Cary A Brown

An expanding body of chronic pain research is now evident within occupational therapy and strong support has developed during the last 10 years for the multidisciplinary approach to the management of chronic pain. Although this stand is now subject to growing scrutiny, a multidisciplinary structure continues to be the environment for most outcome studies. Occupational therapists, as accepted and involved members of pain management programmes, need to examine the values and beliefs that they bring to the treatment team.

As part of a wider research study of the congruence between what service providers and service users believe to be necessary treatments for chronic pain, the members of the National Occupational Therapy Pain Association were surveyed in January 2001. The survey asked therapists’ opinion about whether specific treatment components were needed or not needed for people with chronic pain. The survey also included Skevington’s (1990) Beliefs about Pain Control Questionnaire (BPCQ), which measures beliefs in the internal or personal control of pain, beliefs that powerful others (doctors) control pain and beliefs that pain is controlled by chance events.

The findings showed that there were few treatment components that 100% of the respondents agreed were needed. Endorsements clustered around treatments that focused on self-management and a statistically significant relationship emerged between certain treatment components and BPCQ scores. The paper concludes by discussing some possible influences on occupational therapists’ decision making in relation to treatments for chronic pain.

Introduction

Chronic non-cancer pain is an expensive and growing problem within industrialised countries. In a 1998 review, the United Kingdom direct health care costs for back pain alone were estimated as in excess of £1632 million (Maniadakis and Gray 2000). As the demand for intervention accelerates, socioeconomic forces have driven a parallel growth in demand for rigorous research into the efficacy of resource utilisation (McQuay et al 1997, Spence 1999).

An expanding body of chronic pain research is now evident within the literature of occupational therapy and other health-related disciplines. The literature primarily reflects the strong support that has developed during the last20 years for the multidisciplinary approach to the management of chronic pain (Fields 1995). Although this approach is now subject to growing scrutiny (Turk 1996, LeFort et al 1998, Von Korff et al 1998, Donovan et al 1999), a multidisciplinary structure continues to be the environment for most outcome studies. The multidisciplinary/multimodality approach makes for unique research design challenges in attempts to isolate the effects of individual treatment components and determine their relationship to the putative model of practice.

Occupational therapists, as accepted and involved members of the pain management team (Pain Society 1997), are not exempt from these issues. In the professional literature, there is very little evidence about what attitudes and beliefs occupational therapists hold in relation to chronic pain (Jones et al 2000). It appears that most occupational therapists have very little undergraduate knowledge of pain-related issues (Turnquist and Engel 1994, Unruh 1995, Rochman 1998, Rochman and Herbert 1999, Strong et al 1999). Jones et al (2000) addressed the question of the beliefs and attitudes that occupational therapists hold towards chronic pain. They developed a questionnaire examining three domains of belief related to interventions, people with pain and mechanisms of pain. While the authors did not identify specific beliefs and attitudes scores, they did find a statistically significant change (p<0.001) between pre-education and post-education scores and concluded that participation in a pain education workshop prompted a move towards greater homogeneity in beliefs about mechanisms of pain and people with pain. Conversely, after participating in the workshop, therapists had a wider dispersal of scores in the domain of intervention.

What occupational therapists and other health care providers believe may strongly influence the range of interventions brought to the treatment encounter (Bates et al 1997). Vrancken (1989, p440) proposed that ‘the way the medical community conceptualises what a pain patient is and how he should be treated, exemplifies how the medical community understands pain’. While the studies cited above have served to explore the beliefs and values of occupational therapists related to pain, there is little literature to date regarding how those beliefs translate into specific treatment interventions. It is important to know what treatments occupational therapists endorse in light of emerging research in the field of patient concordance.

Marinker (1998), in a discussion of concordance versus compliance, cited studies indicating that when there is congruence between service providers’ and service users’ beliefs about treatment, concordance is higher. Patient concordance with treatment is inextricably connected with the individual’s perception of whether the intervention is relevant, meaningful and likely to be successful (Kotarba and Seidel 1984, Donovan and Blake 1992, Schussler 1992, Yardley and Furnham 1999). The treatment endorsement patterns of both service providers, like occupational therapists, and service users need to be identified and compared.

A range of research supports the significant role that congruence and shared beliefs play in the chronic pain experience. A study by Seers and Friedli (1996), comprising 75 people with chronic non-malignant pain, revealed that the physician-client/patient interaction had a significant impact on people seeking help for chronic pain. This study suggested that people’s perceptions of disbelief by physicians were determined to have serious negative consequences.

