The use of the Canadian Occupational Performance Measure

as an outcome of a Pain Management Program

• LINDA CARPENTER • GUS A. BAKER • BARBARA TYLDESLEY

KEY WORDS Linda Carpenter DipCOT, Barbara Tyldesley, FCOT, M.Ed.,

AIMgt, SROT, Head T.DipCOT, SROT, Lecturer,
• Canadian Occupational Performance Measure Occupational Therapist Walton Department of Occupational
Centre for Neurology and Therapy, University of Liverpool,
• Outcome assessment (health care)
Neurosurgery, Liverpool Liverpool L69 3GB, UK.
• Pain management Email: bt.saxon@virgin.net
Gus A. Baker, BA, M Clin
Psychol, Ph.D, C Psychol, FBPsS,
Senior Lecturer in
Neuropsychology and Health
Psychology, Dept. of
Neurosciences, University of
Liverpool

ABSTRACT
The last three decades have seen the emergence of measures to
assess the efficacy of pain management programs. Recently
16
there has been interest in measures that assess clients’
perceptions of their own performance. The Canadian
volume 68 • issue 1
RÉSUMÉ
Au cours des trois dernières décennies, de nombreuses mesures
ont été mises au point pour évaluer l’efficacité des programmes de
gestion de la douleur. Tout récemment, les chercheurs se sont
penchés sur les mesures qui évaluent les perceptions qu’ont les

Occupational Performance Measure (COPM) (Law et al, 1994,
1998) is an individualized measure designed for use by occupa-
tional therapists to detect a self-perceived change in
occupational performance problems over time. It may be an
important extra dimension to assessing the outcomes of pain
management programs. The aim of this study was to ascertain
the validity of the COPM as an outcome measure for the
Liverpool Pain Management Program. One hundred and six
clients were recruited to the study and 87 clients completed a
battery of tests including the COPM at baseline, end of program
and 3 month follow-up. Results of the study demonstrated that
the COPM showed good evidence of concurrent criterion
validity and sensitivity to change.
clients de leur rendement personnel. La Mesure canadienne du
rendement occupationnel (MCRO) (Law et al, 1994, 1998) est une
mesure individualisée conçue à l’intention des ergothérapeutes,
en vue de détecter le changement que le client perçoit au fil du
temps relativement à ses difficultés en matière de rendement
occupationnel. Cette mesure peut être considérée comme une
dimension complémentaire importante de l’évaluation au sein
des programmes de gestion de la douleur. Le but de cette étude
était de vérifier la validité de la MCRO en tant que mesure des
résultats pour le Liverpool Pain Management Program. Cent six
clients ont été recrutés pour cette étude et 87 d’entre eux ont été
soumis à une batterie de tests dont la MCRO. La MCRO a été
administrée à ces personnes au début, à la fin du programme et
lors du suivi effectué 3 mois après la fin du programme. Les
résultats de cette étude ont démontré que la MCRO porte des
indices d’une validité concourante relative à un critère et qu’elle
est une mesure sensible du changement.

