Judith P. Hunter

An Interfaculty Pain Curriculum: Lessons learned from six years experience

Abstract Minimal pain content has been documented in pre‐licensure curricula and students lack important pain knowledge at graduation. To address this problem, we have implemented and evaluated a mandatory Interfaculty Pain Curriculum (IPC) yearly since 2002 for students (N = 817 in 2007) from six Health Science Faculties/Departments. The 20‐h pain curriculum continues to involve students from Dentistry, Medicine, Nursing, Pharmacy, Physical Therapy, and Occupational Therapy as part of their 2nd or 3rd year program. Evaluation methods based on Kirkpatrick’s model now include evaluation of a Comprehensive Pain Management Plan along with the previously used Pain Knowledge and Beliefs Questionnaire (PKPQ) and Daily Content and Process Questionnaires (DCPQ). Important lessons have been learned and subsequent changes made in this iterative curriculum design based on extensive evaluation over the 6‐year period. Modifications have included case development more relevant to the diverse student groups, learning contexts that are uni‐, inter‐, and multi‐professional, and facilitator development in working with interprofessional student groups. PKBQ scores have improved in all years with a statistically significant average change on correct responses from 14% to 17%. The DCPQ responses have also indicated consistently that most students (85–95%) rated highly the patient panel, expert‐lead clinically focused sessions, and small interprofessional groups. Relevancy and organization of the information presented have been generally rated highly from 80.3% to 91.2%. This curriculum continues to be a unique and valuable learning opportunity as we utilize lessons learned from extensive evaluation to move the pain agenda forward with pre‐licensure health science students.

STABILITY OF PHANTOM LIMB PHENOMENA AFTER UPPER LIMB AMPUTATION: A LONGITUDINAL STUDY

Amputees may experience stump pain (SP), phantom limb (PL) sensations, pain, and/or a general awareness of the missing limb. The mechanisms underlying these perceptions could involve nervous system neuroplasticity and be reflected in altered sensory function of the residual limb. Since little is known about the progression of post-amputation sensory phenomena over time, we longitudinally evaluated the stability of, and relationships among: 1) subjective reports of PL sensations, pain, awareness, and SP, 2) stump tactile and tactile spatial acuity thresholds, and 3) use of a functional vs. a cosmetic prosthesis in 11 otherwise healthy individuals with recent unilateral, traumatic upper-extremity amputation. Subjects were evaluated within 6 months and at 1-3 years after amputation. Processing of tactile sensory information from the stump remained stable over the study time period. PL awareness was frequent, stable over time, intense, and occurred with or without PL sensations. Functional prosthetic use correlated with stable vividness of PL awareness whereas subjects who used a cosmetic prosthesis had less vivid PL awareness at follow-up. Initial SP correlated with follow-up SP, the initial PL pain correlated with follow-up PL pain but neither initial nor follow-up SP appear to be related to follow-up PL pain after accounting for initial PL pain intensity. Neither limb temperature nor prosthesis-use correlated with the initial vs. follow-up change in PL pain intensity. These data provide evidence that PL pain described 1-3 years after an amputation is not related in any simple way to peripheral sensory function, SP, or limb temperature; and PL awareness but not PL pain may be influenced by the frequent use of a functional prosthesis.

Pain: putting the whole person at the centre.

In the current climate of patient-centred or client-centred care, it is increasingly important to recognize the unique personal experience of pain. As physical therapy students in the 1970s, the authors frequently wondered why the amount of pain experienced in response to a specific injury did not appear to be uniform among patients. Why did some patients have more post-op pain than others? Why did each person behave so differently in response to pain and injury? Why did some patients develop chronic pain after a shoulder injury or become disabled by back pain, whereas others did not, even though they appeared to have a similar injury? At that time there was no “physiological explanation” for the differences in individual outcomes. In fact, we now know that one of the common misconceptions among health care professionals was that the intensity and quality of pain experienced by each person should directly reflect the type and extent of tissue injury.1 This mistaken belief often led clinicians to dichotomize the mind/body experience of pain, so that the clinical approach focused on isolating and treating tissue injury, with little effort to consider the person experiencing the pain. Individual differences in the pain experience and in observed pain behaviours were often considered—consciously or unconsciously—to be “in the patients head.” Thankfully, pain research has grown exponentially in the last 30 years, and we now understand that pain actually is “in the brain” and that differences in each persons pain experience reflect the individuals unique nervous-system processing, based on a complex integration of genetic,2,3 biopsychomotor,4–6 and social/environmental factors. For example, recent genetic research has identified individual differences in pain tolerance and pain threshold.7 In addition, with the advent of central nervous system imaging, the roles of so-called non-physiological factors in pain processing have actually been visualized in the form of brain activity.