Participants in the study attributed a range of negative effects to physicians’ disbelief of their pain. These effects included: growing self-doubt, increasingly unsupportive family members, inaccurate information going to employers, frustration over feeling that the physicians did not listen to them, and the perception that physicians disbelieved their pain. Eccleston et al (1997) compared a composite group of 60 physicians’ and patients’ understandings of the causes of chronic pain. This study revealed that while common categories of belief emerged (blame, responsibility and the need to protect identity), the two groups did not share common beliefs within those classifications.

A third study (Chapman et al 1996) asked 139 participants from one treatment centre and 77 from another to rate the ‘helpfulness’ of the treatments that they had received on the Treatment Helpfulness Questionnaire (a 10-item continuous scale). Chapman et al (1996) proposed that it was not feasible to explore optimal combinations of treatments within their study and, therefore, selected ‘patient satisfaction’ as it existed across broad categories of intervention as the outcome measure (that is, medical assessment/treatment, psychological assessment/treatment, physical therapy, office visits, individual psychotherapy, diagnostic tests, work ability assessments, education and group counselling). The findings from this research highlighted that patients varied in their ratings of treatment helpfulness. The authors also concluded that the helpfulness rating assigned was only partially correlated with the treatment outcome demonstrated by the Beck Depression Inventory, the Sickness Impact Profile and a visual analogue scale of pain intensity. As they pointed out, the study was limited in that it demonstrated only the occurrence, and not the ‘why’, of variation in the ratings that the clients assigned to the modalities.

Aim of the study

The Pain Society (British and Irish Chapter of the International Association for the Study of Pain) identified occupational therapists as important members of the treatment team in its report, Desirable Criteria for Pain Management Programmes (Pain Society 1997). It follows that the issues discussed above are of relevance to occupational therapy and require closer examination. This paper presents the occupational therapist findings that have been extracted from the results of an ongoing much larger multidisciplinary study, examining service providers’ and service users’ congruence of beliefs regarding specific treatments for chronic pain. The specific aim of this study was to identify the treatments that occupational therapists endorse for people with chronic pain and to explore the relationship between endorsement and chronic pain beliefs in the categories of internal control, powerful others and chance happening (Skevington 1990).

Method

Research tools

The literature and websites related to chronic pain intervention were reviewed and all the identified treatment components were listed. The resultant list of 63 treatment components formed the basis of a questionnaire (see Table 1 for the items included). This list was presented in random order within the questionnaire so that respondents would not be influenced by researcher-identified categories. The questionnaire section of interest in this report asked respondents to identify which treatment components they personally endorsed as needed or not needed for people withchronic pain.

The last section of the questionnaire was the Beliefs about Pain Control Questionnaire (BPCQ). This 13-item questionnaire contains three ordinal subscales measuring beliefs about internal or personal control of pain (IS), beliefs that powerful others (doctors) can control pain (PD) and beliefs that pain is controlled by chance events (CH) (Skevington 1990). Higher scores in the subscales indicated stronger endorsements of the respective beliefs. The BPCQ was selected, as opposed to other instruments that specifically measure occupational therapists’ beliefs (Rochman and Herbert 1999, Jones et al 2000), because the larger study that these results are taken from needed to compare the beliefs of both service users and service providers. The BPCQ, which targets both professionals and the general public and is not a measure intended exclusively for people with pain, met this requirement. Skevington’s (1990) previous psychometric testing had shown reasonable internal consistency in the chronic pain and non-patient groups and, using Cronbach’s alpha, internal consistency for each subscale was reported to be PD (0.82), IS (0.73) and, less strongly, CH (0.56). Although normative data do not exist for the BPCQ, previous scores of undergraduates, university applicants, patients and non-patients were available in the literature for comparative purposes (Skevington 1990, Rathbun and Slater 1995).

Participants and procedure

The board of the National Occupational Therapy Pain Association gave its permission to survey the membership (93 therapists at the time of the study) and provided mailing labels. The members were informed in the covering letter that return of the questionnaire would be taken as consent to participate. The participants were also invited to volunteer for a follow-up phase of the larger research project and requested to provide contact information if they were interested. Because of this, in eight cases it was possible to return questionnaires to participants for additional information where sections had been omitted or misunderstood.

