge results in improved attitudes. Both are necessary for improved behaviors related to patient care. There is little information directly related to physical therapists' knowledge and attitudes in regard to patients with chronic pain. Given the high number of patients with chronic pain that orthopedic therapists encounter and the documented lack of pain education among health care professionals, the Chronic Pain Knowledge/Attitude Test* was developed to evaluate physical therapists' knowledge and attitudes toward treating patients with benign chronic pain. The test was designed to answer the following research questions: 1. Do physical therapists demonstrate

sufficient knowledge and appropriate

attitudes for treating patients

with benign chronic pain? 2. Are physical therapists prepared to

address psychosocial issues associated

with patients with benign

chronic pain? 3. Do physical therapists feel that

physical therapy is beneficial for

patients with benign chronic pain? 4. Do physical therapists express a

willingness to work with patients

with chronic pain? 5. Are variations in test scores on the

pain knowledge component and

the attitude component correlated

to each other or to level of degree,

years of experience, or current

level of pain theory and treatment

knowledge?

Method

Sample

The Chronic Pain Knowledge/Attitude Test was mailed to a random sample of 500 members of the Section on Orthopaedics of the American Physical Therapy Association. This sample represents 5% of the section membership. The sample member list was drawn from the following settings: hospitals, private physical therapy offices, and inpatient and outpatient rehabilitation centers. All persons were asked to return the test, anonymously, but to complete it only if they had a minimum of 2 years of orthopedic experience and were currently treating patients. A follow-up mailing was not possible because of budgetary constraints.

Instrumentation

The Chronic Pain Knowledge/Attitude Test is based on treatment objectives written by the authors and listed in the Appendix. The objectives stemmed from a literature review, personal experience, and discussions with clinical experts. These objectives represent the minimum requirements for providing beneficial treatment for patients with benign chronic pain secondary to orthopedic disorders. Content validity of the test questions was established by submitting 50 questions developed by the primary investigator (MSW) to three clinical experts in pain management (a psychiatrist, a neurologist, and a physical therapist), three clinical experts in orthopedic physical therapy, and three specialists in test construction and development. Revisions were made based on the comments of the experts. Clinical questions were rejected if two of the six clinical experts did not agree on content, clarity, or relevance to clinical practice. A selected question was not included if the one reviewer designated as an expert for that question rejected it outright. Test construction specialists reviewed the remaining questions for their match with test objectives and for clarity. The revised instrument was pilot tested on 12 volunteer physical therapists. The pilot test aided in clarifying instructions, eliminating vague questions, and determining time needed to complete the test. Test reliability was assessed by the consistency of responses and the elimination of inconsistent or confusing questions. The final instrument consisted of 28 test questions (18 questions addressing the pain knowledge component of the survey instrument and 10 addressing the attitude component), 3 demographic questions, 5 educational information questions, and a cover letter.

Procedure

Correct answers for each question were determined by consensus of the clinical experts and current physiologic and anatomic principles. Individual knowledge questions were scored as either correct (2 points) or incorrect O points), Individual attitude questions were weighted more heavily and could receive partial credit (0, 2, 4 points), depending on the nearness of the given response to the desired answer. If a question specifically combined a knowledge objective and an attitude objective, the combined score was used. The criterion test scores of 80% correct on each component (pain knowledge and appropriate attitude toward treating patients with chronic pain) were set by the authors as the minimum scores necessary to demonstrate adequate pain knowledge and appropriate attitudes to significantly benefit patients with benign chronic pain. The criterion scores, set prior to the evaluation of the results, were derived from research and personal communications with clinical orthopedic and pain experts.

Data Analysis

Frequencies, means, and Pearson Product-Moment Correlation Coefficients were calculated using the SAS statistical system.' Total scores, means, and frequencies were determined for each pain knowledge and attitude objective. Frequencies were tabulated for demographic and pain education information questions to describe the sample. Correlations were calculated between responses to selected demographic and test questions. The confidence level (alpha) was set at .05 for two-tailed research questions reflective of the descriptive nature of the study.

Results

Sample Characteristics One hundred eighty-three therapists (36.6%) returned the test, resulting in 119 usable returns (23.8%). Highest academic degree held and years of experience are shown in Tables 1 and 2, respectively. Responses to the educational information questions are presented in Tables 3 and 4. Entry level pain education was perceived as less than adequate or very adequate by 72% of the respondents. Table 5 lists sources of pain management and theory information, with continuing education and professional colleagues listed as the two most useful sources of information.