Innovation and Design of a Web-Based Pain Education Interprofessional Resource

INTRODUCTION The present article describes educational innovation processes and design of a web-based pain interprofessional resource for prelicensure health science students in universities across Canada. Operationalization of educational theory in design coupled with formative evaluation of design are discussed, along with strategies that support collaborative innovation. METHODS Educational design was driven by content, theory and evaluation. Pain misbeliefs and teaching points along the continuum from acute to persistent pain were identified. Knowledge-building theory, situated learning, reflection and novel designs for cognitive scaffolding were then employed. Design research principles were incorporated to inform iterative and ongoing design. RESULTS An authentic patient case was constructed, situated in interprofessional complex care to highlight learning objectives related to pre-operative, postoperative and treatment up to one year, for a surgical cancer patient. Pain mechanisms, assessment and management framed content creation. Knowledge building scaffolds were used, which included video simulations, embedded resources, concurrent feedback, practice-based reflective exercises and commentaries. Scaffolds were refined to specifically support knowledge translation. Illustrative commentaries were designed to explicate pain misbeliefs and best practices. Architecture of the resource was mapped; a multimedia, interactive prototype was created. This pain education resource was developed primarily for individual use, with extensions for interprofessional collective discourse. DISCUSSION Translation of curricular content scripts into representation maps supported the collaborative design process by establishing a common visual language. The web-based prototype will be formatively and summatively evaluated to assess pedagogic design, knowledge-translation scaffolds, pain knowledge gains, relevance, feasibility and fidelity of this educational innovation.

A Novel Pain Interprofessional Education Strategy for Trainees: Assessing Impact on Interprofessional Competencies and Pediatric Pain Knowledge

It is well known that pain education in Canadian medical schools needs to be improved, and there have been many initiatives to improve pain education at the preprofessional stage of training. However, the majority of pain education still occurs in a classroom setting. The authors of this article implemented a novel interprofessional education-based teaching strategy in a tertiary care-based setting. This article presents a pilot study of this education model.

Unique influence of stimulus duration and stimulation site (glabrous vs. hairy skin) on the thermal grill-induced percept

The application to the skin of spatially interlaced innocuous warm (40 °C) and cool (20 °C) thermodes (termed a thermal grill – TG) can produce an unusual thermal percept, but the mechanisms remain unclear.

Beyond Learning Management Systems: Designing for Interprofessional Knowledge Building in the Health Sciences

This paper examines theoretical, pedagogical, and technological differences between two technologies that have been used in undergraduate interprofessional health sciences at the University of Toronto. One, a learning management system, WebCT 2.0, supports online coursework. The other, a Knowledge Building environment, Knowledge Forum 2.0, supports the collaborative work of knowledge-creating communities. Seventy students from six health science programs (Dentistry, Medicine, Nursing, Occupational Therapy, Pharmacy and Physical Therapy) participated online in a 5-day initiative to advance understanding of core principles and professional roles in pain assessment and management. Knowledge Forum functioned well as a learning management system but to preserve comparability between the two technologies its full resources were not brought into play. In this paper we examine three distinctive affordances of Knowledge Forum that have implications for health sciences education: (1) supports for Knowledge Building discourse as distinct from standard threaded discourse; (2) integration of sociocognitive functions as distinct from an assortment of separate tools; and (3) resources for multidimensional social and cognitive assessment that go beyond common participation indicators and instructor-designed quizzes and analyses. We argue that these design characteristics have the potential to open educational pathways that traditional learning management systems leave closed.

Outcomes and reflections on a consensus-building workshop for developing a spinal cord injury-related chronic pain research agenda

Context/ Objective: Chronic pain following spinal cord injury (SCI) is a prevalent secondary health condition that significantly impacts quality of life (QoL). Although growing, the number of available effective pain management approaches for SCI is limited. Recognizing the need to “kick-start” activity on this topic, a consensus-building workshop on developing a research agenda for SCI-related chronic pain was held in 2006 with an expert panel. The present paper describes the processes of the consensus-workshop and its associated outcomes towards advancing the research agenda for SCI-related pain in Canada. A commentary on the current state of knowledge regarding SCI-related pain is also provided. Methods: Thirty-nine stakeholders (researchers, clinicians, policy-makers, SCI advocates, and people with SCI) attended the consensus-workshop. A modified Delphi approach was employed to gain consensus on identifying the top five SCI pain research priorities for improving QoL post-SCI. As well, project planning along with infrastructure support opportunities were discussed. Results: The top five pain research priorities were: 1) pain management and treatment; 2) measurement tools; 3) health services policy and advocacy; 4) knowledge transfer; and 5) mechanisms of pain. Recommendations related to the priorities and related resources were generated, and pilot work was initiated. Conclusions: The consensus workshop provided an initial roadmap for research on SCI-related chronic pain, and supported five pilot projects on the identified priorities. Reflections on the current research landscape in Canada and abroad suggest increased activity towards addressing pain post-SCI but evidence-based approaches are still lacking.

