Knowledge about pain among newly graduated occupational therapists: relevance for curriculum development

Current Understanding of Pain Neurophysiology among Physiotherapists Practicing in Saudi Arabia

To ensure the effective management of patients’ pain, it is important that physiotherapists have a good understanding of the neuroscience behind pain. A major barrier to adequate pain management is that, for patients, there is limited access to clinicians who are knowledgeable about pain. This study examined the level of knowledge regarding pain neurophysiology among physiotherapists currently practicing in Saudi Arabia. Method: The study was a cross-sectional web-based survey that utilized the 12-item Revised Neurophysiology of Pain Questionnaire. Descriptive and inferential statistics were used to describe levels of knowledge regarding pain neurophysiology and to examine differences in knowledge based on the characteristics of the participating physiotherapists (gender, educational level, experience, practice region, and country where their highest educational level was attained). Results: One hundred and eleven physiotherapists (58.6% male) from various regions and educational backgrounds participated in the study. Out of a maximum Revised Neurophysiology of Pain Questionnaire score of 12, the mean ± standard deviation (SD) was 6.7 ± 2.2; 90% of physiotherapists scored 9 (75%) or less. None of the examined characteristics of the participants were associated with knowledge. Conclusion: Physiotherapists in Saudi Arabia showed limited knowledge of the neurophysiology of pain; however, this was not related to the personal characteristics that were examined. The continuation of education in modern pain science is recommended for physiotherapists, especially those dealing with patients suffering from chronic pain. Clinical Relevance: The physiotherapists who took part in this study displayed limited knowledge of pain neuroscience; this limited knowledge might suggest the need for a more bio-anatomical approach to pain management. There is a need for tailored medical education to address pain neuroscience knowledge in current physiotherapist practitioners.

The need for novel strategies to address postoperative pain associated with cardiac surgery: A commentary and introduction to "SMArTVIEW"

Background: With coronary heart disease affecting over 2.4 million Canadians, annual cardiac and major vascular surgery rates are on the rise. Unrelieved postoperative pain is among the top five causes of hospital readmission following surgery; little is done to address this postoperative complication. Barriers to effective pain assessment and management following cardiac and major vascular surgery have been conceptualized on patient, health care provider, and system levels. Purpose: In this commentary, we review common patient, health care provider, and system-level barriers to effective postoperative pain assessment and management following cardiac and major vascular surgery. We then outline the SMArTVIEW intervention, with particular attention to components designed to optimize postoperative pain assessment and management. Methods: In conceptualizing the SMArTVIEW intervention design, we sought to address a number of these barriers by meeting the following design objectives: (1) orchestrating a structured process for regular postoperative pain assessment and management; (2) ensuring adequate clinician preparation for postoperative pain assessment and management in the context of virtual care; and (3) enfranchising patients to become active self-managers and to work with their health care providers to manage their pain postoperatively. Conclusions: Innovative approaches to address these barriers are a current challenge to health care providers and researchers alike. SMArTVIEW is spearheading this paradigm shift within clinical research to address barriers that impair effective postoperative pain management by actively engaging health care providers and patients in an accessible format (i.e., digital health solution) to give primacy to the need of postoperative pain assessment and management following cardiac and major vascular surgery.

Pain neurophysiology knowledge among physical therapy students in Saudi Arabia: a cross-sectional study

BACKGROUND

Pain is a leading cause of disability and accounts for many hospital and physical therapy visits. Current pain science understanding has evolved and changed substantially in the past 20 years; however, university health science curricula may not have progressed at the same rate. This study aimed to examine knowledge about pain neurophysiology among physical therapy students in Saudi Arabia, and to compare their knowledge across different education levels and by gender.

METHODS

A cross-sectional study conducted to examine the pain neurophysiology knowledge among college physical therapy students in Saudi Arabia. The Revised Neurophysiology of Pain Questionnaire (12 items) was used. Descriptive statistics including frequencies and percentages were used to describe the sample. Analysis of variance and t-test were also used to examine the significant differences between scores.

RESULTS

Physical therapy students (n = 202) from 18 different universities in Saudi Arabia participated in this study. The mean score of the participants on the questionnaire was 6.20 ± 2.07 (i.e., 52% ± 17%) and there was no significance difference between males and females. There was a statistically significant incremental increase in total score through the educational process (P < 0.05); however, this increase was very small comparing early- and final educational-level students (8% in RNPQ).