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harmacological and other medical advances have
P improved the management of acute post operative pain
and pain in terminal illness, but people with chronic pain
obtain little relief from the current medical or surgical
methods. Treatment of chronic pain requires a move away
from the medical model used with acute pain, towards a
more comprehensive way of overcoming intractable pain by
encouraging self-management and active coping skills.
The Liverpool Pain Management Program (LPMP) was
developed in 1983 by Dr Sam Lipton and Dr Chris Wells
following a fellowship visit to the United States. The
program in Liverpool was the first multidisciplinary cognitive
behavioural program to be established in Britain. Clients who
are normally referred to the Liverpool program present
having tried a number of different treatments, both medical
and complementary, none of which appear to have been
successful.
The Pain Management Program provides a 4 week
intensive course, with new clients joining the course each
week. The multidisciplinary staff team consist of pain
clinicians, clinical psychologists, pain nurses, occupational
therapists, physiotherapists, an art teacher and a Tai Chi
instructor. Clients are carefully assessed before being
accepted into the program by the clinicians, psychologists
and, for the duration of the study, by occupational therapists.
The Liverpool program is designed to empower and enable
clients who experience intractable pain to develop coping
strategies to encourage them to live their lives in as full and
as enjoyable way possible and to achieve some degree of
balance in their lives. Pain management is more effective
when it is based upon problem solving and purposeful,
functional activities which clients can learn for themselves,
enabling personal competence and achievement (Bandura,
1977; Giles & Allen, 1986; Heck, 1988; Steinbeck, 1986).
Efficacy of Pain Management
One of the earliest papers to describe methods of measuring
the efficacy of a pain management program in North
America used a walking exercise with self-reported levels of
activity (Fordyce, Fowler, Lehman & Delateur, 1968). In the
early seventies, measurement tools consisted of informed
self-reports on activity levels, medication use and pain
intensity, together with observation by staff of activity levels,
pain behaviours and attitudes. In the later seventies and the
eighties, more standardized measures were introduced such
as the Beck Depression Inventory (Beck & Emery, 1961) and
activities of daily living. Recently, many more measures have
been developed to assess the efficacy of pain management
programs (Ghadiali 1987). Other commonly used measures
include the Beck Anxiety Inventory (Beck & Emery, 1985),
Oswestry Disability Scale (Fairbank, Couper, Davies & O’Brien,
1980).
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Carpenter et al.
In order to enhance the assessment of the efficacy of
pain management the authors believe that there should be
some way of assessing clients satisfaction with their own per-
formance. The Canadian Occupational Performance Measure
(COPM) is an individualized measure designed for use by
occupational therapists to detect a self-perceived change in
occupational performance problems over time (Law et al.,
1994). The measure was developed from the original model
of occupational performance (Canadian Association of
Occupational Therapists, 1991; Law et al., 1994). The COPM is
intended for use as an outcome measure (Law et al., 1994). It
is designed to assist the client and the therapist to identify
problems in the three areas of occupational performance:
self-care, productivity and leisure. The client provides his or
her perception of personal performance and satisfaction in
these problem areas.This partnership between the client and
therapist ensures that in the assessment the client is involved
in, and engaged with the intervention process. The assess-
ment incorporates the roles and role expectations of the
client, and focuses on the client's own environment, so
ensuring the relevance of the identified problems to the
client. Although the authors are aware of a third edition of
the COPM (Law et al., 1998), as this study took place in
1995/96 the second edition (Law et al., 1994) is the one which
will be referenced.
Aims of the study
The aims of this study were:
1. To ascertain the utility of the COPM (Law et al., 1994) as
an outcome measure for the Liverpool pain program.
2. To compare the COPM with the other standardized tests
used in the Liverpool pain program.
17
Methodology
volume 68• issue 1
Subjects
One hundred and six clients were recruited to the study.
These clients were all assessed for their suitability to be
enrolled into the pain management program based at the
Walton Centre for Neurology and Neurosurgery in Liverpool.
As part of their assessment, they were interviewed by the
multidisciplinary team responsible for the day-to-day
management of the program to determine whether they
would be suitable candidates. At the time of the assessment
they were invited to participate in this study. The assessment
involved being interviewed and assessed by medical staff,
psychologists, physiotherapists and occupational therapists
to determine their motivation towards participating in the
program.
One hundred and six clients were seen at the time of the
initial assessment. Of these 15 declined to enter the program
and four could not be followed up after the program.
Eighty-seven clients completed the three assessments, and
