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Education: pain (FS-07)
Julia Hush (Australia)
Kathleen Sluka (United States of America)
Graciela Rovner (Sweden)
This material is provided with the permission of the presenters and is not endorsed by WCPT
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Focussed Symposium 07
Meeting the global challenge of pain
education for physical therapists
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Objectives
1. To understand how pain education for physical therapists, based on modern pain science, is critical for improving clinical outcomes in pain management.
1. To learn about evidence-based pain education resources available to enhance physical therapist training and clinical competencies.
1. To identify successful practical methods to teach pain science to physical therapists, in entry-level programs or in clinical education.
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Professor Kathleen Sluka, University of Iowa
A/Professor Julia Hush Macquarie University
Graciela Rovner, University of Gothenburg
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Outline
4.00 – 4.10: Introduction from Convener: A/Professor Julia Hush: Current Challenges in Pain Education.
4.10 – 4.30: Speaker 1: Professor Kathleen Sluka: Formation and Integration of Pain Competencies in Physical Therapy Education.
4.30 – 4.55: Speaker 2: A/Professor Julia Hush: Embedding the IASP Pain Curriculum in Pain Education for Physiotherapists in Australia – the Experience Down Under.
4.55 – 5.15: Speaker 3: Graciela Rovner: Sweden and Argentina: how Contextual and Cultural Factors may Influence Pain Paradigms in Education, Guidelines and Practice.
5.15 – 5.25: Discussion with audience and the panel of speakers
5.25 – 5.30: Convener: A/Professor Julia Hush: Summary and take-home messages.
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Introduction from Convener
A/Professor Julia Hush Macquarie University, Australia
Current Challenges in Pain Education
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Incidence of health problems: USA
711.9
16.3
25.8
116
0
20
40
60
80
100
120
Stroke Cancer Heart disease Diabetes Chronic pain
Inci
de
nce
/ m
illio
n A
me
rica
ns
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Institute of Medicine Report
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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IOM Key Findings:
• The total financial costs of this epidemic of pain exceed US$600 billion each year.
• This is higher than the costs for cancer, heart disease, and diabetes combined.
• Yet the treatment covered by these expenditures does NOT adequately alleviate Americans’ pain.
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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What are the challenges?
Pizzo and Clark, 2012
“A major challenge is the limited education that U.S. medical students and physicians receive about pain….training in pain management does not lead to competency.”
“Major impediments to relief include patients’ limited access to clinicians who are knowledgeable about acute and chronic pain –owing in part to the prevalence of outmoded or unscientific knowledge and attitudes about pain.”
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Pain education: challenges and solutions
The Institute of Medicine recommends: “expanding and redesigning education programs to transform the understanding of pain and improved education for clinicians.”
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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is the number one reason people consult a physiotherapist
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Pain education in physiotherapy
“Recent surveys of the curricula of health care professions (including physical therapy) at universities in Canada and the UK showed that current pain education is inadequate preparation for professional practice.”
Foster and Delitto, Phys Ther 2011
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Meeting the global challenge of pain education for physical therapists
Professor Kathleen Sluka: Formation and Integration of Pain Competencies in Physical Therapy Education.
A/Professor Julia Hush: Embedding the IASP Pain Curriculum in Pain Education for Physiotherapists in Australia – the Experience Down Under.
Graciela Rovner: Sweden and Argentina: how Contextual and Cultural Factors may Influence Pain Paradigms in Education, Guidelines and Practice.
Essential Pain Knowledge for
the Physical Therapist
Kathleen A. Sluka, P.T, Ph.D.Professor
Physical Therapy and Rehabilitation Science Graduate Program
Neuroscience Graduate Program
Pain Research Program
University of Iowa
painexhibit.com
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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An unpleasant sensory
and emotional experience
associated with actual or
potential tissue damage, or described in terms as such
Subjective
PAIN
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Declaration of MontrealAccess to Pain Management Is a Fundamental Human Right (IASP 2010)
Article 1. The right of all people to have access to pain management without discrimination
Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed
Article 3. The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Institute of Medicine Report on Pain Conclusions - 2011
Chronic pain affects more than a 100 million Americans, making its control of enormous value to individuals and society
Julie Meese: Chronic pain can make you despondent…I find dealing with pain is like riding a surf board -- I can get thrown into the debilitating turmoil that is pain along with fatigue, brain fog and depression at any moment.