CONCLUSION

While final year physical therapy students showed higher levels of pain science knowledge than those at the beginning of their course, the magnitude of the difference was small and likely of little meaningful relevance. This may reflect the need for more emphasis on pain science in the physical therapy curriculum in Saudi Arabia.

Interprofessional Education for the Dentist in Managing Acute and Chronic Pain

Dental education is at the intersection of affordable health care, opioid-abuse crisis, and collaborative practice benefits. Students must engage in interprofessional education (IPE) for pain management. Graduates must recognize appropriate management of acute dental pain and understand the dentist's role in interprofessional treatment of chronic disease, including management of temporomandibular disorders and orofacial neuropathic pain, chronic pain in general, and the consideration of opioids. This article reviews accreditation standards, compares these standards with recommendations from the International Association for the Study of Pain and regulatory boards, and presents examples of enhanced pain education.

Activity Pacing in Chronic Pain Management: One Aim, but Which Method? Part Two: National Activity Pacing Survey

Part one of this paper suggested that, in order to attain activity goals, it is important to replace activity contingent on pain with activity contingent on quota, such as time or number. This is one aspect of activity pacing, which can help to break the detrimental overactivity-underactivity cycle. However, there are few established guidelines regarding activity pacing. Part two reports a study which sought to answer two questions: what are the main principles underlying activity pacing and how are activity pacing principles taught?

A questionnaire was posted to all 78 members of the National Occupational Therapy Pain Association in order to sample current practice. The 49 (63%) respondents endorsed nine behaviours contributing to activity pacing, including planning activities, breaking activities into manageable parts, increasing activity amounts gradually and alternating tasks. The occupational therapists used varied methods to teach these behaviours and only half of them used time as the unit of increase. These therapists disagreed about how long to continue timer use for and what activities to use it for.

The importance of time-contingency in activity pacing, and related teaching methods, is contentious. No alternatives were suggested to time-contingency to break the pattern of pain-contingency in activities. Studies are urgently needed concerning the efficacy of time-contingency, the efficacy of any alternatives and their acceptability to patients.

Occupational Therapists' Beliefs regarding Treatment Options for People with Chronic Pain

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.

Acute Pain Management

Acute pain management is improving steadily over the past few years, but training and professional education are still lacking in many professions. Untreated or undertreated acute pain could have detrimental effects on the patient in terms of comfort and recovery from trauma or surgery. Acute undertreated pain can decrease a patient's vascular perfusion, increase oxygen demand, suppress the immune system, and possibly risk increased incidence of venous thrombosis. Although acute postoperative pain needs to be managed aggressively, patients are most vulnerable during this period for developing adverse effects, and therefore, patient assessment and careful drug therapy evaluation are necessary processes in therapeutic planning. Acute pain management requires careful and thorough initial assessment and follow-up reassessment in addition to frequent dosage adjustments, and managing analgesic induced side effects. Analgesic selection and dosing must be based on the patient's past and recent analgesic exposure. There is no single acute pain management regimen that is suitable for all patients. Analgesics must be tailored to the individual patient.

Occupational therapists' pain knowledge: a national survey

PURPOSE

This study surveyed Canadian occupational therapists to identify whether their pain knowledge is current or if the gaps identified in past studies have remained the same. The findings will provide information to guide the development of targeted pain knowledge translation strategies for occupational therapists.

METHOD

A self-report survey, including demographic questions and part of the City of Boston's Rehabilitation Professionals' Knowledge and Attitude Survey (COBS), was disseminated electronically to all members of the Canadian Association of Occupational Therapists.

RESULTS

A total of 354 therapists, most came from Ontario, Alberta and Nova Scotia and working in the community, acute care and private practice, participated. Over 50% had 10 years or less of experience. Deficit knowledge areas were identified in pediatric pain, chronic versus acute pain, pain assessment and medications. These findings are largely consistent with deficits identified in pre-2000 studies.

CONCLUSIONS

Pain knowledge gaps persist among Canadian occupational therapists and this can, and should, be addressed within the occupational therapist (OT) curriculum and in professional development initiatives. It is concerning that this study identified similar knowledge gaps as those identified in previous studies of OT students and clinicians. Pain is a growing and complex issue with negative impact on occupational performance across the lifespan. Knowledge dissemination of occupational therapy pain assessment and management approaches should be a priority for the profession.