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 Carpenter et al.
of these 30 were interviewed over the telephone at the time
of the third follow-up assessment. Forty-five per cent of the
sample was male and the mean age was 44 years with a
range of 19 to 72 years. Sixty-one were married or cohabiting.
Sixty-four clients lived in the Liverpool area, 23 lived further
afield and were externally contracted referrals (ECR).
Measures
Each client completed a battery of questionnaires including
the following:
1. COPM (Law et al., 1994)
Instructions for the assessment of clients are clearly indicat-
ed in the manual of the COPM. In a semi structured interview,
the client is encouraged to discuss areas of activity that may
present problems that they may need to, want to, or are
expected to carry out on a regular basis. These problem
areas are then rated in terms of importance to the client's life
using the rating scale from 1 - 10, where 1 = not at all impor-
tant, and 10 = extremely important to the client. The five
most important problems are then the focus of intervention
and the outcome measurement. The client, using a similar
scale, is then asked to rate his/her perception of performance
and satisfaction with this performance in the selected
problem areas. The two scores are separately summed and
divided by the number of problem areas, giving the mean for
each. On completion of the program the COPM form is
revisited and possible changes in the client's perceptions
recorded. The difference between the initial and the subse-
quent scores gives the measure of outcome, with a 2-point
difference in either direction indicating significant change.
Evidence of the reliability and validity of the scale has been
18
previously published (Law et al., 1994). Clients reported no
difficulty with completion of the COPM in this study.
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2. Beck Anxiety Inventory (Beck & Emery, 1985)
The Beck Anxiety Inventory (BAI) is a 21 item self-
administered test of current anxiety. The BAI has been used
extensively in clinical research and clinical practice.
Respondents are instructed to select statements which best
describe the way they have been feeling over the past 2
weeks. Sample items include: dizziness, feeling of choking,
fear of losing control. Clinical cut-off scores for the BAI are as
follows: 0 – 9 = none or minimal anxiety; 10 – 18 = mild to
moderate anxiety; 19 – 29 = moderate to severe anxiety;
30 – 63 = severe anxiety.
3. Beck Depression Inventory (Beck et al.,1961)
The Beck Depression Inventory (BDI) is a 21 item self-admin-
istered test of current depression. The BDI has been used
extensively in clinical research and clinical practice.
Respondents are instructed to select statements which best
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describe the way they have been feeling over the past 2
weeks. Clinical cut-off scores for the BDI are as follows: 0 – 9 =
none or minimal depression; 10 – 18 = mild to moderate
depression; 19 – 29 = moderate to severe depression;
30 – 63 = severe depression.
4. Oswestry Disability Scale (Fairbank et al., 1980)
The Oswestry Disability Scale views disability as the dimin-
ished capacity for everyday activities and gainful employ-
ment or the limitation of a particular person’s performance
compared to a fit individual of the same age (Waddell, Maine,
Morris, Di Paula & Gray, 1984). The Oswestry Disability Scale
examines the common or usual effects of physical disability.
Possible scores from the Oswestry Disability Scale range from
0 – 100. Scores above 70 represent severe disability. The
Oswestry Disability Scale should be interpreted in this
context as a broad definition of overall physical disability for
clients with chronic pain conditions. (Waddell et al., 1984).
5. Pain Self-Efficacy Questionnaire (Nicholas, 1989)
The Pain Self-Efficacy Questionnaire (PSEQ) is a 10 item scale,
which was developed to assess the self-efficacy of people
with chronic pain. It measures confidence in coping with
activities of daily living despite pain. The clients rate 10 state-
ments on a 0-6 scale, where 0 = not at all confident and
6 = completely confident. Scores for the test range from 0-60.
The higher the score the greater the degree of self-efficacy in
coping with pain. Evidence of the reliability and validity has
been documented (Nicholas, 1989).
6. Pain Visual Analogue Scale (Jensen, Karoly, &
Braver, 1986)
Pain intensity was assessed using the Pain Visual Analogue
Scale (PVAS). The clients were instructed to indicate the
severity of pain, by putting a mark on a line 10 centimeters
long with two extreme responses: "no pain" and "worst
possible pain".The distance from the no pain end to the mark
provided by the client was measured. This distance defines
the client’s pain intensity. Evidence of the reliability and valid-
ity has been documented (Jensen, Karoly, & Braver, 1986).
Clients completed a battery of questionnaires at baseline and
at the end of the 4 week program.
Statistical Analysis
Statistical tests were used to determine the significance of
difference between baseline and end of treatment. Data from
the battery of questionnaires was analyzed using the
Statistical Package for the Social Sciences. Spearman’s rank
correlation coefficients were derived to test the level of asso-
ciation between scores on the COPM and scores on other
measures of psychological and physical functioning.
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 Carpenter et al.