"Pool of Darkness" represents the times when I fall off my surf board and am unable to claw my way back to the surface.
Painexhibit.com
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Institute of Medicine Report 2011
A moral imperative
Effective pain management is a moral imperative
A professional responsibility
The duty of people in the healing professions
Need for interdisciplinary approaches
Produces the best results for people with the most severe and persistent painAgainst The Barrier To Life
by Judith Ann Seabrook
painexhibit.com
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Institute of Medicine Reporton Pain 2011-Conclusions
To reduce the impact of pain and suffering we need to transform how pain is perceived and judged by:
people with painsocietyhealth care providers who help care for them
Goals better understand pain of all types (research and education)improving efforts to prevent, assess, and treat pain (research and education)
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Only 1/3 faculties could identify designated pain content hours in health sciences.
Veterinary Medicine had 3X more designated pain content hours on average, & 5x medicine.
Watt-Watson, McGillion et al., Pain Res Manage 2009 14(6), 439-444
Pain Education in Canada
J Watt-Watson 2015
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Entry-Level EducationScudds et al., 2001
Pain in PT curriculum averages 4 h (US) (faculty survey)
Most faculty believe pain is adequately covered in curriculum (faculty survey)
Similar in all professional programs
Medicine
Nursing
Pharmacy
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Average number of hours
31 contact hours
Range 5-115 hours
61% believe adequately covered
49% aware of IASP guidelines
48% aware of IOM report on Pain
96% use evidence-based approach
6% (11 schools) have an independent pain course
Current SurveyHoeger Bement and Sluka,
J Pain 2015 Feb;16(2):144-52
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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What is covered? Hoeger Bement and Sluka,
J Pain 2015 Feb;16(2):144-52
PAIN
Content Categories Mean + S.E.M. Median Mode Range
Pain Science 9.5 + 0.38 8 6 2-27
Pain Assessment 4.0 + 0.22 3 2 0-10
Pain Intervention and Management 27.2 + 1.3 24 16 6-84
Education and self-management strategies 3.2 + 0.19 3 2 0-10
Exercise therapy for pain control 3.9 + 0.25 3 2 0-10
Manual therapy for pain control 4.4 + 0.26 3 2 0-10
Electrical agents for pain control (TENS and
IFC)
4.6 + 0.23 4 2 0-10
Thermal agents for pain control 3.9 + 0.23 3 2 0-10
Psychological management 2.7 + 0.17 2 2 0-10
Physician Management 2.2 + 0.14 2 2 0-10
Multidisciplinary (interdisciplinary)
management
2.3 + 0.14 2 2 0-3
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Science Category Assessment Category
Topic % covered Topic % covered
Gate Control Theory 95% Subjective Pain Scales 99%
Biopsychosocial Model 95% Pain Specific Questionnaires 83%
Acute vs. Chronic Pain 97% Disease Specific Questionnaires 91%
Pain Pathways 97% Functional Assessments 86%
Peripheral Sensitization 84% Psychological Assessments 80%
Central Sensitization 87% Pain across the lifespan 68%
Cortical Processing 85%
Central Inhibition 85%
Neurotransmitters and Receptors 93%
PAIN
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Outline
I. Multidimensional Nature of Pain
II. Pain Assessment and Measurement
III Management of Pain
IV. Clinical Conditions
IASP Curriculum Guidelines 2012Physical Therapy Pain EducationDrs. Slater, Sluka, Söderlund, Watson
http://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=2055
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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DOMAINSI. Multidimensional nature of pain
II. Pain assessment & measurement
III. Pain management
IV. Clinical conditions
www.ucdmc.ucdavis.edu/paineducation
Core Competencies in Pain Education 2013Interprofessional Consensus
http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/fullFishman et al., Pain Medicine 14: 971-981, 2013
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Threaded throughout curriculum
Core principles and assessments
Specialized courses in orthopedics, neurology, cardiopulmonary
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/table/T1/
Stand-alone course
Detailed pain science
Psychological barriers to management
Importance of interdisciplinary management
Integration into curriculumBement et al., Physical Therapy 94: 451-465, 2014
