The biomedical model of pain remains heavily dominant in most avenues of life. Despite strong scientific support for the biopsychosocial model the vast majority of patients and the public do not understand pain beyond the age-old idea of pain means damage/injury. Unfortunately, holding such an understanding appears to predispose people to develop persistent pain and can be a barrier to good pain management (Picavet et al. 2002; Leeuw et al. 2007).
Luckily, all health care professionals have the biopsychosocial model deeply ingrained within them with respect to musculoskeletal pain. All of whom take great care to interact with people with musculoskeletal pain in a way that will dispel harmful, inappropriate, simplistic, hurt equal harm belief systems. Oh no wait – perhaps not! Unfortunately, I fear that broadly the reverse is true. I fear the majority of healthcare professionals hold the same purely biomedical views as the general public and perpetuate these beliefs by talking about them with an air of authority. I believe this may have significant iatrogenic effects.
So what can we do about this situation?
I think we will find the greatest success by influencing health care professionals during their training at the time when they are still forming their beliefs about pain and pain management. At Teesside University we are attempting to do just that by integrating pain neurophysiology education into the heart of our undergraduate physiotherapy training – but is it effective? In collaboration with colleagues at the University of Limerick we have attempted to answer this question.
We undertook a multisite randomized controlled trial (Colleary et al. 2017). We investigated the effectiveness of pain neurophysiology education (PNE) (based upon the manual Explain Pain [Butler and Moseley, 2003)) regarding pain knowledge, pain attitudes and pain treatment in undergraduate physiotherapy students. A red flags-based education, which covered the signs and symptoms associated with serious/sinister spinal pathology and how to manage the symptoms clinically was used as the comparison group. The two interventions were very different with no overlap in the material presented beyond the fact that both interventions focused upon people with back pain. Both interventions lasted seventy minutes. Before and after both education sessions students completed the 13-item pain neurophysiology quiz (PNQ) to assess pain knowledge, the health care professional’s pain and impairment relationship scale (HC-PAIRS) to assess pain attitudes, and a case vignette with questions about activity, bed-rest, exercise and work to assess behaviours. Students knew we were comparing two educational approaches but were unaware of the differences between the educational approaches.
I have been an active researcher for almost fifteen years – this is the first time ever the results have turned out as I had hypothesized! Those who received PNE significantly improved their knowledge and attitudes in comparison to the control group. In addition, after PNE, students were more likely to make recommendations about activity, bed-rest, exercise and work in keeping with current clinical guidelines compared to the control group. For me, one of the most striking findings was the size of improvement on the HC-PAIRS. At baseline, the HC-PAIRS scores were 58±6 and 56±9 for the PNE and control group, respectively. Students who received PNE improved on average 18 units more than the control group. In previous work with undergraduate physiotherapists and medics we found an increase in 9 units (Ryan et al. 2010; Morris et al. 2012) from first to final year. Thus in 70 minutes we doubled the improvement in attitudes usually seen on completion of a full degree program. This is important because clinicians with more positive attitudes, as indicated by a better score on the HC-PAIRS, are more likely to make positive recommendations in keeping with current clinical guidelines. Of course, like all studies there were plenty of limitations. The deliverer of the education was not blind to the aims of the study. In addition, the students were not followed up beyond the immediate term. We have no idea as to whether these improvements were maintained. Nor do we know if these changes actually altered clinical behaviour as recommendations in a case vignette setting may differ considerably from recommendations in a real-life situation.
Limitations aside, these findings provide evidence that adding PNE into the undergraduate physiotherapy curriculum may be a useful step towards instilling a biopsychosocial view of pain into the clinicians of the future. There is a need to replicate these findings with longer-term follow up. Additionally there is a need to investigate if these findings generalise into other clinical professional groups. If we could facilitate all health care professionals to sing from the same hymn sheet, delivering a consistent message to patients – I think we could really make a difference.
About Cormac Ryan
Cormac is a Reader in Physiotherapy at Teesside University. He graduated from the University of Limerick in 2002 with a BSc in Sports and Exercise Science, and completed an MSc in Physiotherapy (pre-registration) at Queen Margaret University College, Edinburgh. He was awarded his PhD from Glasgow Caledonian University, in 2008, for investigating the relationship between physical activity and chronic low back pain. Cormac’s research interests are primarily in the area of chronic pain, its impact on patients, and interventions to manage the condition. He also has three kids under the age of eight and, as a result, is not getting much sleep, so please excuse any errors/typos!
Picavet, H.S.J., Vlaeyen, J.W. and Schouten, J.S., (2002) Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. American journal of epidemiology, Vol. 156: 1028-1034.
Leeuw, M., Goossens, M.E., Linton, S.J., Crombez, G., Boersma, K. and Vlaeyen, J.W., (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of behavioral medicine, Vol. 30: 77-94.
Colleary G, O’Sullivan K, Griffin D, Ryan CG, Martin DJ. (2017) Effect of pain neurophysiology education on physiotherapy students’ understanding of chronic pain, clinical recommendations and attitudes towards people with chronic pain: a randomised controlled trial. Physiotherapy Vol. 103: 423-429.
Butler, D.S, and Moseley, G.L. (2003) Explain Pain. Adelaide: Noigroup Publications.
Morris H, Ryan C, Lauchlan D, Field M. (2012) Do medical student attitudes towards patients with chronic low back pain improve during training? A cross-sectional study. BMC Medical Education, 12:10. Doi:10.1186/1472-6920-12-10.
Ryan CG, Murphy D, Clark M, Lee, A. (2010) The effect of physiotherapy education compared to a non-health care education on the attitudes and beliefs of students towards functioning in individuals with back pain. Physiotherapy. Vol. 96(2): 144-150.