IMPLICATIONS FOR REHABILITATION

Pain is a prevalent condition in all age groups of occupational therapists' clients. There appear to be gaps in occupational therapists' evidence-based knowledge of aspects of pain. Occupational therapy training programs and occupational therapy associations should provide education with a particular focus on identified pain knowledge gaps.

Mitigating the risk of opioid abuse through a balanced undergraduate pain medicine curriculum

Chronic pain is highly prevalent in the United States and Canada, occurring in an estimated 30% of the adult population. Despite its high prevalence, US and Canadian medical schools provide very little training in pain management, including training in the safe and effective use of potent analgesics, most notably opioids. In 2005, the International Association for the Study of Pain published recommendations for a core undergraduate pain management curriculum, and several universities have implemented pilot programs based on this curriculum. However, when outcomes have been formally assessed, these initiatives have resulted in only modest improvements in physician knowledge about chronic pain and its treatment. This article discusses strategies to improve undergraduate pain management curricula and proposes areas in which those efforts can be augmented. Emphasis is placed on opioids, which have great potency as analgesics but also substantial risks in terms of adverse events and the risk of abuse and addiction. The authors conclude that the most important element of an undergraduate pain curriculum is clinical experience under mentors who are capable of reinforcing didactic learning by modeling best practices.

Development and mixed-methods evaluation of a pain assessment video training program for long-term care staff

INTRODUCTION

Inadequacies in pain assessment and management in long-term care have been well documented. Insufficient pain education and inaccurate beliefs about the nature of pain and aging have been identified as possible contributors. The present study addresses the need for improved, efficient and feasible continuing pain education through the use of an assessment training video.

METHODS

A total of 148 long-term care staff viewed and evaluated the training video. Knowledge changes and pain beliefs were assessed postvideo and at a four-week follow-up. Beliefs about pain, as well as pain and aging, were also examined using multivariate procedures to determine whether these variables influenced participants' evaluation of the video. Focus groups were also conducted, and transcripts were analyzed using thematic content analysis.

RESULTS

Pain assessment knowledge improved postvideo and at the four-week follow-up. Participants positively evaluated the content and quality of the video. Individuals who held stronger beliefs (at baseline) about the organic nature of pain provided more positive evaluations. Barriers to implementation of practices in the video identified by the focus groups (and qualitative analysis) included time, workload and resistance to change. Facilitators to implementation included continued management support and observing the benefits to implementation.

DISCUSSION

The present study provides support for the use of video training. However, based on the focus group results, top-down implementation approaches with ongoing management involvement throughout the implementation process may be needed to achieve sustained changes in pain assessment practices. A model useful for sustained implementation was proposed and discussed, and is hoped to facilitate future research.

Core competencies for pain management: results of an interprofessional consensus summit

Objective

The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported.

Methods

An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached.

Results

The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain.

Conclusions

These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.

Evaluation of a pain curriculum for occupational therapists: experiences from a master's-level graduate program over six years

PURPOSE

Deficiencies in pain knowledge and attitudes among students and health practitioners are well documented. Occupational therapists (OTs) commonly care for patients who present with pain, and their knowledge of the field presumably impacts that care. This study presents the results of testing OT students' pain knowledge in order to assess the effects of embedding pain teaching in a generic master's-level OT course and to determine specific topics that should be addressed to improve upon existing OT curricula.

METHOD

During the academic years 2004 through 2009, 194 OT students were administered a test of pain knowledge and attitudes on the first and last day of a required class which focused on procedural reasoning.

RESULTS

The results indicated significant (p < 0.001) improvement in test scores after participation in the class. Whereas only 35% of students met the minimum "adequate" standard for pain knowledge at pre-test, 92% of students met this standard at post-test.

CONCLUSIONS

The results demonstrate the effectiveness of a course taught by an instructor with pain expertise. In addition, analysis of individual items highlights the need for curricula to address theoretical versus practical understanding of pain, the ever-evolving science of pain, and pervasive biases about specific pain topics.