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/#app2
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Didactic lecture
Group discussions
Pain Laboratory
Small Assignments
Practical Exams
Case-based learning
Simulated patients
Learning activities
painexhibit.com
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Experimental Pain LaboratoryStudents Share Personal Pain Experiences from Biopsychosocial Perspective
Students perform Temporal Summation and Conditioned Pain Modulation
Rate pain to different chemical, mechanical, thermal and ischemic stimuli
Students fill out pain questionnaires
Learning Activities
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Simulated Patient Evaluation
Evaluation
Write an evidence based treatment plan
Search and grade evidence
Assigned pain condition and PT intervention
Discuss findings
Write and practice explaining
Referral to psychology to patient
Mechanisms of pain to patient
Effectiveness of intervention to physician
Learning experiences
painexhibit.com
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Search and share scientific literature on a basic science subject not discussed in class
Do search in 30 minutes, write in 15 minutes
From case studies identify potential underlying mechanisms
Peripheral sensitization
Central sensitization
Neuropathic
Psychosocial concerns
Learning experiences
painexhibit.com
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Lack of faculty expertise
Educate faculty
Designated faculty to coordinate
Incentives needed
Accreditation needs to include pain competencies
Licensure exam needs to test over competencies
Public demand and knowledge
Implementation
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Pain Mechanisms and Management for the Physical Therapists, Sluka KA, IASP Press, 2009 (update in 2015)-textbook for PT students
Explain Pain, Butler DS and Moseley GL, 2013
Centers of Excellence in Pain Education (CoEPE), National Institute of Health http://painconsortium.nih.gov/NIH_Pain_Programs/CoEPES.html
International Association for the Study of Pain, www.iasp-pain.org
Hoeger Bement and Sluka, J Pain 2015 Feb;16(2):144-52 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full
Fishman et al., Pain Medicine 14: 971-981, 2013 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full
Bement et al., Physical Therapy 94: 451-465, 2014http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/#app2
painHEALTH http://painhealth.csse.uwa.edu.au/
Interprofessional Pain Management Competency Program
http://www.ucdmc.ucdavis.edu/paineducation/Happenings/index.html
Resources
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Improved education in PT over last decade
Need to expand education
Pain Science
Biopsychosocial approach
Education, self-management and active approach critical
Interdisciplinary approach
Summary
Kathleen A. Sluka, P.T, Ph.D.Professor
Physical Therapy and Rehabilitation Science Graduate Program
Neuroscience Graduate Program
Pain Research Program
University of Iowa
painexhibit.com
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms as such
Subjective
Article 1. The right of all people to have access to pain management without discrimination
Article 2. The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed
Article 3. The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals
Chronic pain affects more than a 100 million Americans, making its control of enormous value to individuals and society
Julie Meese: Chronic pain can make you
despondent…I find dealing with pain is
like riding a surf board -- I can get thrown
into the debilitating turmoil that is pain
along with fatigue, brain fog and
depression at any moment.
"Pool of Darkness" represents the times
when I fall off my surf board and am
unable to claw my way back to the surface.
Painexhibit.com
A moral imperative◦ Effective pain management is a
moral imperative
◦ A professional responsibility
◦ The duty of people in the healing professions
Need for interdisciplinary approaches◦ Produces the best results for
people with the most severe and persistent pain
Against The Barrier To
Life
by Judith Ann Seabrookpainexhibit.com
To reduce the impact of pain and suffering we need to transform how pain is perceived and judged by:◦ people with pain◦ society◦ health care providers who help care for them
Goals ◦ better understand pain of all types (research
and education)◦ improving efforts to prevent, assess, and treat
pain (research and education)
Only 1/3 faculties could identify designated pain content hours in health sciences.
