Pain Neuroscience in the DPT Curriculum

Background

Pain is a “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”¹ The experience of pain is a very common reason patients seek outpatient physical therapy services. We learn a lot of techniques for evaluating and treating mechanically driven pain throughout the DPT curriculum. However, I soon realized on my first clinical rotation at an outpatient physical therapy clinic that many patients do not fit into “neat” diagnostic categories or respond to traditional PT treatments. I was left asking questions about what exactly pain is, what drives it, and how we can explain the chronic pain that plagues so many people. I started reading more about the growing field of “pain science” and wondered why this area with so much research had not made it into the DPT curriculum. Therefore, when it was time for me to choose a Capstone topic, I knew that creating an “Pain Science Module” for the DPT curriculum would not only give me the opportunity to learn more about the topic myself, but also ensure first-year DPT students were exposed to formal education about this important and rapidly growing topic.

 

Statement of Need

There is very little material within the DPT curriculum dedicated to teaching students about the complexities of the pain experience. Basic pain pathways are discussed in CBPH 793 Functional Neuroanatomy and chronic pain is introduced during a single guest lecture in PHYT 734 Musculoskeletal II: PT Intervention. However, this does not include many of the important pain neuroscience concepts that have been recognized as an important part of DPT education.²

In 2018, the APTA’s House of Delegates passed a motion to endorse and integrate curricular guidelines for pain education established by the IASP [International Association for the Study of Pain] due to a lack of guidance by CAPTE and other professional organizations.² In fact, CAPTE standards only mention the word “pain” once and provide no guidance for specific pain assessment or interventions.² As a result, the APTA’s Academy of Orthopedic Physical Therapy (AOPT) created a Pain Education Committee, which recently released a manual for integrating pain science education into DPT curriculums.²

It is time for UNC’s DPT program to incorporate the most recent evidence surrounding pain neuroscience into the first-year curriculum. This will help students create a framework for understanding pain so they can better assess and treat their patients. This content is well positioned for PHYT 722 Therapeutic Modalities, which takes place during the spring semester of DPT student’s first year. While pain science is not a traditional “therapeutic modality”, this content will help students conceptualize the “why” behind modality choice while also teaching them about patient education, an extremely important intervention that should accompany any therapeutic modality.

 

Purpose

The purpose of this Capstone is to create presentation materials and activities for a “Pain Science Module” for first-year DPT students. The is module will take place over two, 4-hour lecture blocks in PHYT 722 Therapeutic Modalities. The first day of the module will be focused on introducing pain neuroscience concepts, including basic neuroanatomy, mechanisms of pain, and risk factors for developing chronic pain. The second day of the module will attempt to make pain science concepts practical by discussing evaluation and treatment techniques for patients with acute and chronic pain. Learning Objectives for both class sessions were developed based on the AOPT Pain Science Education Manual in order to reflect the APTA’s priorities in pain science education.²

 

Products

All of the products created for this Capstone are related to the presentation materials and activities conducted during the two-day Pain Science Module.

PHYT 722 Pain Science Module Learning Objectives is a PDF containing the learning objectives for both days of lecture along with the coinciding “domain” in the AOPT manual from which the learning objective is based.

Day1_IntroToPainNeuroscience_student is a PDF of the “student” version of first presentation given on 4/20/2022, including a full reference list. The “presenter” version with full presenter notes is available upon request.

Day2_ApplicationOfPainNeuroscience_student is a PDF of the “student version of the second presentation given on 4/25/2022, including a full reference list. The “presenter” version with full presenter notes is available upon request.

Key_MiniCaseStudies is a PDF utilized during the first presentation for an activity where students worked in groups to identify the driving pain mechanism in 3 separate “mini” case studies.

Pain Neuroscience Education Stories for Lab is a PDF with the script for common “stories” and metaphors used to help patients make sense of their pain using pain neuroscience education (PNE). Students practiced giving PNE to multiple partners utilizing various stories.

Other activities that were completed over the course of the Pain Science Module include: filling out the Neurophysiology of Pain Questionnaire (NPQ)³ at the beginning and end of the module, competing against classmates in a Pain Neuroanatomy Review Kahoot, vocally participating in a live demonstration of evaluating a chronic pain patient, working in groups to create a graded exposure progression for various feared movements, and searching the literature for an article relating chronic pain to lifestyle factors.

 

Evaluation   

Because this is a complex topic that involves much more lecture time than lab time, I wanted to make sure the presentation slides were clear, concise, and engaging. My goal was to include enough relevant information on the slides so students could engage with the material visually and use the slides for reference in the future, while also trying not to overcrowd the slides with too much information.