IMPLICATIONS FOR REHABILITATION

Deficiencies in pain knowledge and attitudes among students and health practitioners are well documented. Occupational therapists (OTs) commonly care for patients who present with pain, and their knowledge of the field presumably impacts that care. The results of this study demonstrate the effectiveness of an OT course taught by an instructor with pain expertise. OT curricula should address pain in special populations (e.g. children and the elderly), acute versus chronic pain, theoretical versus practical understanding of pain, the ever-evolving science of pain, and pervasive biases about specific pain topics (e.g. malingering and opioid addiction).

The Postoperative Pain Assessment Skills pilot trial

BACKGROUND⁄

OBJECTIVES

Pain-related misbeliefs among health care professionals (HCPs) are common and contribute to ineffective postoperative pain assessment. While standardized patients (SPs) have been effectively used to improve HCPs' assessment skills, not all centres have SP programs. The present equivalence randomized controlled pilot trial examined the efficacy of an alternative simulation method - deteriorating patient-based simulation (DPS) - versus SPs for improving HCPs' pain knowledge and assessment skills.

METHODS

Seventy-two HCPs were randomly assigned to a 3 h SP or DPS simulation intervention. Measures were recorded at baseline, immediate postintervention and two months postintervention. The primary outcome was HCPs' pain assessment performance as measured by the postoperative Pain Assessment Skills Tool (PAST). Secondary outcomes included HCPs knowledge of pain-related misbeliefs, and perceived satisfaction and quality of the simulation. These outcomes were measured by the Pain Beliefs Scale (PBS), the Satisfaction with Simulated Learning Scale (SSLS) and the Simulation Design Scale (SDS), respectively. Student's t tests were used to test for overall group differences in postintervention PAST, SSLS and SDS scores. One-way analysis of covariance tested for overall group differences in PBS scores.

RESULTS

DPS and SP groups did not differ on post-test PAST, SSLS or SDS scores. Knowledge of pain-related misbeliefs was also similar between groups.

CONCLUSIONS

These pilot data suggest that DPS is an effective simulation alternative for HCPs' education on postoperative pain assessment, with improvements in performance and knowledge comparable with SP-based simulation. An equivalence trial to examine the effectiveness of deteriorating patient-based simulation versus standardized patients is warranted.

A survey of prelicensure pain curricula in health science faculties in Canadian universities

OBJECTIVE

The present exploratory, descriptive study aimed to determine the designated time for mandatory pain content in curricula of major Canadian universities for students in health science and veterinary programs before being licensed.

METHOD

Major Canadian university sites (n=10) were chosen where health science faculties included at least medicine (n=10) and nursing (n=10); many also included dentistry (n=8), pharmacy (n=7), physical therapy (n=8) and/or occupational therapy (n=6). These disciplines provide the largest number of students entering the workforce but are not the only ones contributing to the health professional team. Veterinary programs (n=4) were also surveyed as a comparison. The Pain Education Survey, developed from previous research and piloted, was used to determine total mandatory pain hours.

RESULTS

The majority of health science programs (67.5%) were unable to specify designated hours for pain. Only 32.5% respondents could identify specific hours allotted for pain course content and/or additional clinical conferences. The average total time per discipline across all years varied from 13 h to 41 h (range 0 h to 109 h). All veterinary respondents identified mandatory designated pain content time (mean 87 h, range 27 h to 200 h). The proportion allotted to the eight content categories varied, but time was least for pain misbeliefs, assessment and monitoring/follow-up planning.

CONCLUSIONS

Only one-third of the present sample could identify time designated for teaching mandatory pain content. Two-thirds reported 'integrated' content that was not quantifiable or able to be determined, which may suggest it is not a priority at that site. Many expressed a need for pain-related curriculum resources.

Implications of IASP Core Curriculum for Pre-Registration Physiotherapy Education

There are concerns about the effectiveness of health professionals when they are working with people who have pain.Health professionals have reported a lack of confidence when working with people with complex pain conditions.Review of pain education in health professional training may improve clinical practice.The International Association for the Study of Pain curricula can be useful in developing pain education initiatives.The up-dated IASP core curriculum appears to be a useful resource for curriculum designers of pre-registration physiotherapy programmes, while the IASP discipline-specific curriculum is in need of revision.

