https://orcid.org/0000-0003-4900-4822
The Pain Education Evolution
Pain is one of the most common symptoms encountered by physical therapists and can be one of the most challenging to address in clinical practice. Our understanding of pain continues to evolve as new evidence shapes our understanding of this significant health care issue. Historically, physical therapists have viewed pain primarily from the biomedical model in which pain is a symptom of tissue damage. This understanding of pain was highlighted in the Institute of Medicines Report1 “Relieving Pain in America,” stating that a major barrier to adequate pain relief was patients’ limited access to clinicians who are knowledgeable about pain due to the prevalence of outmoded or unscientific knowledge and attitudes about pain. Our understanding has evolved to a biopsychosocial model of pain that recognizes neuroplasticity of nociceptive pathways that may occur in individuals with chronic pain.2 Further, when these changes are maladaptive, interventions should target these aberrant mechanisms. Along with these pain advancements, the profession of physical therapy has progressed to a mechanisms-based approach that incorporates psychosocial and sensory/motor function that occurs within different classifications of pain.3 Therefore, to meet the needs of society, entry-level (professional) doctorate of physical therapy (DPT) programs must educate students on the physiology, psychosocial dimensions, assessment, and treatment strategies associated with pain.
Although pain has been taught since the beginnings of physical therapist professional education, our understanding of pain has dramatically changed over time, requiring faculty to reflect these changes in DPT curricula. For instance, the International Association for the Study of Pain (IASP) updated the definition of pain in 2021.2 With this definition change, pain researchers Sluka and George2 charged physical therapists to embrace pain as a personal experience that is influenced by biological, psychological, and social factors; recognize pain and nociception as different constructs; and acknowledge that pain is influenced by prior life experiences; clinicians should respect a person’s pain experience and its effect on well-being. However, before this call to action, the IASP created international curricular guidelines for the implementation of modern pain education, including physical therapist professional education programs.4 In 2013, Fishman and colleagues5 developed core competencies for pain education with the creation of an interprofessional committee representing 10 professions. Bement et al6 followed with the application of these core competencies to physical therapist curricula.
As momentum for the international curricular guidelines and core competencies for pain grew, the American Physical Therapy Association's (APTA) House of Delegates passed a motion (RC-43-18) in 2018 to endorse and integrate curricular guidelines for pain education established by the IASP. Over the past several years, it has become clear that certain standards surrounding pain are needed within our physical therapist professional education programs. The problem has been known for over a decade, the guidelines, competencies, and information are present, but are programs implementing the best available evidence regarding pain within their program walls? The aim of this commentary is to highlight the current state of physical therapist pain education and provide recommendations on how to continue the momentum of implementing modern pain education into physical therapist professional curricula.
The State of Pain Education in Physical Therapy
Despite the clear role physical therapists play in treating those in pain and the mounting availability of educational resources, there is evidence showing varying pain content in physical therapist professional education programs. In 2015, Bement and colleagues7 reported that physical therapist education programs spent an average of 31 contact hours covering pain content; however, the reported contact hours ranged from 5 to 115 hours. Of the programs included in the study, only 6% of programs had a course focused on pain, and less than one-half were aware of the IASP pain curricular guidelines.7 Given these findings, 61% of respondents from the Bement study believed their students received adequate pain education; however, the treatment of pain continues to be a struggle for practicing clinicians. During the 2016 John H.P. Maley Lecture, Dr Steven George urged educators to increase the amount of time dedicated to modern pain education.8 Although progress has been made since these articles have been published, significant work remains to be done to meet the needs of society.
One would assume that there are clear curricular elements delineated in physical therapist education program accreditation standards; however, this is not the case. The Commission on Accreditation in Physical Therapy Education (CAPTE)9 addresses pain in standard 7D, specifically 7D19, an element related to administering tests and measures within physical therapist practice. Due to this broad CAPTE element, DPT programs are left to determine how to optimally ensure that graduates are knowledgeable and competent in the area of pain assessment.
Another CAPTE standard, standard 7A, sets forth curricular requirements related to “anatomy, physiology, genetics, exercise science, biomechanics, kinesiology, neuroscience, pathology, pharmacology, diagnostic imaging, histology, nutrition, and psychosocial aspects of health and disability.”9,(p28) Although treating pain requires “the integration of many of these content areas, the CAPTE Standards are silent on pain science and how these basic and clinical science content areas might be integrated to understand pain science.”10(p9) Furthermore, although there are a number of possible interventions described in element 7D27 that may potentially be used to treat those in pain, interventions explicitly designed to treat pain are not clearly addressed or linked in the CAPTE standards.