The returned questionnaires were entered into SPSS Version 10® for descriptive statistical analysis and a chisquare was used to examine the relationship between the treatment components identified as needed or not needed and the BPCQ (beliefs about pain) subsets of IS (internal control), PD (powerful doctor) and CH (chance happening).

Findings

Participant profile

Of the 93 questionnaires, 44 (47.3%) were returned. There were 41 women and 3 men, whose ages ranged between 28 and 60 years (mean = 41 years) and years in practice between 1 and 31 years (mean =14 years). The most commonly reported type of pain-related work was with mixed caseloads (n = 33, 75%), followed by work with people having pain related to orthopaedic conditions (n = 8, 18.2%). The respondents showed a wide range in hours of undergraduate training, with 34 (77.3%) reporting that they had received 0 hours of training in pain and pain management. Only 3 (6.8%) of the total group had received more than 15 hours of pain education as undergraduates. At a continuing professional development (CPD) level, although 7 (15.9%) therapists reported having only 10 hours or less of additional training, 29 (65.9%) had participated in over 30 hours of pain-related CPD.

Organising therapists’ beliefs about treatment components

The range of treatment components that therapists ranked as needed or not needed was grouped into five general categories: (A) Education for self-management, (B) Health care professional applied biomedical interventions, (C) Health care professional applied psychosocial interventions, (D) Facilitation of peer-support network and (E) Complementary therapies. A panel of occupational therapy lecturers at the University of Liverpool reviewed the categories and demonstrated a range of agreement, between 75% and 100%, with how the treatments were grouped. Each treatment component was further categorised by the percentage of the responding therapists who identified the treatment as needed or not needed in the treatment of chronic pain (Table 1).

A review of Table 1 illustrates that there were very few of the 63 possible treatment components where the study respondents had 100% agreement in their endorsements. Only 10 (15.8%) of the possible treatment components (including the categories of ‘Health care professional’ and ‘Organisational structure’) were agreed upon as needed by all the respondents. The treatment category of Education for self-management demonstrated the highest consistency, with 80-100% of the respondents agreeing that 15 of the possible 20 treatment options (75%) were needed. The category of Health care professional applied biomedical interventions displayed a trend towards decreasing consistency and only 4 of the possible 14 treatments (28.6%) were seen as needed by 80%-100% of the respondents. The Complementary therapies category showed the lowest rate of congruence, with less than 80% agreeing about any of the 8 possible treatment options as being needed.

BPCQ scores

The respondents reported higher rates of endorsement for beliefs around internal (IS) factors as influencing pain, followed by chance happening (CH) and an overall low belief in powerful doctors (PD). In comparison with Skevington’s (1990) findings for these subscales with nonpatients, marked differences are evident in the PD and CH scores (Table 2). Because Skevington’s (1990) figures are not normative, the two groups can only be compared for the purpose of provoking discussion; no statistically significant relationship is implied.

Relationship between BPCQ scores and treatment components

BPCQ scores were divided into categories of ‘high’ and ‘low’, with the mean score used as the divide for ranking. Chisquare analysis of the high/low BPCQ scores and therapists’ beliefs that each individual treatment component was needed or not needed served to highlight several interesting trends. Statistically significant findings, as detailed in Table 3, emerged for the treatment components of TENS (transcutaneous electrical neuromuscular stimulation), yoga, tai chi and client access to research findings. Therapists who scored high on the IS (internal factors) scale in the BPCQ tended to see the use of TENS as a needed treatment for chronic pain (p = 0.039). Therapists who scored high in PD (powerful doctor) tended to believe that the yoga (p = 0.002) and tai chi (p = 0.028) treatment options were needed. The analysis also revealed that therapists who scored high on CH (chance happening) were more likely to endorse that people with pain needed access to research findings (p = 0.016).

Study limitations

There are several key limitations to the findings presented. Only 44 of the possible 93 (47.3%) questionnaires were returned, so the sample is less than ideal and no claims of representativeness should be inferred. Because the respondents could choose to be anonymous and there were financial restraints, no follow-up of non-respondents could be carried out. Therefore, it was not possible to determine demographic characteristics that might have influenced participation in the study. Also, the respondents, because of their membership in the National Occupational Therapy Pain Association, should be viewed as a sub-specialty group of occupational therapists that may have a wider knowledge and experience base in chronic pain than other occupational therapists.