An integrated undergraduate pain curriculum, based on IASP curricula, for six Health Science Faculties

Pain education, especially for undergraduates, has been identified as important to changing problematic pain practices, yet, no published data were found describing an integrated, interprofessional pain curriculum for undergraduate students. Therefore, this project aimed to develop, implement, and evaluate an integrated pain curriculum, based on the International Association for the Study of Pain curricula [http://www.iasp-pain.org/curropen.html], for 540 students from six Health Science Faculties/Departments. Over an 18-month period, the University of Toronto Centre for the Study of Pain's Interfaculty Pain Education Committee developed a 20-h undergraduate pain curriculum to be delivered during a 1-week period. Students from Dentistry, Medicine, Nursing, Pharmacy, Physical Therapy, and Occupational Therapy participated as part of their 2nd or 3rd year program. Teaching strategies included large and small groups, Standardized Patients, and 63 facilitators. Evaluation methods included: (a) pre- and post-tests of the Pain Knowledge and Beliefs Questionnaire (PKBQ) and (b) Daily Content and Process Questionnaire (DCPQ) to obtain feedback about process, content, and format across the curriculum's 5 days. A significant improvement in pain knowledge and beliefs was demonstrated (t = 181.28, P < 0.001), although non-responders were problematic at the post-test. DCPQ overall ratings of 'exceeding or meeting expectations' ranged from 74 to 92%. Ratings were highest for the patient-related content and panel, and the small-group discussions with Standardized Patients. Overall evaluations were positive, and statistically significant changes were demonstrated in students' pain knowledge and beliefs. This unique and valuable learning opportunity will be repeated with some modifications next year.

The attitudes and beliefs of physiotherapy students to chronic back pain

OBJECTIVES

To describe the attitudes and beliefs of physiotherapy students to chronic low back pain (LBP) and to investigate whether these attitudes change following exposure to a teaching module on chronic back pain. Also, to investigate the effect of current or previous LBP on student attitudes and beliefs.

METHODS

Six hundred and eighteen third and fourth year undergraduate physiotherapy students completed the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), 305 of these completing a further scale following exposure to a specialized teaching module about chronic back pain. The scale contains 15 statements that attribute patients' impairment and disability to pain. The student marked on a Likert scale how strongly they agreed with each item, with possible scores varying from 15-105.

RESULTS

The mean HC-PAIRS scores for Year 3 physiotherapy students in 1998, 1999, and 2000 were 54.2 (SD = 8.7), 55 (SD = 9.4), and 50.9 (SD = 9.3) respectively. The mean HC-PAIRS score for Year 4 physiotherapy students in 1998 was 52 (SD = 8.9). There was no difference in HC-PAIRS scores between subjects with and without a history of LBP (HC-PAIRS score 50.5 vs. 50.0 P = 0.4). There was a significant difference between the before and after teaching scores for Year 3 students surveyed immediately following the teaching module (1998 Year 3 cohort, mean difference -6.6, 95% CI -8.6 to -4.5, 2000 Year 3 cohort, mean difference -7.7, 95% CI -10.9 to -4.6); however this result needs to be viewed with caution due to the number of students unable to be followed up.

DISCUSSION

These results suggest that the attitudes and beliefs of third year physiotherapy students not exposed to teaching are similar to those of community providers. There is no difference between students with and without a history of LBP.

Service users' and occupational therapists' beliefs about effective treatments for chronic pain: a meeting of the minds or the great divide?

PURPOSE

Research supports that beliefs about chronic pain and its treatment are individually constructed. It also suggests that lack of agreement between people with pain and treatment providers may contribute to negative treatment outcomes. The aim of this study is to identify patterns of congruence that exist between service users and occupational therapists in relation to beliefs about which treatments for chronic pain are important.

METHOD

These findings are extracted from a wider research study exploring congruence between service providers from a range of professional groups and service users regarding their endorsement of treatments for chronic pain. The survey findings reported here asked occupational therapists and service users their opinion about whether specific treatment components are important for people with chronic pain. The survey also included Skevington's Beliefs About Pain Control Questionnaire (BPCQ) which measured 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.

RESULTS

There were few treatment components that 100% of the respondents agreed were important. Occupational therapists' and service users' responses demonstrated statistically significant differences in endorsement of treatments, BPCQ scores and the relationship between BPCQ scores and treatment endorsements.

CONCLUSIONS

Occupational Therapists and service users are distinctly heterogeneous groups in regards to what treatments they believe are important for chronic pain. It is possible that the therapeutic relationship and the outcome of available treatments are negatively affected as a consequence of disagreement about what treatments are important.