Mapping of pain curricula across health professions programs at the University of Toronto

ABSTRACT Background: There is a growing societal need for health professional competency in pain care. The University of Toronto Centre for the Study of Pain–Interfaculty Pain Curriculum (UTCSP-IPC) has been offered since 2002. Content and process have been updated annually. In addition, participating health professions programs have advanced their pain teaching. A curricular scan was needed to creatively and constructively advance the UTCSP-IPC. Aim: The aim of this study was to map curricular pain content in participating health professions programs onto the UTCSP-IPC content as a first step to further curriculum design. Methods: UTCSP-IPC committee members and faculty representatives from six health profession programs completed a 27-item online survey in this collaborative action study. Descriptive statistics were completed in Microsoft Excel. Results: The UTCSP-IPC provided an average of 43.3% (range 32%–62%) of total pain content teaching hours to participating health professions students and a range of 8% to 100% of total opioid-related teaching hours. Curricular overlaps and gaps in pain content were identified and will be used to update and inform the iterative design of the UTCSP-IPC. Ninety-three percent of participating health professions faculty indicated that the interprofessional focus on pain care in the UTCSP-IPC was important. Conclusion: This study highlighted the value of the UTCSP and areas of curricular refinement to ensure continued relevance in relationship to pain content within the six participating health professions programs. Mapping a coordinated approach between uniprofessional and interprofessional teaching will both meet the demands of professional competence and create greater applicability to future practice settings.

The Explain Pain Handbook: Protectometer by G.L. Moseley and D.S. Butler

This is the newest publication from the Neuro Orthopaedic Institute, or Noigroup, and the prolific Lorimer Moseley–David Butler partnership. It is a patient-targeted handbook, fittingly described by one online patient-reviewer as ‘‘quirky—[an] accessible workbook,’’ and an updated and interactive alternative to the previous publication by the same authors, Explain Pain. If you are reading this review, you have likely already heard of the book because it has been well promoted by the successful marketing force that is the Noigroup. As the title describes, the book is meant to be a workbook that allows individuals to better understand their chronic pain and to take action to manage it and move forward successfully. In this manner, the book presents the latest evidence: that the pain experience is individual, is constructed in the brain, and can be changed. As well, the book’s content is supported by consistent evidence that individualized self-management and pain science education are basic to the rehabilitation management of chronic pain. The workbook also follows the principles of adult learning. It presents a series of short, concise, plainlanguage messages, well supported by cartoonlike diagrams, and is interactive. An interactive component of the book is described in its subtitle, Protectometer. It is a diagram on substantial, glossy, foldout paper that is as durable as the cover of a paperback. Readers are instructed to use this diagram as they apply the book’s teaching about understanding pain science to better manage their chronic pain. First, readers work to increase their awareness of the factors that can possibly affect their pain. They are asked to identify and label these factors as ‘‘DIMs—Danger in Me’’ or ‘‘SIMs—Safety in Me.’’ They are instructed that the more DIMS they have, the greater the risk of hitting the pain threshold, and the more SIMS they have, the lower the risk of hitting the pain threshold. An example given of a DIM is a diagnosis such as osteoarthritis of the spine; an example of a SIM is spending time with friends. The diagram guides readers through seven categories of factors to consider in detail, including ‘‘things you do,’’ ‘‘things you think and believe,’’ ‘‘things happening in your body,’’ and ‘‘people in your life.’’ This activity is introduced midway through the book and then used continually, with the teaching goal of integrating pain science into the readers’ understanding of their pain and how they can best manage it, especially with movement and exercise. Thus, the interactive task involves learning how and why to eventually decrease the DIMs and increase the SIMs to successfully self-manage one’s pain. Readers or clients with chronic pain can use the book on their own, but there is potential for clinicians to partner with a client to establish an individualized treatment and education plan. This book follows the quirky nature of the other publications authored by this partnership, which means it will invite an emotional reaction—its language and diagrams will be loved by some and disliked by others depending on their taste and learning style. It successfully avoids medical jargon, thereby making it accessible to the adult reader who is highly proficient in the English language. It is much clearer, more concise, and more applied than the Explain Pain book.