Veterinary Medicine had 3X more designated pain content hours on average, & 5x medicine.
Watt-Watson, McGillion et al., Pain Res Manage 2009 14(6), 439-444
Pain Education in Canada
J Watt-Watson 2015
Pain in PT curriculum averages 4 h (US) (faculty survey)
Most faculty believe pain is adequately covered in curriculum (faculty survey)
Similar in all professional programs◦ Medicine
◦ Nursing
◦ Pharmacy
Average number of hours◦ 31 contact hours
◦ Range 5-115 hours
61% believe adequately covered
49% aware of IASP guidelines
48% aware of IOM report on Pain
96% use evidence-based approach
6% (11 schools) have an independent pain course
PAIN
Content Categories Mean + S.E.M. Median Mode Range
Pain Science 9.5 + 0.38 8 6 2-27
Pain Assessment 4.0 + 0.22 3 2 0-10
Pain Intervention and Management 27.2 + 1.3 24 16 6-84
Education and self-management
strategies
3.2 + 0.19 3 2 0-10
Exercise therapy for pain control 3.9 + 0.25 3 2 0-10
Manual therapy for pain control 4.4 + 0.26 3 2 0-10
Electrical agents for pain control
(TENS and IFC)
4.6 + 0.23 4 2 0-10
Thermal agents for pain control 3.9 + 0.23 3 2 0-10
Psychological management 2.7 + 0.17 2 2 0-10
Physician Management 2.2 + 0.14 2 2 0-10
Multidisciplinary (interdisciplinary)
management
2.3 + 0.14 2 2 0-3
Science Category Assessment Category
Topic % covered Topic % covered
Gate Control Theory 95% Subjective Pain Scales 99%
Biopsychosocial Model 95% Pain Specific Questionnaires 83%
Acute vs. Chronic Pain 97% Disease Specific Questionnaires 91%
Pain Pathways 97% Functional Assessments 86%
Peripheral Sensitization 84% Psychological Assessments 80%
Central Sensitization 87% Pain across the lifespan 68%
Cortical Processing 85%
Central Inhibition 85%
Neurotransmitters and
Receptors
93%
PAIN
Outline◦ I. Multidimensional Nature of Pain
◦ II. Pain Assessment and Measurement
◦ III Management of Pain
◦ IV. Clinical Conditions
DOMAINSI. Multidimensional nature of pain
II. Pain assessment & measurement
III. Pain management
IV. Clinical conditions
www.ucdmc.ucdavis.edu/paineducation
Threaded throughout curriculum◦ Core principles and assessments
◦ Specialized courses in orthopedics, neurology, cardiopulmonary
◦ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/table/T1/
Stand-alone course◦ Detailed pain science
◦ Psychological barriers to management
◦ Importance of interdisciplinary management
Didactic lecture
Group discussions
Pain Laboratory
Small Assignments
Practical Exams
Case-based learning
Simulated patients
painexhibit.com
Experimental Pain Laboratory◦ Students Share Personal Pain Experiences from Biopsychosocial Perspective
◦ Students perform Temporal Summation and Conditioned Pain Modulation
◦ Rate pain to different chemical, mechanical, thermal and ischemic stimuli
◦ Students fill out pain questionnaires
Simulated Patient Evaluation◦ Evaluation
◦ Write an evidence based treatment plan
Search and grade evidence◦ Assigned pain condition and PT intervention
◦ Discuss findings
Write and practice explaining ◦ Referral to psychology to patient
◦ Mechanisms of pain to patient
◦ Effectiveness of intervention to physician
painexhibit.com
Search and share scientific literature on a basic science subject not discussed in class◦ Do search in 30 minutes, write in 15 minutes
From case studies identify potential underlying mechanisms◦ Peripheral sensitization
◦ Central sensitization
◦ Neuropathic
◦ Psychosocial concerns
painexhibit.com
Lack of faculty expertise◦ Educate faculty
◦ Designated faculty to coordinate
Incentives needed◦ Accreditation needs to include pain competencies
◦ Licensure exam needs to test over competencies
◦ Public demand and knowledge
Pain Mechanisms and Management for the Physical Therapists, Sluka KA, IASP Press, 2009 (update in 2015)-textbook for PT students
Explain Pain, Butler DS and Moseley GL, 2013
Centers of Excellence in Pain Education (CoEPE), National Institute of Health http://painconsortium.nih.gov/NIH_Pain_Programs/CoEPES.html
International Association for the Study of Pain, www.iasp-pain.org
Hoeger Bement and Sluka, J Pain 2015 Feb;16(2):144-52 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full
Fishman et al., Pain Medicine 14: 971-981, 2013 http://onlinelibrary.wiley.com/doi/10.1111/pme.12107/full
Bement et al., Physical Therapy 94: 451-465, 2014http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4023081/#app2
painHEALTH http://painhealth.csse.uwa.edu.au/
Interprofessional Pain Management Competency Program