Test Results

Do physical therapists demonstrate sufficient knowledge and appropriate attitudes for treating patients with benign chronic pain? Table 6 gives raw score totals and percentages of respondents who met the criterion score for each component (pain knowledge and attitude toward treating patients with benign chronic pain). Table 7 lists the percentages of respondents who met the criterion score on the pain knowledge component of the test. Figure 1 demonstrates the frequency of actual pain knowledge scores. The criterion score on the pain knowledge component was met by 49.6% of the respondents. Figure 2 demonstrates the frequency of actual attitude scores. The criterion score on the attitude component was met by 7.8% of the respondents. Are physical therapists prepared to address psychological issues associated with patients with benign chronic pain? This research question required recognition of premorbid factors that may influence the patient with chronic pain, identification of psychological responses associated with chronic pain, and the therapists' willingness to address these issues when treating patients with benign chronic pain. The scores of this part of the test demonstrated that slightly more than half of the respondents recognize premorbid factors that can influence the patient and that two thirds of the respondents can identify responses associated with chronic pain and may be willing to address these issues in physical therapy intervention (Tab. 8).

Do physical therapists feel that physical therapy is beneficial for patients with benign chronic pain? The criterion score was met by 27.7% of the respondents. Are physical therapists willing to work with patients with chronic pain? The criterion score was met by 4.1% of the respondents. When specific diagnoses associated with acute and chronic pain conditions were listed, 95.0% of the respondents preferred to treat acute pain conditions. in this sample, 47.9% of the respondents felt there was often not enough time for treatment, and 84.9% indicated that successful rehabilitation requires more resources than physical therapy alone.

Are variations in test scores on the pain knowledge component and the attitude component correlated to each other or to level of degree, years of experience, or current knowledge satisfaction? The sum scores between pain knowledge and attitude were correlated. No covariance was found at a confidence level of .05. Correlations between test scores, years of experience, entrylevel pain education, and pain knowledge satisfaction were not found to be significant at a confidence level of .05 (Tab. 9). Discussion

Do Physical Therapists Demonstrate Sufficient Knowledge and

Appropriate Attitudes for Treating Patients with Benign Chronic Pain? The inability of over half of the respondents to meet the minimum score raises concerns about the pain knowledge base of the respondents. The scores on the attitude component clearly demonstrated poor attitudes toward treating patients with benign chronic pain, with less than 8% of the sample meeting the criterion score. The sample's mean score of 20.5 seems meaningfully different from the criterion score of 28.8 points. As demonstrated by the education information responses, 75% of the physical therapists in this sample felt they had received inadequate entrylevel education in pain management and theory. Despite this finding, 77% were satisfied with their current level of pain knowledge. These findings may indicate a significant amount of on-the-job learning has occurred in regard to pain management. It was encouraging to note that 50% of the respondents reported continuing education the most useful source of pain management information, and continuing education may account for the increased percentage of respondents who were satisfied with their current level of knowledge. The sample appeared to demonstrate insufficient pain knowledge and inappropriate attitudes, which could lead to potentially inadequate treatment of the patient with benign chronic pain. Are Physical Therapists Prepared to Address Psychological issues Associated with Patients with Benign Chronic Pain? In this sample, 73% of the respondents understood that the severity of the pain may not correlate directly with the severity of the injury. This finding demonstrates an awareness of the patient's personal pain history and ability to adapt to outside stress, cultural influences, and significance of the pain to the patient. Three fourths of the respondents indicated a willingness to address the functional, sensory, and emotional aspects of a chronic pain problem. Because a chronic pain problem also affects the patient's family, friends, and social network, it is important to include others in the patient's immediate surroundings to play positive roles in the patient's attempt to return to functional activity.(30) One half of the therapist respondents felt that the inclusion of a "significant other" was a necessary component of the physical therapy program. Two thirds of the respondents indicated a willingness to teach the patient coping skills in order to manage pain.

Do Physical Therapists Feel that Physical Therapy is Beneficial for Patients with Benign Chronic Pain?