Although physical therapist education programs look to CAPTE as the accrediting body for their programs, they are also influenced by the Federation of State Boards of Physical Therapy (FSBPT). The FSBPT creates the National Physical Therapy Examination (NPTE) that students graduating from physical therapist education programs must pass to achieve licensure. Unfortunately, the NPTE content areas are also silent on pain. The NPTE content guideline document indicates that pain is a component of the “Systems Interactions” section, which in total accounts for ≤6% of the NPTE-PT content questions.11 Test questions for the NPTE fit into a blueprint for the various body systems and non-system areas, and currently the word “pain” does not show up in this blueprint. Although this does not exclude questions specifically related to pain from being included in the NPTE, it does not provide an explicit directive that questions specifically related to pain must be present. This potentially creates a gap in assessing if the examinee has adequate entry-level knowledge required to provide safe and effective pain care.
The Pain Education Landscape Is Changing but Not Without Challenges
Prior to and with the passing of the House of Delegates motion endorsing the IASP guidelines, some “early adopter” physical therapist education programs have forged ahead in implementing modern pain education successfully within their programs despite the lack of CAPTE guidelines. Some programs have adopted stand-alone course work, and others have utilized a threaded content approach within existing course work. Both have been shown to be effective delivery methods.12,13 As more programs continue to adopt and implement modern pain education into their curriculums, it should help push to increase the majority.
With the addition of any new curricular content, concern over curricular creep is ever present. Currently it seems that physical therapist education programs are being bombarded with new curricular requirements that are beyond pain (eg, nutrition, sleep, imaging). Program faculty and administrators alike may be asking themselves what content needs to be removed to make room for the necessary education on pain; however, some programs have already successfully added pain content with limited to no curricular expansion. A key component of doing this is through integration into existing course work and updating content with attention to a pain mechanisms/biopsychosocial framework. For example, replacing older pain models (eg, gate theory) with updated clinically applicable models (eg, pain neuromatrix theory) may be an easy first step. When critically reviewing current pain content delivery, one may recognize that implementing modern pain education is less about adding in more information and more about refining, linking, or scaffolding what is currently being taught. The key element is that faculty across the curriculum collaborate and intentionally map where modern pain content is delivered.
Solutions to Empower Physical Therapist Professional Education Programs to Deliver Modern Pain Content
With the evolution of our understanding of pain and the current state of pain education, there are several solutions that we feel will improve the delivery of pain content in physical therapist professional curricula.
The Pain Education Manual
The Pain Education Manual (PEM)10 was developed by a committee of pain specialist clinicians, researchers, and academicians from the Pain Special Interest Group of the Academy of Orthopaedic Physical Therapy (AOPT), with input from representatives from other academies and sections, with the primary goal being to provide information to support faculty in curriculum planning, development, and academic and clinical teaching related to addressing acute and persistent pain. The PEM establishes 8 didactic and clinical curricular dimensions (Fig. 1) based on the IASP curricular guidelines and provides sample course objectives, suggested readings, lecture material, and formative and summative learning activities. The IASP curricular competencies guide global teaching of modern pain content; however, IASP understands there can be considerable variation in academic structure, practice settings, and scope existing from country to country. For this reason, the PEM provides very specific information for the implementation of pain education into the United States’ DPT programs that the IASP guidelines were not intended to provide. Similar work is being done in other countries as well.14
The Pain Education Manual10 establishes 8 didactic and clinical curricular dimensions based on the International Association for the Study of Pain4 curricular guidelines. PT = physical therapist. Reprinted with permission from Shepherd M, Courtney C, Wassinger C, Davis SD, Rubine B. Pain Education Manual for Physical Therapist Professional Degree Programs. Academy of Orthopaedic Physical Therapy; 2021.
Suggested Updates to CAPTE Standards and Elements9
| CAPTE Standard and Element | Suggested Updates |
|---|---|
| 7A | • Explicitly include “Pain biology and psychosocial aspects of pain” in topics to be covered. |
| 7C | • Include “Biopsychosocial model of pain” as required content and learning experiences. |
| 7D8 | • Revise to: “Identify, respect, and act with consideration for patients’/clients’ differences, values, preferences, pain experiences, and expressed needs in all professional activities.” |
| 7D19 | • Add “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Quantitative Sensory Testing.” |
| 7D19p | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Neuromotor Development, Sensory Processing, and Laterality.” |
| 7D19u | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Sensory Integrity, Discrimination, and Tactile Acuity.” |
| 7D22 | • Revise to: “Determine a diagnosis, inclusive of pain mechanisms where appropriate, that guides future patient/client management.” |
| 7D27 | • Add “Competently perform physical therapy interventions to achieve patient/client goals and outcomes. Interventions include: Implicit and Explicit Motor Imagery, Sensory Discrimination, Laterality Training, and Mirror Training.” |
| CAPTE Standard and Element | Suggested Updates |
|---|---|
| 7A | • Explicitly include “Pain biology and psychosocial aspects of pain” in topics to be covered. |