http://www.ucdmc.ucdavis.edu/paineducation/Happenings/index.html
Improved education in PT over last decade
Need to expand education◦ Pain Science
◦ Biopsychosocial approach
◦ Education, self-management and active approach critical
◦ Interdisciplinary approach
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Embedding the IASP Pain Curriculum in
Pain Education for Physiotherapists in
Australia – the Experience Down Under.
A/Professor Julia Hush
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Outline
• IASP Pain Curriculum for Physical Therapists
• Doctor of Physiotherapy Program at Macquarie University
• Integration of the IASP Curriculum into the DPT Program at MQ
o Principles
o Practice
o Simple teaching tools
o Evaluation
• Pain education resources
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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International Association for the Study of Pain
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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IASP Pain Education Curricula
“These curricula outlines are helpful for establishing teaching courses
on acute, chronic, and cancer pain at both the undergraduate and
graduate level” (IASP, May 2012)
Physical Therapy Task Force Committee:• Helen Slater• Kathleen Sluka• Anne Söderlund• Paul Watson (Chair)
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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The DPT Program at Macquarie University
• Three-year entry-level Doctor of Physiotherapy Program (DPT)
commenced in 2012 at Macquarie University, in Sydney, Australia.
• Extended Masters (Level 9 in Australian Qualifications Framework)
• The program was designed to meet international benchmarks as well as
national regulatory and professional standards.
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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The DPT Program at Macquarie University
Is unique in its co-location within Australia’s first University private hospital (Macquarie
University Hospital and Clinic) – now integrating with the new Faculty of Medicine and
Health Sciences to form Australia’s first academic health campus.
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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IASP Pain Education Curriculum for PTs
1. The multidimensional nature of pain
2. Pain assessment and measurement
3. Management of pain
4. Clinical conditions
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Integrating the IASP curriculum into the DPT Program - principles
• Vertical and horizontal integration of content – embedded in units
rather than stand alone subjects
• Build complexity throughout program
• > 30 hours of core pain education
• Integration with clinical education (embedded in DPT program)
• Blended learning
• Evaluate pain-specific knowledge and clinical competencies
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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IASP Pain Education Curriculum for PTs
1. The multidimensional nature of pain
2. Pain assessment and measurement
3. Management of pain
4. Clinical conditions
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
73
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Mapping the IASP Curriculum in the MQ DPT Program
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Pedagogical Framework
Knowledge
Skills and competencies
Attitudes and beliefs
IOM recommendation: “expanding and redesigning education programs to transform the understanding of pain and improved education for clinicians.”
Pizzo, NEJM 2012
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Bringing 21st C pain neuroscience into PT education
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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How pain works: From Descartes to the 21st C.
Bingel et al. Physiology 2008
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Consider
Pain education requirements for:
• Faculty
• Sessional teaching staff
• Clinical educators
Training:
• Pain neuroscience and clinical models
• Workshops
• Provide resources
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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MQ DPT Pain curriculum
Semester A:
• Intensive training in current pain neuroscience, the biopsychosocial model and it’s integration into the assessment and management of pain.