Nearly 75% of the respondents felt that physical therapy is not beneficial for the patient with benign chronic pain. With only 12% of the respondents disagreeing with the statement that chronic pain is associated with chronic disability, there seems to be a preconception that a patient with chronic pain is likely to remain disabled despite physical therapy intervention. As noted by Wolfe,(22) feelings of job satisfaction may be influenced by the success of treatment outcomes. if treatment of chronic pain is inappropriately directed at the pain or at an alleged peripheral source of continuous pain, success will elude both patient and therapist. Willingness to continue contact will diminish. Further research is necessary to determine the cause of pessimistic and stereotypic attitudes. Do the therapist and the patient with chronic pain enter the treatment with the idea that therapy will fail? if so, where do such ideas originate and how can they be corrected? Pessimistic attitudes about the limited benefits of therapy may stem from past experiences of inappropriate treatments resulting in failure. We believe inappropriate treatments may result from insufficient education on the subtleties of chronic pain and the various means of management. Are Physical Therapists Willing to Work with Patients with Chronic Pain? We believe the word willing" should not be regarded as an implication of the possibility of a refusal to treat a patient, but rather as a preference that includes the therapist's own desire for successful treatment outcomes and continuation of contact with the patient. This preference is determined by a therapist's experience with similar patient conditions and expectations for successful treatment outcomes. The preference, in this sample, was to treat patients with acute pain over patients with chronic pain. Given the significant portion of the orthopedic patient population with subacute or chronic pain, the scores on this section are distressing. The patient with chronic pain may require multidisciplinary services because of the multidimensional nature of the pain.(31) Physical therapy for patients with chronic pain that is based on the acute care model and limited by economic constraints may not allow for the intensity or duration of successful treatment. Are Variations in Test Scores on the Pain Knowledge Component and the Attitude Component Correlated to Each Other or to Level of Degree, Years of Experience, or Current Knowledge Satisfaction? No correlation was demonstrated between the pain knowledge and attitude scores in this sample (Tab. 9). Previous research of health care professionals has demonstrated that a sufficient knowledge base may not be directly associated with appropriate attitudes or effective use of the knowledge,18 whereas other studies(25,27) indicate that the lack of knowledge may prevent the health care professional from providing optimal health care, potentially prolonging patient suffering and disability. A significant amount of research and theory indicates that attitudes and knowledge are positively correlated. 16,17,26 The small number of respondents who met the criterion score in each component makes it difficult to draw a reasonable conclusion from the present sample. Perhaps the variables tested were inappropriate to use to determine correlations. The survey and data-analysis methods, however, were constructed to specifically identify separate knowledge and attitude components, so the variables' lack of correlation may simply reflect the unique measurement method used in this study. Further research is necessary to determine what variables may be associated with pain knowledge and attitude. Limitations The rate of test returns in our study 36.6%), according to Babbie,(32) is less than adequate, although he provides no statistical basis for this judgment. Of the 500 mailed tests, it is not known how many actually reached the addressee or how many were not returned because the addressee let the requested return date pass. The questionnaire may have appeared too complex or too long. The unusable returns were from therapists who had less than the specified minimum of 2 years of orthopedic experience or were returns that were incomplete. The cost of printing and distributing an additional mailing or reminder postcard was prohibitive. The summer mailing may also have contributed to the low return rate, because summer is a popular vacation time. The respondents may have been therapists with confidence in their knowledge of pain mechanisms and management and an interest in the pain component of treatment. The self selection inherent in mailed survey returns may represent a group of respondents who scored higher than those who chose not to return the test. The low rate of return limits the generalizability of the study. The sample is not representative of all physical therapists, because the list was drawn from a random sample of members of the American Physical Therapy Association's Section on Orthopaedics. The objectives on which the test is based represent content areas of content validity by the selected experts in orthopedic physical therapy and pain management and therefore may not be all-inclusive. Conclusion The low rate of response and the difficulty in testing attitudes by a multiple-choice test are serious considerations when