| 7C | • Include “Biopsychosocial model of pain” as required content and learning experiences. |
| 7D8 | • Revise to: “Identify, respect, and act with consideration for patients’/clients’ differences, values, preferences, pain experiences, and expressed needs in all professional activities.” |
| 7D19 | • Add “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Quantitative Sensory Testing.” |
| 7D19p | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Neuromotor Development, Sensory Processing, and Laterality.” |
| 7D19u | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Sensory Integrity, Discrimination, and Tactile Acuity.” |
| 7D22 | • Revise to: “Determine a diagnosis, inclusive of pain mechanisms where appropriate, that guides future patient/client management.” |
| 7D27 | • Add “Competently perform physical therapy interventions to achieve patient/client goals and outcomes. Interventions include: Implicit and Explicit Motor Imagery, Sensory Discrimination, Laterality Training, and Mirror Training.” |
Suggested Updates to CAPTE Standards and Elements9
| CAPTE Standard and Element | Suggested Updates |
|---|---|
| 7A | • Explicitly include “Pain biology and psychosocial aspects of pain” in topics to be covered. |
| 7C | • Include “Biopsychosocial model of pain” as required content and learning experiences. |
| 7D8 | • Revise to: “Identify, respect, and act with consideration for patients’/clients’ differences, values, preferences, pain experiences, and expressed needs in all professional activities.” |
| 7D19 | • Add “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Quantitative Sensory Testing.” |
| 7D19p | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Neuromotor Development, Sensory Processing, and Laterality.” |
| 7D19u | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Sensory Integrity, Discrimination, and Tactile Acuity.” |
| 7D22 | • Revise to: “Determine a diagnosis, inclusive of pain mechanisms where appropriate, that guides future patient/client management.” |
| 7D27 | • Add “Competently perform physical therapy interventions to achieve patient/client goals and outcomes. Interventions include: Implicit and Explicit Motor Imagery, Sensory Discrimination, Laterality Training, and Mirror Training.” |
| CAPTE Standard and Element | Suggested Updates |
|---|---|
| 7A | • Explicitly include “Pain biology and psychosocial aspects of pain” in topics to be covered. |
| 7C | • Include “Biopsychosocial model of pain” as required content and learning experiences. |
| 7D8 | • Revise to: “Identify, respect, and act with consideration for patients’/clients’ differences, values, preferences, pain experiences, and expressed needs in all professional activities.” |
| 7D19 | • Add “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Quantitative Sensory Testing.” |
| 7D19p | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Neuromotor Development, Sensory Processing, and Laterality.” |
| 7D19u | • Revise to: “Select and competently administer tests and measures appropriate to the patient’s age, diagnosis and health status including, but not limited to those that assess: Sensory Integrity, Discrimination, and Tactile Acuity.” |
| 7D22 | • Revise to: “Determine a diagnosis, inclusive of pain mechanisms where appropriate, that guides future patient/client management.” |
| 7D27 | • Add “Competently perform physical therapy interventions to achieve patient/client goals and outcomes. Interventions include: Implicit and Explicit Motor Imagery, Sensory Discrimination, Laterality Training, and Mirror Training.” |
Action for Change
There are several opportunities for CAPTE to ensure that modern pain content is delivered in DPT curricula and are specified in the Table. Coordination between the AOPT and the American Council of Academic Physical Therapy is currently underway to actively engage with CAPTE. The FSBPT should incorporate pain content into the various body systems detailed in the examination blueprint descriptions, including pain neuroscience, assessment, and treatment of acute and chronic pain. The FSBPT should include the addition of a non-system area dedicated to pain-related content such as the multidimensional nature of pain, pain mechanisms, contributing and predisposing factors to chronic pain, and interdisciplinary care of pain. Finally, a letter from the AOPT with specific suggestions aligning with the PEM was recently submitted for the revision of the “Guide to Physical Therapist Practice.”15
Pain Schools
The goal of the Pain School is to provide evidence-based pain content to DPT educators, essentially a “teach the teacher” course using the PEM to empower DPT faculty and program leadership on how to apply modern pain content. Details about pain schools can be found in Figure 2. The pain school curriculum will build from the PEM and allow professional education faculty opportunities to learn evidence-based pain assessment and treatment strategies and apply this content to drive towards a praxis of learning.16
Details about the goal and purposes of pain schools.
Summary
It is abundantly clear that physical therapists play a vital role in the treatment of pain. However, it is essential that DPT programs deliver content that aligns with a modern-day understanding of pain. The IASP curricular guidelines provided global support for pain content guidelines and the various efforts within our profession hope to better support US DPT programs with this endeavor. With the creation of the PEM and the development of pain schools, it is essential that CAPTE work to better align their standards and that the FSBPT updates their content blueprint to ensure that the programs teaching the next generation of physical therapist clinicians are prepared to address a society in pain.
Author Contributions
Concept/idea/research design: M.H. Shepherd, K. Zimney, M.H. Bement, C. Wassinger, C. Courtney
Writing: M.H. Shepherd, K. Zimney, M.H. Bement, C. Wassinger, C. Courtney
Project management: M.H. Shepherd
Consultation (including review of manuscript before submitting): M.H. Bement, C. Wassinger, C. Courtney
Funding
There are no funders to report for this work.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
References
Commission on Accreditation in Physical Therapy Education.
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