Lastly, survey data do not capture the full range of responses possible in exploring a complex area such as pain. This postal survey focused on ‘what’ occupational therapists endorse and provided predominately quantitative data. However, without a follow-up examination of ‘why’ the therapists held these preferences, interpretation can only be incomplete and speculative at best. The second, qualitative stage of this research is currently being designed.

Discussion and conclusion

This survey has provided a preliminary profile of a group of occupational therapists’ beliefs in relation to chronic pain treatments. There was a wide range in respondents’ years of experience and hours of CPD training related to chronic pain. Most of the therapists worked with clients from a mixture of diagnostic groups, and nearly 75% of all the therapists participating in this study had received no dedicated training on pain during their undergraduate education. The study respondents appeared to be a heterogeneous group of therapists, each bringing a unique blend of training and experience to his or her practice. This lack of consistency was mirrored in what individual therapists felt were necessary treatments for chronic pain, although a definite trend was evident in the categories of treatment that the therapists tended to endorse more uniformly.

The therapeutic interventions related to Education for self-management were found to be more consistently identified as needed for treatment. It is possible that this is partially a function of the high amount of CPD that the therapists engaged in. Also, this may be related to the profession’s core philosophy of enabling occupation. According to Law (1997, p2), ‘enabling occupation means collaborating with people to choose, organise and perform occupations which people find useful or meaningful in a given environment’. Self-management approaches to chronic pain are evidently one such enabling tool that occupational therapists are well prepared to facilitate.

A potential explanation for another of the study’s findings may lie in the combination of this focus on enabling, the profession’s philosophical roots of client-centredness (Law and Baptiste 1995, Sumsion 2000) and the concept of occupational competence (Matheson and Bohr 1997). The BPCQ scores reflected that the National Occupational Therapy Pain Association group of occupational therapists tended to believe less strongly in the idea of a ‘powerful doctor’ (or other health care professional) and in ‘chance happening’ than non-patients from other studies (Skevington 1990). Occupational therapists ascribe to a belief system that people have mastery in their own lives and are not controlled by random fates.

The study produced some less easily understood findings, particularly in light of the above-mentioned beliefs. As identified, there was a positive relationship between high BPCQ scores in the ‘powerful doctor’ (PD) category and endorsement of yoga (p = 0.002) and tai chi (p = 0.028). While it may be argued that it is in keeping with occupational therapists’ philosophy of client-centredness to support lifestyle choices for complementary therapies (such as tai chi and yoga), it was puzzling that this endorsement was found within the subgroup of respondents (31.8%) who scored high in their belief in ‘powerful doctors’. Although the majority of respondents did not strongly endorse ‘powerful doctors’, the findings seem to suggest that there may be a subgroup of therapists that is supportive of alternative interventions focusing on a client-centred definition of ‘useful’, while at the same time still operating within a medical model endorsing the concept of professional expertise.

Two features of current health care may offer some insight into this apparent contradiction. First, most occupational therapists, as demonstrated in the findings of this and other studies (Scudds and Solomon 1995, Unruh 1995, Rochman 1998, Strong et al 1999), have a paucity of undergraduate education and training in pain. This may leave them poorly equipped to formulate an evidence-based argument for the pain interventions that they provide and/or endorse. Although the therapists did report a high rate of CPD in chronic pain, this expertise is acquired over time.

The question of whether practice and beliefs change with CPD is only now beginning to be addressed within the discipline (Jones et al 2000). Often working within large hospital-based services and multidisciplinary teams, therapists may adopt the values of other team members whose professional underpinnings and treatment approaches are theoretically grounded in biomedical reductionism (Freeman et al 2000). In this scenario, it would be possible to see an occupational therapist as swaying between the influences of the team milieu and his or her professional tenets.

A second consideration in exploring these unexpected findings is that health care practitioners are subject to the social forces in which the health care service is provided. Recently, Weinblatt and Avrech-Bar (2001) challenged occupational therapists to develop a questioning attitude towards what they traditionally hold to be ‘truths’ about science and medicine. They proposed that occupational therapists need to understand how postmodernism challenges commonly held modernist beliefs that health care consists of universal truths and principles explained through scientific analysis. In postmodernist thinking, there are no universal givens and personal reality changes in relation to the sociopolitical, temporal and environmental contexts in which an individual lives (Siahpush 1998). The emerging social phenomenon in western cultures of challenging biomedicine’s superiority has seen a growing exploration and endorsement of interventions that previously were held to be from the fringe and ‘alternative’ (Hodgkin 1996, Raithatha 1997, Siahpush 1998). The findings of this study, where 50%-79% of occupational therapists stated that they believed interventions such as acupuncture, yoga and meditation to be needed for the treatment of chronic pain, lend some degree of support to this idea.

