An Interprofessional Consensus of Core Competencies for Prelicensure Education in Pain Management: Curriculum Application for Physical Therapy

Background

One hundred million adults in America have chronic pain.² This statistic is greater than the number of individuals affected by diabetes, cancer, and heart disease combined.^2,3 Chronic pain management costs the United States more than $600 billion per year in health care costs and lost wages² and creates major human and economic costs for patients, families, and society.¹ Inadequate treatment or mismanagement of pain can cause delays in healing as well as long-lasting changes to the peripheral and central nervous systems.⁴ The Institute of Medicine published a report on pain in 2011 that highlighted it as a national challenge and recognized the need for a cultural transformation to effectively prevent, assess, treat, and understand pain of all types.² This report addressed the deficit in pain education across all professions and promoted the inclusion of standardized information about pain within an “interprofessional setting.”² Specific to physical therapy, a faculty survey of accredited physical therapist education programs in North America revealed 4 hours of pain education as the most frequently reported in the curricula.⁵ Those findings are contrasted with a study of Canadian health sciences programs wherein the 7 physical therapy programs responding reported a mean of 41 hours in pain education.⁶

Over the last several decades, the science of pain has made significant advances in both basic science and clinical science domains.^7–12 For example, the plasticity in the nociceptive system both at the peripheral nociceptor level—termed peripheral sensitization—and in the central nociceptive pathways—termed central sensitization—is commonly recognized by pain researchers and clinical pain specialists.^11,13–15 It is also commonly recognized by researchers and pain clinicians that people with chronic pain have enhanced peripheral and central excitability and simultaneously have reduced central pain inhibition.^14,15 Furthermore, the influence of psychosocial factors on the pain experience has been extensively documented in a variety of painful conditions.^{12,13,16–18} As an example, it has become increasingly clear that pain catastrophizing is a predictor of poor outcomes and that fear of movement limits participation in daily activities and exercise.^12,19–22

Expert pain clinicians support a mechanism-based treatment approach to pain that would focus on the underlying nociceptive plasticity peripherally or centrally and further address psychosocial factors that enhance the pain experience.^15,23,24 Those individuals with high pain catastrophizing or depression prior to treatment, including both those with acute pain (<3 months' duration) and those with chronic pain (>12 months' duration), did not show improvements and had elevated levels of disability following physical therapy interventions.²⁴ Pain clinicians and the International Association for the Study of Pain (IASP) define several different pain conditions: (1) nociceptive pain arises from actual or threatened damage to non-neural tissue and is due to activation of nociceptors, (2) neuropathic pain is caused by a lesion or disease of the somatosensory nervous system, and (3) pain of unknown origin persists in the absence of tissue injury or is out of proportion to the initial insult and is thought to have enhanced central excitability, loss of central inhibition, or both.^22,25 Understanding these constructs would assist physical therapists in clinical decision making.

Currently, most physical therapist education programs do not directly address pain science but rather teach management of diseases from a biomechanical approach to the joint or site in question. For example, clinical orthopedic classes are often organized around specific body areas such as the shoulder, knee, or back and address specific tests, manual therapies, and exercises for that particular area. However, patients generally seek medical help, including physical therapy, because of the pain, and nearly all patients have alterations in nociceptive processing and confounding psychosocial factors that need to be addressed. A better understanding of the underlying mechanisms, psychosocial constructs, and effective therapies for pain management would improve pain management and quality of life and lower health care costs.^26–28

Improving pain education is fundamental for primary care providers, given they play a key role in pain management as the point of entry for most patients.² Physical therapists are often a point of entry to the health care system for many patients^29,30; therefore, adequate pain education will put physical therapists in a unique position to be leaders in the clinical practice of pain management and to facilitate interprofessional pain management health care teams. Physical therapists are increasingly seen as primary care providers, and direct access to physical therapists is a central component of the American Physical Therapy Association's (APTA's) strategic plan, Vision 2020.²⁹

Core Competencies in Pain Management

Core competencies in pain management for prelicensure health professional education were recently established through an interprofessional summit that engaged health care experts.¹ The goal of this summit was to identify core competencies in pain management for prelicensure clinical education that can serve as a foundation for the development of comprehensive pain management curricula across all health professions. The structured process took place in 2 phases. The first phase consisted of an executive committee of 7 experts in pain education. The executive committee synthesized current evidence and existing profession-based competencies and developed a draft set of competencies. The second phase consisted of 29 members representing 10 professions who met in person to recommend a set of consensus-based competencies. A 2-day summit for interprofessional consensus on pain management competencies was held in Sacramento, California, in August 2012. Competencies were reviewed as a group, which was followed by small-group discussions led by the executive committee using the World Café model. The full summit group then reassembled to review and discuss each domain and finalize the competencies. A final draft of domains and competencies was sent for review and refinement in October 2012. Additional background and resources to help integrate the interprofessional pain management competency program are available online (see Appendix 2).