generalizing from this study. Further study is warranted on the attitudes of orthopedic physical therapists in regard to treating patients with chronic pain. The percentage of respondents who met or exceeded the criterion score on any component of the test seems to represent an insufficient number of therapists who are responding appropriately to the patient with benign chronic pain. No correlation was found between pain knowledge and attitude. The acute care model, which predominates in physical therapy academic preparation, may be a contributing factor to the low scores on both the pain knowledge and the attitude components of the test. Therapists in this sample demonstrated a marked preference for treating patients who have acute pain conditions over those with chronic pain. This preference may be due to feelings of frustration and lack of professional preparation. The current literature supports our conclusion that not enough is taught about the physiologic and cognitive mechanisms of pain during entry-level training and in clinical practice. The results of this study support the need to expand the education of physical therapists in basic mechanisms of pain, as well as pain assessment and management. Formal academic programs or continuing education courses need to address this issue if we are to improve the care of patients with subacute or chronic pain. References 1 Black RG. The clinical management of chronic pain. In: Hendler N, Long D, Wise N, eds. Diagnosis and Treatment of Chronic Pain. Boston, Mass: john Wright, Publisher; 1982:211-224. 2 Hackett TP. Pain and prejudice: why do we doubt that the patient is in pain? Medical Times. 1971;99:130-144. 3 Quill TE. Patient-centered medicine: increasing patient responsibility. Hosp Pract. 1985;20:6-17. 4 Daniel M, Long C, Murphy W, et al. Therapists' and chronic pain patients' perceptions of treatment outcome. J Nerv Ment Dis. 1983;171:729-733. 5 Leventhal H, Everhart D. Cited by: Taylor AG, Skelton JA, Butcher J. Duration of pain condition and physical pathology as determinants of nurses' assessments of patients in pain. Nurs Res. 1984;33:4. 6 Skelton JA, Pennebaker JW. Cited by: Taylor AG, Skelton JA, Butcher J. Duration of pain condition and physical pathology as determinants of nurses' assessments of patients in pain. Nurs Res. 1984;33:4. 7 Peric-Knowlton W. The understanding and management of acute pain in adults: the nursing contribution, Int J Nurs Stud 1984;21:131143. 8 Bonica JJ. Introduction. In: Bonica JJ, ed. Considerations in Management of acute Pain. New York, NY: HP Publishing Co; 1977:ii. 9 Stewart CE, MacMurdo D. Chronic pain. In: Paris PM, Stewart RM, eds. Pain Management in Emergency Medicine. East Norwalk, Conn: Appleton & Lange; 1988:377-400. 10 Lipman AG. Drug therapy in cancer pain. Cancer Nurs. 1980;3:39-46. 11 Jacox AK. Assessing pain. Am J Nurs. 1979;79:895-900. 12 Siracusano G. Problems faced by the physical therapist in the treatment of chronic pain. Journal of Orthopaedic and Sports Physical Therapy. 1984;6:3-5. 13 Charap AD. The knowledge, attitudes, and experience of medical personnel treating pain in the terminally ill. Mt Sinai j Med. 1978;45:561-580. 14 Marks RM, Sacher Ej. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med. 1973;78:173-181. 15 Ignelzi Rj, Atkinson JH. Pain and its modulation, part 1: afferent mechanisms. Neurosurgery 1980;6:577-583. 16 Hauck SL. Pain: problem for the person with cancer. Cancer Nurs. 1986;9:66-76. 17 Whelan J. Oncology nurses' attitudes toward cancer treatment and survival. Cancer Nurs, 1984;7:375-383. 18 Fanslow J. Attitudes of nurses toward cancer and cancer therapies. Oncology Nursing Forum. 1985;12:43-47. 19 Bagley CS, Falinski E, Gamizo N, Hooker C. Pain management: a pilot project. Cancer Nurs. 1982;5:191-199. 20 jacox AK, Rogers AG. The nursing management of pain. In: Marino LB, ed. Cancer Nursing. St Louis, Mo: CV Mosby Co; 1981:381404. 21 Stockwell F. Cited by: Whelan J. Oncology nurses' attitudes toward cancer treatment and survival. Cancer Nurs. 1984;7:376. 22 Wolfe GA. Burnout of therapists: inevitable or preventable? Phys Ther. 1981;61:10461050. 23 Curtis KA. Physical therapist role satisfaction in the treatment of the spinal cord-injured person. Phys Ther. 1985;5:197-200. 24 Mendel W. Staff burn-out: diagnosis, treatment and prevention. New Dir Ment Health Serv. 1979;2:75-83. 25 Fox IS. Pain management in the terminally ill cancer patient: an investigation of nurses' attitudes, knowledge, and clinical practice. Milit Med. 1982;147:455-459. 26 Myers JS. Cancer pain: assessment of nurses' knowledge and attitudes. Oncology Nursing Forum. 1985;12:62-66. 27 Craytor JK,Brown JK, Morow GR. Assessing learning needs of nurses who care for persons with cancer. Cancer Nurs. 1978; 1:211220. 28 Winger JM, Smyth-Staruch K. Your patient is older: what leads to job satisfaction? Journal of Gerontological Nursing, 1986;12:31-35. 29 Reed-Ash C. Pain and the cancer patient. Cancer Nurs. 1982;5:179. 30 Aronoff GM, Psychological aspects of nonmalignant chronic pain: a multidisciplinary approach. Resident Staff Physician. 1984;3: 10-13. 31 Paris SV. The role of the physical therapist in pain control programmes. Clinics in Anaesthesiology. 1985;3:155-167. 32 Babbie ER. The Practice of Social Research. 3rd ed. Belmont, Calif; Wadsworth Inc; 1983:226.