• Commence clinical education
Semester B:
• Consolidate in discipline-specific content (MSK, CR, Neuro) and EBP
• Extend clinical education
• Semester C:
• Application in block clinical placements
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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MQ DPT Pain curriculum
Semester D:
• Pain across the lifespan
• Reintegration into sport / work
• Chronic and complex conditions
• Introduction to chronic pain management
Semester E:
• Develop advanced competencies in pain management – full day workshop
Semester F:
• Elective clinical placements – include pain management programs
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Advanced pain management workshop
• Key components of pain management programs for chronic pain
• Explaining pain to patients
o Different approaches – discussion and videos
o Principles
o Content – tailored to individual patients
o Case-based clinical simulation practice
• Resources for clinicians and patients
• Addressing psychological factors
• Novel treatments for chronic pain
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Clinical simulation student practice
• Case based – different pain vignettes
• Small group identifies relevant issues and develops content of education
• In-class simulation of explaining pain to “patient”
• Peer feedback and evaluation
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Student practice of explaining pain
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Simple teaching tools
• Six core concepts of pain
• Clinical model of pain
injury Signal generator
Amplifier
Gain setter
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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injury Signal generatorAmplifier
Gain setter
Clinical model of pain
Pain is driven by 3 interrelated and almost universally present factors:• A signal (from the periphery)• An amplifier (central sensitisation)• A gain setter (descending controls from the brain)
Adapted with permission from Siddall, P (2012) Neurobiological contributors to pain [study guide],
Postgraduate Degree Program in Pain Management, University of Sydney
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Evaluation of students’ knowledge and competencies - examples
Semester 1:
• Pain neuroscience knowledge – Questionnaire
• Ability to apply knowledge to fundamental principles of patient assessment and treatment – Assignment
• Competencies in patient assessment and management of painful conditions – Clinical simulation exams
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Evaluation: Pain Neurophysiology Knowledge
First year students (2014 intake)
Increase in knowledge from week 1 to week 12 (Semester 1)
Catley et al, J Pain 2013
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10
20
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100
NP
Q %
CO
RR
ECT
WEEK 1 WEEK 12
Neurophysiology of Pain Questionnaire: DPT 3.0 Semester A
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Pain education resources
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Resources - books
Manage Your Pain. 3rd edition, ABC Books; Nicholas et al.
The Pain Book: finding hope when it hurts. Siddall et al.
Explain Pain. D. Butler & L. Moseley. NOIgroup
Therapeutic Neuroscience Education. Louw & Puentedura
Pain: Why and how does it hurt? G.L. Moseley. In: Brukner and Kahn: Clinical Sports Medicine.4th edition.
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Resources - online
• TEDxAdelaide video Professor Moseley: “Why Things Hurt”
• ACI Pain Management Network website (NSW)
• Hunter Brainman videos (NSW)
• painHEALTH website (WA)
• HealthTalk Online website (Oxford University)
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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ACI Pain Management Network - NSW
ACI Pain Management Network.
• 7 episodes presented in short video clips
• Download a Health Care Plan for the patient to fill out and take to their GP for review and to establish a pain management plan
• Other useful resources on this website tailor this information for:
o Teenagers PainBytes
o SCI pain Spinal Cord Injury Pain
o Healthcare practitioners For healthcare professionals
FACULTY OF MEDICINE AND HEALTH SCIENCESDEPARTMENT OF HEALTH PROFESSIONS | DISCIPLINE OF PHYSIOTHERAPY
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Hunter Brainman Videos
Hunter Brainman videos: the “brainchild” of the team at Hunter Integrated Pain Service at John Hunter Hospital and Hunter Medicare Local, Australia.
3 videos:• Understanding pain and what to do about it in less than five minutes• Understanding Pain: Brainman chooses• Understanding Pain Brainman stops his opioids
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painHEALTH website (Western Australia)
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HealthTalk Online website
Videos of real patients with chronic pain talking about their experiences of using specific elements of pain management.