The core competencies in pain management intentionally paralleled the framework of the guidelines for pain education published by the IASP in 2012.³¹ The IASP has established coordinated curriculum guidelines for individual professions, including physical therapy, and an interprofessional curriculum guideline³² (Appendix 2). The curriculum guidelines are outlined around the following content areas: multidimensional nature of pain, pain assessment and measurement, management of pain, and clinical conditions. Furthermore, the interprofessional core competencies summit included key individuals involved in the development of the IASP curriculum guidelines.

The newly established core competencies in pain management facilitate the development of a cohesive and comprehensive foundation for educational programs that can be readily shared among health care teams. When all health care professionals have the same basic expected foundation of pain education, they will be able to improve their practice within their respective disciplines. For example, ensuring that all health care practitioners understand the concept of central sensitization and its impact on chronic pain is likely to expedite clinical decision making. If a patient with chronic pain with central sensitization is prescribed a centrally acting medication, the physical therapists will understand the rationale and impact of this medication on the chronic pain condition. This information includes potential side effects and the impact on nonpharmacological pain approaches implemented by the physical therapist. Ultimately, establishing core competencies for pain education will improve clinical outcomes, regardless of the profession. In support, it has been shown that education of physical therapists in psychosocial risk factors and pain reduced disability for those with the highest risk compared with physical therapists who did not receive the education.^33,34 Each profession will contribute its expertise to the 4 domains with the focus of treating the patient in pain.

Description of Each Domain and Relation to Physical Therapy

Although the core competencies apply to prelicensure health professional education across all health professions, the authors explicitly state that they are intended to be flexible and moldable to each profession and each school or curriculum or learning experience that seeks to meet the core competencies as a minimal expected outcome.¹ They may be used as a guide for physical therapist educators to evaluate and advance pain education based on the specialized role and needs of the physical therapist student.

Core Values and Physical Therapy

Embedded within each of the 4 domains are core values that parallel the principal values of physical therapy such as advocacy, collaboration, compassion, effective communication, and evidence-based practice (Appendix 3). Throughout their education, physical therapy students learn to demonstrate patient advocacy and communicate respectfully in a therapeutic manner with patients, which clearly improve patient satisfaction and outcomes.^49,50 Physical therapists are ideally suited to provide patient education given that it is central to their role and the nature of their involvement with patients and caregivers when providing physical therapy through an episode of care.⁵⁴ It is critical, therefore, that physical therapists understand the nature of acute and chronic pain with the latest science. Physical therapists also exhibit the ability to coordinate the interventions recommended in the individualized care plan using evidence-based practice.⁵³ Thus, physical therapy students must learn to communicate the latest science underlying pain and its management, communicate in a professional manner, work well with various members of the interprofessional health care team, and understand the roles of other members of the health care team in managing patients' pain.

Integration of Competencies Into a Physical Therapist Curriculum

Pain science, assessment, and management are multidimensional constructs that affect nearly all aspects of patient care and should be a thread throughout the curriculum. A stand-alone course on pain and its management, as an addition to pain management concepts threaded throughout the curriculum, can emphasize detailed pain science, psychosocial barriers to patient management, and the importance of interdisciplinary pain management strategies. Finally, there are challenges that physical therapy educators must overcome to incorporate pain science and management throughout the curriculum and in using competency-based education to fulfill this goal. Incentives will need to be built in throughout all levels of the discipline to emphasize pain management as an important construct in physical therapy.

