Evaluation of physiologic pain knowledge by physiotherapy students

BACKGROUND AND OBJECTIVES: Pain is a severe world health problem, making its management a challenge for health professionals. The study of pain has been superficially addressed during health professionals’ qualification, reflecting in ineffective clinical practices. This study aimed at evaluating the level of neurophysiologic pain knowledge of physiotherapy students after using active teaching-learning strategies to address the subject. METHODS: This was an uncontrolled experimental study with 14 students of the fifth period of the Physiotherapy course. During the school year, pain neurophysiology teaching was based on active teaching-learning strategies, focused on problems and practical application of possible solutions by students. Neurophysiologic Pain Questionnaire was used to evaluate pain neurophysiology knowledge before and after the discipline. RESULTS: There has been significant improvement (p=0.002) in the number of right answers to the Neurophysiologic Pain Questionnaire at intervention completion as compared to baseline evaluation. CONCLUSION: Physiotherapy students have improved their knowledge about pain neurophysiology with the use of active teaching-learning strategies.


INTRODUCTION
Pain may be considered a major health problem, representing 70% of emergency assistance and one third of medical consultations 1 .Musculoskeletal disorders (MSD) correspond to approximately 80% of outpatient physiotherapeutic services consultations being pain the most prevalent complaint 2 .MSD is the second most common condition contributing for years lived with incapacity, being second only to mental and behavioral disorders.Among musculoskeletal disorders, lumbar and cervical pain are the second and the fourth, respectively 3 .Chronic pain is classified as pain persisting beyond normal tissue healing time, lasting more than three months and without apparent biological value 1 .Considered a worldwide public health problem, chronic pain affects approximately 60 million people, corresponding to 10% of the world population 4,5 .Scarce knowledge about pain mechanisms, as well as its inadequate management, may generate major human resources Rev Dor.São Paulo, 2016 jan-mar;17 (1): 29-33   ORIGINAL ARTICLE DOI 10.5935/1806-0013.20160008costs for patients, their families and society 6 .The understanding of biological, social and psychological factors involved in pain evaluation and management should be acquired during health graduation programs 7 .However, deficits in the construction of knowledge they have been observed in the formation of health professionals [7][8][9] .Once graduated, such professionals consider themselves unprepared to assist patients with persistent pain and attribute this to the period of professional qualification 9,10 .The teaching of pain for health professionals in all qualification levels has been identified as an important measure to change ineffective pain management practices.However, most educational programs, especially for graduation students, include minimum or no content about pain and/or its management 11,12 .Aiming at minimizing the lack of knowledge about pain (acute, chronic or cancer-related) among health professionals, the International Association for the Study of Pain (IASP) has established since 1994 curriculum recommendations for different health courses, among them physiotherapy.The curriculum highlights four components to measure biological and psychosocial factors contributing to pain, dysfunction and incapacity: 1) multidimensional nature of pain (mechanisms and basic concepts); 2) pain evaluation and measurement; 3) pain management (rehabilitation and interdisciplinary management); and 4) clinical conditions (commonly treated clinical conditions) 13 .Notwithstanding IASP recommendations, few courses in the health area have an exclusive discipline for education on pain, rather addressing this content along other disciplines 14,15 .In Brazil, there is a proposal to include a "Minimum program on Pain mechanisms and Analgesia" as independent discipline 16 , however there are no studies evaluating the implementation of such program.In addition to this gap in health professionals qualification aimed at understanding pain, there is also a deficit in the use of pedagogic methodologies encouraging the active knowledge building by students, as well as the incentive to health education proposals giving priority to pain prevention and management by patients.In this context, in light of the professional qualification deficit about pain and the major relevance of the subject, it is necessary that health students and professionals have advanced knowledge about pain concepts, mechanisms, evaluation, quantification and management.This study aimed at evaluating the level of neurophysiologic knowledge of pain of physiotherapy students using active teaching-learning strategies to address the subject.