Weinblatt and Avrech-Bar (2001) emphasised that occupational therapy is well positioned to offer interventions from within both traditional science driven models (such as biomechanics and exercise physiology) and methods that reflect a postmodern redefinition of health based on individual perceptions, beliefs and values. The profession’s client-centred philosophy allows occupational therapists to work flexibly with a variety of clients, each of whom defines his or her own ‘truth’. The findings of this survey, where therapists support traditional biomedical constructs at the same time as endorsing ‘alternative’ interventions (such as yoga), may cautiously be interpreted as lending support to Weinblatt and Avrech-Bar’s (2001) proposition. As discussed above, this survey only examined the ‘what’ of occupational therapists’ beliefs. Stronger evidence-based interpretation cannot go forward until the ‘why ‘ is added to the equation. Occupational therapy is only beginning to deal with the philosophical issues of constructivism and postmodernism and this paper makes no claims related to either paradigm. The introduction of these terms should be seen rather as a provocation, to stimulate and perhaps even aggravate the reader into further discourse.

Much more research is obviously needed. A qualitative second stage to this study is now in development to explore what explanation occupational therapists themselves bring to their decision making about chronic pain interventions. Chronic pain is a complex and life-altering condition. Occupational therapists, by virtue of their unique philosophical background, have much to offer to people with chronic pain. The challenge now is for occupational therapists to be willing to explore their own beliefs and attitudes while they seek a shared understanding of pain and treatment interventions with the clients that they serve.

Acknowledgements

This study would not have been possible without the financial support of the Constance Owens Trust; the willing participants from the National Occupational Therapy Pain Association members; my research supervisors, Professor A Jacoby (Department of Primary Care, University of Liverpool) and Dr G Baker (Walton Neurological Centre); Dr Maria Leitner (Director of Research, School of Health Sciences, University of Liverpool); and my academic colleagues’ supportive but critical perspectives. My particular appreciation to the thoughtful comments and guidance of the anonymous BJOT reviewers. Thank you all

References

Bates MS, Rankin-Hill L, Sanchez-Ayendez M (1997) The effects of the cultural context of health care on treatment of and response to chronic pain and illness. Social Science and Medicine, 45, 1433-47.

Chapman SL, Jamison RN, Sanders S (1996) Treatment helpfulness questionnaire: a measurement of patient satisfaction with treatment modalities provided in chronic pain management programmes. Pain,68, 349-61.

Donovan J, Blake DR (1992) Patient non-compliance: deviance or reasoned decision making. Social Science and Medicine, 34, 507-13.

Donovan MI, Evers K, Jacobs P (1999) When there is no benchmark: designing a primary care-based chronic pain management programme from the scientific basis up. Journal of Pain and Symptom Management, 18(1), 38-48.

Eccleston C, Williams AC, Stainton Rogers W (1997) Patients’ and professionals’ understandings of the causes of chronic pain: blame, responsibility and identity protection. Social Science and Medicine, 45(5), 699-709.

Fields HL (1995) Core curriculum for professional education in pain: a report of the Task Force on Professional Education of the International Association for the Study of Pain. Seattle: IASP Press.

Freeman M,Miller C, Ross N (2000) The impact of individual philosophies of teamwork on multi-professional practice and the implications for education. Journal of Interprofessional Care, 14(3), 237-47.

Hodgkin P (1996) Medicine, postmodernism and the end of certainty. British Medical Journal, 313(7072), 568-69.

Jones D, Ravey J, Steedman W (2000) Developing a measure of beliefs and attitudes about chronic non-malignant pain: a pilot study of occupational therapists. Occupational Therapy International, 7(4), 232-45.

Kotarba JA, Seidel JV (1984) Managing the problem pain patient: compliance or social control? Social Science and Medicine, 19, 1393-1400.

Law M (1997) Core concepts in occupational therapy. In: E Townsend, ed. Enabling occupation: an occupational therapy perspective. Ottawa: Canadian Association of Occupational Therapists.