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Filling the GAP… with Continuing Education in
Behavioral & Lifestyle- based PT
SWEDEN AND ARGENTINA: How contextual and cultural factors may influence pain paradigms in education, guidelines and practice
Graciela Rovner, PT & PhD in Rehabilitation MedicineInternational ACT trainer, peer reviewed by
the Association for Contextual Behavioral Sciences (ACBS)Dept. Neurosciences and Physiology
University of Gothenburg SWEDEN
THE GAPS & DIFFERENCES
• Pain Education in Sweden-overview
• Continuing education
COMMONALITIES
• Behaviors
• Myths and misconceptions we carry
from education
• Pitfalls in the clinic
POTENTIAL GLOBAL MODEL?
• Behavioral physiotherapy in Sweden
• Acceptance & Commitment Therapy
(ACT pronounced ‘act’)
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COMMONALITITES: People with chronic pain presents:
• Besides physiological signs…
• Emotional distress, and cognitive, and…and…..
…and other typical behaviors….
When the problem is not longer the problem…
…and the solution became
the biggest problem…
•C
ON
TR
OL
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Control excercise
Pain formulae:
Suffering= pain x control(or rejection or avoidance)
Suffering= 10 x ?
?= 20 Suffering= 200?= 2 Suffering= 20
Serenity Prayer
God, give us grace to accept with serenity the things that cannot be
changed, courage to change the things that can be changed, and the wisdom to
distinguish one from the other
Accept Changeadiction
depression
painisolation
anxiety
inactivity
Reinhold Niebuhr
Case conceptualization
Desired outcome
BIOMEDICALMODEL
Illness, presence of symptom, disruption of homeostasis
Symptom elimination or relief.
BIOPSYCHOSOCIALMODEL
Illness, interaction between psychological, social and pathophysiological aspects & ‘maladaptive behaviors.’
Symptoms relief with pharmacological and non-pharmacological interventions offered by several professions.
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Case conceptualization Desired outcome
CBT Evaluates & control negative (”maladaptive”) behaviors.
Eliminate behaviors with exposure or transform their content into something positive. Behave well!
ACT Identification of non-flexible and non-functional avoidance behaviors
Clarify the patients’ values and help them to take the necessary steps/behaviors towards living a meaningful life despite pain of discomfort.
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PAIN: six core concepts
1. Mental processes
2. tissue damage
3. Influenced by behaviors
4. Acute chronic pain
5. Chronic pain dysfunctional NS
6. Modifying behaviors non-inflammatory lifestyles ‘turns down’ NS increases functional level (physical and psychological) and thus quality of life.
Non-communicable diseases (NCDs)
NCDs disproportionately affect low- and middle-income countries
Lifestyle changes as first line intervention for chronic diseases
LIFESTYLES
Review of ACT- pain & Physical Function PerspectiveBarrable, C. & Rovner, GR (master diss, 2015 )
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What is relevant to measure and focus on in behavioral and lifestyle-based pain rehabilitation?
WE need more focus on:•FUNCTION •Behaviors healthy ones!•Lifestyles increase non-inflamatoryactivities (physical, dietary, social, etc)
•Detect Myths and Misconceptions
What is relevant to measure and focus on in behavioral and lifestyle-based pain rehabilitation?
They say WHAT I should do, but not HOW…
GAPS:• how do we implement
these recommendations in ‘real life?
• How is assessment done and systematized?
• Are really important the different diagoses and syndromes in rehabilitation?
• Are these diferent pains predicting outcome for rehabilitation?
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Want to know more?• GENERAL ACT BOOKS
ACT made simple by Russ Harris
ACT for Chronic pain by J. Dahl
Focused ACT by Strosahl, Robinson & Gustavsson (2014)
Acceptance and Commitment Therapy (ACT) for the mindful physiotherapist. By Rovner. In Probst, M & Skjærven, L.H. (Eds.), Physiotherapy in Mental Health and Psychiatry: a Scientific and Clinical Based Approach. IOPTMH Book in press.
• BOOKLET for physios
ACTivePhysio, basic guidelines how to assess, motivate and outline the ACTivePhysio rehab-plan (in press)
Find the e-book link at: smartrehab.nu
If you want to buy the hard copy (20 USD), please approach me!