METHODS
This is an experimental, uncontrolled study carried out with a convenience sample of 14 students of the fifth period of a physiotherapy course.Exclusion criteria were individuals not participating in the activities proposed by the discipline.All participants have signed the Free and Informed Consent Term (FICT).
Neurophysiologic Pain Questionnaire (NPQ) was used to evaluate knowledge about pain neurophysiology before and after attending the fifth period of physiotherapy.NPQ is a self-applied tool, originally developed with 19 items to evaluate knowledge related to pain neurophysiology, where each item has three options of answer: true, false or not sure.After evaluating NPQ psychometric properties, it was observed that just 12 items are needed to reach the same results of the original questionnaire 17 .Final result is described in absolute and relative values of correctly answered items.The reviewed questionnaire, made up of 12 items, was adapted to the Portuguese language and answered by students of the discipline.Scores equal to or above 65% of NPQ right answers, in 90% of participants, were considered satisfactory to evaluate the acquisition of neurophysiologic pain knowledge 18 .During one semester, there have been 12 formative meetings among students and professors, where active teachinglearning strategies were used aimed at providing knowledge building about pain neurophysiology.Before and after such meetings, students have answered the NPQ.The number of right answers was compared for both evaluation moments.Students learning about pain neurophysiology was based on active teaching-learning strategies, which have led students to reflection and afterward to practical application of possible solutions.In such strategies, two active education elements were stressed, professor-facilitator and students as protagonists in knowledge building.Professors have the role of facilitators, favoring students' autonomy in the learning process, while students are the active part of the process, which helps them to become reflexive, creative and independent professionals in the future 18 .Within active learning approach carried out by students, different teaching-learning strategies were adopted to build knowledge about pain neurophysiology, namely: a) Text study -activity characterized by critical text study and active search for information and ideas of the studied author 19 .In our case, it was the reading and discussion of the book "Explaining Pain" 20 .This book has a wide variety of educative interventions aiming at changing the understanding of people about pain and its function, promoting pain neurophysiology knowledge, pain rehabilitation based on biopsychosocial model, in addition to decreasing kinesiophobia and pain catastrophizing 21 .b) Role play -characterized by theatrical performance as from a subject or problem focus.In this study, this was implemented by means of appreciation and then dubbing by students of the video "Understanding pain in five minutes" (available at https://www.youtube.com/watch?v=Y2kNiHHFYh0) 22 .c) Directed study -the act of studying under professor guidance, aiming at answering specific questions.This study was carried out by means of research and discussion of articles about "Education on pain" and their approaches, being emphasized Cognitive Behavioral Therapy (CBT) and the use of metaphors.CBT values the act of establishing goals, of making choices, of acting and of having control over reality 23 , being observed good results in the management of chronic pain patients 24 .The use of metaphors and histories during pain education techniques is effective for presenting complex information in a simple way and with everyday elements 25 .d) Strategies of Health Education -students as protagonists, in the role of professor/facilitator of the teaching process for users of the Single Health System (SUS).This strategy consisted of two meetings lasting approximately 60 minutes each, being held in consecutive weeks, and having as target audience musculoskeletal patients of the Hospital Universitário Gaffrée e Guinle and of the Instituto de Neurologia Deolindo Couto.Meetings consisted of presentations and chats about health education, recommending actions for health education and promotion.Meetings were developed, prepared and presented by students.During health education meetings, emphasis was given to pain, its neurophysiology, pain-related psychosocial risk factors, benefits and ideal intensity of physical exercises and guidance about improving quality of life.Presentations were made in a playful manner, using visual resources of slides presentation, animated videos, drawings and metaphors.

Statistical analysis
Data were stored in electronic file using the program Excel and were processed with the Statistical Package for the Social Sciences (SPSS).Success rate of each student and of each NPQ question were calculated and statistical analysis was applied to each one of them.Results are presented in percentages, as well as mean and standard deviation.For being a single population evaluated in two different moments, we decided to use paired Student t test due to the parametric nature of data distribution.Scores before and after evaluation of results were compared, considering statistically significant less than 5% p<0.05.This study was carried out according to guidelines of Resolution 466-12, of the National Health Council, in compliance with the Declaration of Helsinki of 1975 and was approved by the Research Ethics Committee, Instituto Federal do Rio de Janeiro, under CAAE number 47161015.7.0000.5268.

RESULTS
All students (n=14) have participated in proposed activities and have answered the questionnaire, with no losses during the study.Figure 1 shows distribution of scores obtained by students in the NPQ in evaluation moments.At baseline evaluation, students have answered correctly in average 7.5 (SD=4.8)items of the questionnaire, representing 62.5% of success.Just 21.4% of students had scores above 65% of right answers, showing a dissatisfactory level of knowledge about pain neurophysiology in the beginning of the study.In the final assessment, the average of the items was 10.8 (SD=3.7)representing 90% right answers.Scores above 65% of right answers were observed in 90% of students.There has been statistically significant difference (p=0.002) between students' scores before and after attending the discipline (Figure 2).
Table 1 shows absolute and percentage values of the number of right answers per item.Four items (3, 7, 11 and 12), had high initial success rate, above 85%, while seven items (1, 2, 4, 5, 6, 8 and 9) had success rate below 60%.Items 1, 5, 7, 10, 11 and 12 of the questionnaire, after intervention, had success rate above 85%.Success rate before and after intervention was higher for items 1, 4, 5 and 9, while items 3 and 7 had a slight decrease in success rate.