Competency-based education emphasizes a specified level of performance based on a student's knowledge, skills, and attitude.^81,82 The application of these competencies would ensure that physical therapist students effectively perform and demonstrate skills to reduce pain, improve function and quality of life, and reduce comorbidities and costs related to unrelieved pain. The pain management domains and core competencies are meant to be used as a guide and applied to learning activities in the physical therapy prelicensure curriculum and incorporated into outcome assessment. These learning activities include, but are not limited to, didactic approaches, practical examinations, case-based learning opportunities, and simulation or standardized patient encounters throughout the span of physical therapist education.

To instill the importance of pain management to the profession of physical therapy, pain education should occur early and often. The relatively recent endorsement and integration of the International Classification of Functioning, Disability and Health (ICF) model from the World Health Organization⁸³ as a foundational model into the education of physical therapists can facilitate the infusion of education about pain throughout a curriculum. Pain within the ICF model is represented as an impairment that influences and is influenced by activity limitations and participation restrictions, as well as environmental and personal factors.⁸³ Therefore, the relevance of virtually all of the pain management domains and core competencies related to health, at both the level of the individual and society, can be explicitly linked to the ICF to facilitate students' learning about pain sciences, assessment, and management as an integral component to the practice of physical therapy consistent with a biopsychosocial approach to health care.

In addition, learning about pain assessment and management within a larger framework of clinical reasoning about pain can facilitate the integration of pain education throughout the curriculum, with clinical reasoning about pain serving as part of the early scaffolding upon which students learn to reason through patient presentations in all practice settings. One example is the research-derived model of clinical reasoning strategies proposed by Edwards and colleagues,⁸⁴ which emphasizes reasoning that focuses on the interplay between quantitatively and qualitatively assessed aspects of patients' presentations in the clinical reasoning of expert physical therapists, consistent with a biopsychosocial approach. When applied to the assessment and management of patients with pain, it is one example of a clinical reasoning model that can explicitly highlight the development of an understanding of patients' pain experiences that includes both more traditional quantitative assessment and measurement of the pain impairment itself, integrated within a larger, more qualitative understanding of how an individual's pain experience is influenced by and exerts influence on the relevant personal and environmental factors involved. Developing an understanding of a patient's story or narrative has been shown to be a hallmark of effective, collaborative clinical reasoning that results in the development of an individualized patient-centered plan of care.⁸⁴ When comparing this approach to clinical reasoning with the biopsychosocial framework represented in the pain core competencies, it is reasonable to conclude that an approach to clinical reasoning that integrates quantitative and qualitative reasoning is necessary.^85,86

Pain assessment is generally one of the first pain concepts introduced in courses such as introduction to physical therapy, principles of physical therapist practice, and tests and measures. It would be important at this stage to start highlighting how to assess pain from a multidimensional perspective beyond the use of numeric rating scales (eg, verbal analog scale, visual analog scale). Incorporation of assessments and the impact of pain on function and quality of life, as assessed through the Brief Pain Inventory or the SF-36, are directly applicable to designing appropriate treatment plans.³⁶ The physical therapist curriculum is generally aligned around several practice domains: orthopedics, neurology, integumentary, and cardiopulmonary.⁵⁴ Because the majority of people in each of these practice domains have pain, acute and chronic, it is important to meet the core competencies and incorporate the IASP curriculum guidelines into these courses. Table 1 describes several examples to further illustrate ways in which pain education can be intentionally and explicitly woven into a curriculum through a series of patient/client management courses.

Most physical therapist education programs integrate pain directly into their existing curriculum. A stand-alone pain management course can supplement the integration of pain education throughout the curriculum to emphasize the underlying science of pain; the complex biological and psychosocial effects of pain; the impact of pain on the patient, family, and society; and the interprofessional management of pain.³² An example of a stand-alone pain course in the physical therapist curriculum would include an emphasis on the science of pain, in-depth assessment, empathetic and therapeutic communication, pain management strategies, and the interdisciplinary nature of pain management (Tab. 2). Alternatively, given the importance of interprofessional care that is integral to these competencies (see domain 4 in Appendix 1), interprofessional learning experiences could be an ideal way to meet the competencies. These learning experiences might include courses in which physical therapist students are educated with physicians, nurses, psychologists, pharmacists, and social workers.⁸⁷ Another approach could be a case-based learning or assessment approach in which pain is a key feature of the case.^88–90 That model could serve as an effective approach for learning effective, evidence-based pain management during clinical learning experiences. Much of the understanding of pain science, assessment, and management principles is not specific to a particular profession but rather spans professions. If all health professions understand and manage pain from the same multidimensional perspective, and if all health professions understand specific roles of each profession in pain management, greater success in the management of pain should occur.