Table 1.
Mean scores at baseline, end of program and follow-up for men and women (ns = no significance)
COPM Men (S.D.) Women (S.D.) Significance
N = 39 (45%) N = 48 (55%)

Performance 1
(Baseline) 2.8(0.8) 2.6(0.9) ns

Performance 2
(End of Program) 5.0(1.5) 5.3(1.7) ns

Performance 3
(Follow-up) 4.5(2.3) 4.9(1.8) ns

Satisfaction 1
(Baseline) 1.9(1.1) 1.9(1.0) ns

Satisfaction 2
(End of Program) 5.1(2.2) 5.5(2.2) ns

Satisfaction 3
(Follow-up) 4.5(2.5) 4.8(2.2) ns

Comparison of the mean scores of the COPM for both

Results performance and satisfaction revealed no significant
The results of the COPM are presented as the means of the
differences for gender (see Table 1). Overall there was no
scores calculated for the self-perceived performance (P) and
significant differences for these same scores when compar-
satisfaction with that performance (S). The timing of the
ing individuals who lived alone with those who did not.
assessments are shown as (P1) and (S1) the initial
However, individuals who lived alone were significantly more
assessment; (P2) and (S2) at the end of the program and (P3)
likely to report higher scores in satisfaction at baseline than
and (S3) at the time of the follow-up .
those who were living with others (p=0.02). This difference

Table 2 19
Mean scores at baseline, end of program and follow-up for subjects living alone and with others (ns = no significance)

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COPM Alone (S.D.) With others (S.D.) P values
N = 23 (26%) N = 64 (74%)

Performance 1
(Baseline) 3.1(0.8) 2.6(0.9) ns

Performance 2
(End of Program) 6.2(0.8) 5.1(1.6) ns

Performance 3
(Follow-up) 4.6(2.3) 4.7(2.0) ns

Satisfaction 1
(Baseline) 2.7(0.6) 1.9(1.0) 0.02

Satisfaction 2
(End of Program) 6.6(1.1) 5.2(2.2) ns

Satisfaction 3
(Follow-up) 4.6(2.4) 4.7(2.3) ns

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Table 3
Comparison of mean scores on the COPM for baseline, end of treatment, and follow-up
COPM Baseline End of Mean differ- SD Minimum Maxi mum P
Treatment ence score difference difference values

Performance 2.7 5.2 2.5 1.6 -0.6 8.0 <0.01

Satisfaction 1.9 5.3 3.4 2.3 -2.8 8.6 <0.01

COPM Baseline Follow-up Mean differ- SD Minimum Maxi mum P

ence score difference difference values

Performance 2.7 4.7 2.0 2.0 -1.8 6.4 <0.01

Satisfaction 1.9 4.7 2.8 2.5 -4.3 7.2 <0.01

COPM End of Follow-up Mean differ- SD Minimum Maxi mum P

Program ence score difference difference values

Performance 5.2 4.7 -0.5 1.7 -7.4 3.5 0.01

Satisfaction 5.3 4.7 -0.6 2.1 -8.0 3.8 <0.01

would not be significant when taking into account multiple
comparisons (see Table 2).
There was a significant increase in the COPM scores for
both performance and satisfaction when comparing base-
line and end of program scores, and this difference was
maintained at follow-up (Table 3). A comparison of the COPM
scores at end of program versus follow-up revealed a small
but significant difference (see Table 3).
The results were further analyzed by examining the
percentage of clients who improved or deteriorated at either
end of program or follow–up (see Table 4). In terms of the
performance scores 59% of the participants improved at end
of program and a further 5% continued to improve at
20 follow-up. None of the participants showed any deterioration
during the course of the program, however some deteriora-
volume 68 • issue 1
A number of the clients had other problems such as
domestic, financial or medical difficulties in addition to their
intractable pain. It was not possible to identify how many of
those who deteriorated, did so as a result of external compli-
cations.This lack of control in the evaluation of those who fail
to improve is a problem that is difficult to eliminate in a study
because clients and the causes of their pain are so diverse.
The evaluation of a similar pain management program
(Williams et al., 1996), found that of the 60% of clients
followed up after 6 months, 57% continued to carry out
prescribed exercise routines, and 75% used satisfactory
coping strategies. They argued that the strength of their
study was due to the large sample (212 clients of whom 182
could be followed up), the broad acceptance screening, low
drop-out rate and the personal follow-up interviews. At the