DISCUSSION
Pedagogic teaching-learning strategies used to build neurophysiologic pain knowledge of physiotherapy students were successful as shown by the higher number of right answers for most items of the questionnaire applied at the end of the discipline.At baseline evaluation, students had a low level of neurophysiologic pain knowledge.After intervention there has been improvement in scores being reached moderate scores on pain knowledge.Most students (79%) have improved their neurophysiologic pain knowledge with strategies used along the period.From 12 evaluated items, nine items had a higher number of right answers at final evaluation.Baseline evaluation of pain neurophysiologic knowledge has shown a superficial knowledge of students about the subject.Alves et al. 9 have investigated pain physiology and management knowledge of physiotherapy students with a 27-question questionnaire.Questions were divided in groups addressing different characteristics, such as pain pathophysiology, pain subjectivity and evaluation, physiotherapeutic resources to control pain, non pharmacological and pharmacological therapy to control pain.Low success rates were observed both for pain pathophysiology and multidimensionality and therapy.These findings are in line with our study which has shown lack of knowledge about the relationship between pain intensity and injury severity, in addition to lack of understanding of pain triggering and maintaining mechanisms on part of students.Results might be justified by the way in which pain is addressed during graduation, being seen as a complementary concept for different disciplines rather than a central subject 14 .
The set of strategies used in the discipline has provided expressive improvement of neurophysiologic pain knowledge in our study.Latimer, Maher and Refshauge 26 , using the Health Care Providers Pain and Impairment Relationship Scale questionnaire (HC-PAIRS), have also observed improved chronic pain knowledge through the change in beliefs and attitudes of physiotherapy students after the holding of a chronic pain teaching module, being observed a lower association by students between pain and functional incapacity or limitation.The effect of education could be perceived immediately after the module and one year after it.Students beliefs about pain may be influenced by professors' beliefs, especially those conducting the clinical practice, and by social representations built throughout life.Educative approaches, promoting adequate knowledge about pain physiology and its management, should be provided not only to students, but also to professors and to the clinical team 26 , since learning is associated to education institutions, to professorsfacilitators and to professional models with which they interact.
A study by Ferreira et al. 27 has evaluated beliefs and attitudes of physiotherapy students with regard to chronic low back pain using the HC-PAIRS questionnaire.Authors have identified the belief that pain justifies functional incapacity and limitation of these patients.Results found by the authors may be justified by the low level of knowledge about pain neurophysiology, as observed in our study before attending the discipline.Deficiencies on basic knowledge about pain were also observed among medical students 28 , young anesthesiologists 29 and nursing students 30 .
Students with high scores in the test about pain management had positive attitudes to manage pain 30 .So, it is believed that beliefs and attitudes may be changed after the building of knowledge based on a biopsychosocial model 31 or after a chronic pain course 26 .These findings confirm our study results, which have observed increased knowledge about pain neurophysiology after attending a discipline addressing the subject.Physiotherapists' beliefs and attitudes are also able to influence the prognosis of patients with chronic pain, due to long interaction times during treatment 32 .This way, adequate knowledge of neurophysiologic pain mechanisms may favor the use of a broader evaluation of chronic pain patients, providing a humanized approach and, as a consequence, a more favorable prognosis.The use of active teaching-learning strategies in the discipline, as well as the problem-based methodology, may favor the qualification of independent students able to reflect about the process and to develop adequate skills to apply this knowledge 33 .As from this experience, it was possible to observe positive results in knowledge building about pain neurophysiology among students of the fifth period of the Physiotherapy course.So, it is necessary to think about curriculum changes to implement basic disciplines and differentiated pedagogic strategies aiming at improving the understanding of pain physiology and management 34,35 .Limitations of our study were the small number of participants (n=14) and the lack of a control group.These limitations may restrict the generalization of our study results.However, other previous studies have observed similar results about physiologic pain knowledge among health area students.Improved knowledge building after the implementation of an active teaching-learning process has also been observed.Our study may indicate the need for the implementation of new strategies to favor the learning of chronic pain mechanisms and management of Brazilian physiotherapists, in order to improve the quality of assistance to chronic pain patients.

CONCLUSION
The level of neurophysiologic pain knowledge of Physiotherapy students was enhanced by disciplines specifically addressing contents about pain.Active teaching-learning strategies were able to favor this knowledge building.

Figure 1 .
Figure 1.Success rate of students observed before and after attending the discipline

Figure 2 .
Figure 2. Boxplot indicating the percentage of right answers by items observed before and after intervention

Table 1 .
Absolute and percentage values of right answers by items observed before and after attending the discipline