There are significant challenges for incorporating learning activities focused on pain competencies into physical therapist education either within an existing program or through an interprofessional curriculum. These challenges include the amount of time necessary to educate about pain in the curriculum and research that is needed so that evidence-based practice is standard in the curriculum. Education within a physical therapist curriculum generally spans the 4 key systems important in physical therapist practice (ie, musculoskeletal, neuromuscular, cardiopulmonary, and integumentary) and other systems (eg, renal, immune).

Given that pain can be an impairment that influences activity and participation in any of these systems, it is important that there be a thoughtful consideration of how pain is addressed throughout the curriculum.^54,56 Although integration into an existing curriculum is likely the easiest way to address the pain competencies, there may be a lack of expertise within the existing faculty. Implementation may require education of existing faculty in pain science and management, designation of one faculty person with content expertise to coordinate the curricular pain management thread with faculty responsible for the various patient client management courses across all practice domains, hiring new faculty to address the core competencies, or using existing resources to supplement current curriculum. As online courses are developed, it may be possible to adequately address the competencies through these materials. Interprofessional education poses additional and specific challenges, including extra financial resources, communication and scheduling among programs, and buy-in from administration and faculty across colleges within a university setting. Finally, not all of the competencies are evidence based to guide teaching and application. For example, evidence is lacking for the management of acute-on-chronic conditions (domain 3, competency 7). If someone has a total knee replacement, physical therapy rehabilitation tends to be similar regardless of whether the person also has a chronic pain condition such as fibromyalgia. This issue extends to other professions. Surgical protocols, including postsurgical medications, have a tendency to be similar whether or not chronic pain is in the medical history. Thus, the application of the competencies into curricula will continue to evolve as evidence-based practice advances to meet the growing demands for appropriately trained health care providers.

To help guarantee the adoption of the core competencies on pain management into a physical therapist curriculum, additional incentives may be required. Competencies are aligned, measured, and incentivized in health care education to meet the needs of society.⁸² These authors asserted that accreditation bodies, and by extension the health professions education institutions they accredit, are accountable to society to ensure that priority health needs of society are being met.⁸² For physical therapy, the accrediting agency is the Commission on Accreditation in Physical Therapy Education (CAPTE). One criterion CAPTE uses as a foundation for the Evaluative Criteria for Physical Therapy Programs⁵⁶ is the contemporary practice of physical therapy that is grounded in the current literature. Physical therapists frequently treat people with pain problems in their practices, yet the current evaluative criteria explicitly mention “pain” only in relation to curriculum content on patient examination. Therefore, contemporary entry-level physical therapist curriculum plans should include these core competencies in pain management. Current trends in accreditation toward assessment of student learning outcomes and, increasingly, toward competency-based approaches may provide incentives to ensure competencies, such as the core competencies in pain management, as integral components of entry-level physical therapy education.

The National Physical Therapy Examination (NPTE) is based on an analysis of practice, most recently conducted in 2011,⁹¹ and assesses minimum standards for safe and effective practice. In the prior analysis, “pain” was directly assessed under evaluation and diagnosis. Thus, the incorporation of these pain competencies in the NPTE will occur only to the extent these competencies are reflected in a practice analysis itself, making it difficult for physical therapist education programs to rely on the NPTE to provide a significant incentive to curricular change that would include these competencies. The American Council of Academic Physical Therapy,⁹² the component of APTA representing the entry-level physical therapist education programs, could endorse the competencies and thus provide an imprimatur for their adoption within physical therapist education.

Moreover, these competencies are applicable beyond prelicensure education because they represent the critical content for pain science, assessment, and management. All health professionals, including physical therapists, should be competent within the 4 domains because of the prevalence of pain in patients seeking physical therapy.^2,3 In addition, physical therapists need to be current with pain knowledge to remain experts on the pain management team and, as clinical instructors to physical therapist students and in mentoring new graduates, must be prepared to reinforce and extend students' learning from the academic setting related to up-to-date pain management information. Inclusion into postlicensure education may include continuing education opportunities, licensure renewal, and possibly certificate programs. Pervasive adoption may necessitate requirement for core competency in pain management by accreditors of prelicensure physical therapy schools as well as postgraduate or continuing education programs.