tion was evident particularly at follow-up. A slightly higher
number of participants reported improved satisfaction levels
(74%), but there was also a higher number of participants
who reported a deterioration from end of program to
follow-up (see Table 5).
Discussion
Given the difficulties and problems that fill the lives of the
clients who seek to undertake the pain management
program, it is encouraging that by the end of the program a
significant proportion of participants felt that their perfor-
mance had improved and they were satisfied with their
progress. While there was some deterioration at follow-up,
overall progress compared to baseline was maintained. A
significant proportion expressed the opinion that they had
benefited from the program and felt more satisfied and
positive in their outlook since attending.
follow-up assessments of the Liverpool pain management
program, clients reported that this period, which followed
intensive pain management when they were thrown back
onto their own resources, was a challenging and difficult time
for them. The degree of camaraderie that developed among
the program participants was often identified as being one
of the helpful aspects. The loss of this support and encour-
agement at discharge may slow down the rate of progress in
the 3-month period immediately after the end of the
program. Moreover, if a client finds it difficult to participate in
the activities in the program and therefore does not start to
benefit until the third week, then they have very limited
resources on which to draw to see them through the years
ahead. Participants are encouraged to keep in touch with
each other and to join local self-help groups.These strategies
are fairly effective for participants who live in the Liverpool
area but clients who travel some distance to attend cannot
always find or access this type of group in their area.

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Table 4
Comparison of improvement and deterioration in COPM scores
COPM Improved Same Deteriorated
Performance

End of program 51 (59%) 36 (41%) 0

End to follow-up 5 (6%) 71 (82%) 11 (12%)
Baseline to follow-up 43 (49.5%) 43 (49.5%) 1 (1%)

COPM Improved Same Deteriorated

Satisfaction

End of program 64 (74%) 23 (26%) 0

End to follow-up 8 (9%) 60 (69%) 19 (22%)
Baseline to follow-up 53 (61%) 30 (34.5%) 4 (4.5%)

The COPM provided an excellent medium for discussion
of specific and significant problems in day-to-day occupa-
tional performance in the areas of self-care, productivity and
leisure. The semi-structured interview approach allows the
client to feel that his or her problems matter, and that even
though pain relief may not occur, coping strategies would be
addressed. The change in medication scores demonstrated a
concrete achievement, giving proof to the client of his or her
ability to benefit from the various techniques of self-help
that form the basis of the pain management program. Each
client was working on the personal problems rather than the
problems identified by the group, eliminating to some extent
the Hawthorn effect, in that each client had a different
agenda. Nevertheless, the group support and encourage-
ment does give impetus to the desire to conform to peer
expectations and the absence of this driving force may well
be one of the reasons why there is a falling off of self-
perceived progress at the follow up interview.
The concurrent criterion validity of the COPM was
clearly demonstrated in this population with significant
correlations between this scale and other tests of psycholog-
ical functioning. All the correlations observed were in the
expected direction at the end of the 4 week program. One
interesting finding was that at baseline only one test (BDI)
had a significant correlation with the two COPM measures at
baseline. This result is somewhat surprising as significant
correlations would be expected with the other measures.
Further analysis is warranted using a logistic model equation
to determine what factors might have influenced scores on
the COPM at baseline, however this was not possible within
the confines of this study.
The inclusion of the Canadian Occupational
Performance Measure (Law et al., 1994) as part of the initial
assessment of clients accepted onto the Liverpool Pain
Management Program gave the occupational therapists
greater insight into the needs of the clients and the way in 21

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Table 5
Correlations of COPM with other standardized psychological measures
Measures Baseline End of Treatment Follow up
Performance Satisfaction Performance Satisfaction Performance Satisfaction

Beck Anxiety Inventory (BAI) NS NS -0.3* -0.3* -0.4** -0.3*

Beck Depression Inventory (BDI) NS -0.3* -0.4** -0.4** -0.3* -0.4**

Oswestry Disability Scale (ODS) NS NS -0.4** -0.3* -0.4** -0.4**

Pain Self-Efficacy Questionnaire (PSEQ) NS NS 0.3* 0.3* 0.6** 0.5**

Pain Visual Analogue Scale (PVAS) NS NS -0.4** NS -0.4** -0.3*

*p < 0.001
**p < 0.0001

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 Carpenter et al.
which the important difficulties identified by them could be
used in the Targeting and Self-pacing aspect of the Pain
Management Program. The method of reassessment of the
COPM involves the client providing positive feedback on
his/her own perception of progress over the 4 week course.
The correlation of this instrument with the other five stan-
dardized assessments serves to endorse the validity of the
COPM. In contrast to the other five assessments which are
completed by the client on their own, the COPM enhances
the therapeutic relationship between a client and the
therapist and gives the client the important opportunity to
share problems and fears with someone who is interested,
understands and who will set up situations in which the
solving of these problems is paramount.
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