I utilized many of the tips in the PowerPoint VoiceThread to keep my slides clear and concise.⁴ In general, I tried to keep slides to 6-7 lines of information and avoided extraneous or repeated words that didn’t add any meaning to the slide. Additionally, I tried to give the PowerPoint structure by providing a “road map” of where the lecture was going and including transition slides when there was a major shift in topic. Because there is so much information on this topic, I structured the presentation in a way that emphasizes key points and summarizes larger swaths of information. I also tried to utilize simple transitions and animations to emphasize certain diagrams or pieces of information. This was especially important when a diagram had lots of information that would’ve looked “busy” without animations to emphasize specific points. Finally, I incorporated quite a few “mini” case examples into the presentation to help students conceptualize the information and apply it to a “real life” example.

 

I also created an evaluation form for students to fill out at the completion of the Pain Neuroscience Module. I received 31 responses, which is a 100% response rate from the first-year students. A full summary of their feedback is in the hyperlink below, but the general sentiment from the students was that they really enjoyed having this type of material in the curriculum. Many found the presentations relevant, engaging, and applicable. Suggested improvements included adding more case examples for treatment interventions and more lab time to practice PNE. The students overwhelmingly recommended this material be made a permanent part of the DPT curriculum.

Pain Neuroscience Module Evaluation_Results Summary

 

Self-Reflection     

This project grew out of my own desire to learn more about “pain science” and how I can integrate it into my future clinical practice. I believe it has turned into a helpful resource that will serve as a good foundation for a pain science module for future DPT students. Going through the program, I was surprised at the disconnect between how much research was emerging about pain, yet how little of it was in the DPT curriculum. With the help of Bria Dunn, I think we are starting to bridge that gap.

The process of creating this Capstone started in the fall when I first discussed a “pain science module” with Bria, who teaches PHYT 722 (Therapeutic Modalities). If I’m being completely honest, as I started to do research for the lectures, I realized I bit off more than I could chew. This is such a large topic with so much new research coming out. But what helped focus me was zeroing in on the following question: “what is the foundational information that will introduce first-year DPT students to this topic enough that they can incorporate this knowledge into clinical practice?” I soon realized I don’t have to teach them everything about pain. Rather, I can give them the foundational knowledge that will hopefully spark interest for future study.

Creating these lecture and lab materials was a lot of work, but it has been a valuable experience and has grown my own knowledge base about this topic. Learning more about specific neuroanatomical changes that occur in the spinal cord and the brain gives me greater confidence in using PNE to help my future patients make sense of their pain. Furthermore, I think I have a greater appreciation for treating patients holistically, rather than looking narrowly at the specific body part that is painful. I will certainly need lots of clinical experiences to start applying this knowledge into practice effectively. But I think I have given myself a solid knowledge base to draw from as I treat patients this summer and in the future as an independent clinician.

 

Acknowledgments

A special thanks to Bria Dunn, PT, DPT, for being my Capstone Advisor and entrusting me to help integrate this important topic into your Therapeutic Modalities class. You have been very generous with your time, flexibility, and knowledge base about this topic.

To Jean Masse, PT, DPT, PRC, OCS, ATC, thank you for being on my Capstone Committee and sharing your invaluable expertise in treating patients with chronic pain. You brought an important clinical perspective and were very helpful in shaping the way I talk about chronic pain.

To Sarah van der Horst, PT, DPT, OCS, thank you for being a part of my Capstone Committee and providing me with a clinical and educational perspective for teaching students about pain science topics. Your willingness to share relevant research and give constructive feedback helped shape my presentations into the final products they are.

To the UNC DPT Class of 2024, thank you for your attentiveness and participation throughout the two-day Pain Science Module. You were very gracious to me as a student lecturer and stayed engaged despite the quantity of information being thrown your way. Your positive feedback was nice to receive and will help improve this module for future classes.

 

References

(Full reference lists for this project are provided at the end of each presentation)

1. Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-1982. doi:10.1097/j.pain.0000000000001939
2. Shepard M, Courtney C, Wassinger C, Davis DS, Rubine B. Pain Education Manual For Physical Therapist Professional Degree Programs. Academy of Orthopaedic Physical Therapy, APTA, Inc.; 2021.
3. Adillón C, Lozano È, Salvat I. Comparison of pain neurophysiology knowledge among health sciences students: a cross-sectional study. BMC Res Notes. 2015;8:592. doi:10.1186/s13104-015-1585-y
4. McCulloch K. PowerPoint Example – Live Presentation. Presented at the: PHYT 854 – Voicethread; March 12, 2010