Law M, Baptiste S (1995) Client-centred practice: what is it and does it make a difference? Canadian Journal of Occupational Therapy, 62, 250-57.

LeFort SM, Gray-Donald K, Rowat KM, Jeans ME (1998) Randomised controlled trial of a community-based psychoeducation programme for the self-management of chronic pain. Pain, 74(2-3), 297-306.4

Maniadakis N, Gray A (2000) The economic burden of back pain in the UK. Pain, 84(1), 95-103.

Marinker M (1998) Compliance is not all. British Medical Journal, 316(7125), 150-51.

Matheson LN, Bohr PC (1997) Occupational competence across the life span. In: C Christiansen, C Baum, eds. Occupational therapy: enabling function and well-being. New York: Slack.

McQuay HJ, Moore RA, Eccleston C, Morley S,Williams AC (1997) Systematic review of outpatient services for chronic pain control. Health Technology Assessment, 1(6), 1-135.

Pain Society (1997) Desirable criteria for pain management programmes. London: Pain Society.

Raithatha N (1997) Medicine, postmodernism and the end of certainty. Postmodern philosophy offers a more appropriate system for medicine. British Medical Journal, 314(7086), 1044.

Rathbun CR, Slate JR (1995) Lack of comparability of two pain locus of control measures. Assessment in Rehabilitation and Exceptionality, 2(3), 153-61.

Rochman DL (1998) Students’ knowledge of pain: a survey of four schools. Occupational Therapy International, 5(2), 140-54.

Rochman DL, Herbert P (1999) Rehabilitation professionals’ knowledge and attitudes survey regarding pain. Boston,Mass: Boston School of Occupational Therapy.

Schussler G (1992) Coping strategies and individual meanings of illness. Social Science and Medicine, 34(4), 427-32.

Scudds R, Solomon P (1995) Pain and its management: a new pain curriculum for occupational therapists and physical therapists. Physiotherapy Canada, 47(2), 77-78.

Seers K, Friedli K (1996) The patients’ experiences of their chronic non-malignant pain. Journal of Advanced Nursing, 24, 1160-68.

Siahpush S (1998) Postmodern values, dissatisfaction with conventional medicine and popularity of alternative therapies. Journal of Sociology, 34(1), 58-70.

Skevington SM (1990) A standardised scale to measure beliefs about pain control (BPCQ): a preliminary study. Psychology and Health, 4, 221-32.

Spence A (1999) Services for people with pain. London: Clinical Standards Advisory Group.

Strong J, Tooth L, Unruh A (1999) Knowledge about pain among newly graduated occupational therapists: relevance for curriculum development. Canadian Journal of Occupational Therapy, 66(5), 221-28.

Sumsion T (2000) Client-centred practice: the challenge of reality. OT Now, July/August, 22-23.

Turk DC (1996) Biopsychosocial perspectives on chronic pain. In: RJ Gatchel, DC Turn, eds. Psychological approaches to pain management: a practitioner’s handbook. New York: Guilford Press.

Turnquist K, Engel J (1994) Occupational therapists’ experience and knowledge of pain in children. Physical and Occupational Therapy in Pediatrics, 14, 35-51.

Unruh A (1995) Teaching student occupational therapists about pain: a course evaluation. Canadian Journal of Occupational Therapy, 62(1), 30-36.

Von Korff M, Moore J, Lorig K, Cherkin DC, Saunders K, Gonzalez VM, Laurent D, Rutter C, Comite F(1998) A randomised trial of a layperson led self-management group intervention for back pain patients in primary care. Spine, 23(23), 2608-15.

Vrancken MA (1989) Schools of thought on pain. Social Science and Medicine, 29(3), 435-44.

Weinblatt N, Avrech-Bar M (2001) Postmodernism and its application to the field of occupational therapy. Canadian Journal of Occupational Therapy, 68(3), 164-70.

Yardley L, Furnham A (1999) Attitudes of medical and non-medical students toward orthodox and complementary therapies: is scientific evidence taken into account? Journal of Alternative and Complementary Medicine, 5(3), 293-95.

Author

Cary A Brown, MA, OTM(C), SROT, Lecturer, Division of Occupational Therapy, University of Liverpool, Johnston Building, Brownlow Hill, Liverpool L69 3GB.