Effectiveness of two educational models on pain neuroscience for physical therapy undergraduate studentsABSTRACT
The adaptation of health professionals to new concepts of pain has become essential as new evidence is found on the subject. Previous studies analyzed the insertion of a single pedagogical strategy without a control group or observed student’s knowledge based on the existing academic curriculum. This study aims to compare the effectiveness of two educational models on pain neuroscience for undergraduate students of a physical therapy course, contributing to the promotion of knowledge and attitudes related to pain. An experimental prospective longitudinal study was conducted, with simple randomization of participants into two groups: classes group and text group. Knowledge was assessed using the Neurophysiology of Pain Questionnaire (NPQ). Quantitative variables were described as mean and standard deviation. Qualitative variables were described by absolute number and frequency (%). Student’s t-test was applied for stratified univariate analyses with a 5% significance level. The classes group participated in expository classes and the text group received informative materials for guided study. The programs lasted five weeks, with follow-up after 30 days of exposure. Comparing the groups in the pre- and post-intervention periods (classes group: mean=4.5, SD±1.94; text group: mean=3.34, SD±1.46), a significant difference favorable to the classes group was found (p<0.001). No significant difference was observed for the times before and 30 days after intervention between groups (p<0.082). The two educational models on pain neuroscience improve the knowledge of undergraduate students of a physical therapy course, and the classes program was more effective than the guided study program.
Keywords
Health Education; Chronic Pain; Musculoskeletal Pain
RESUMO
A adaptação dos profissionais de saúde aos novos conceitos de dor tornou-se fundamental. Os estudos prévios analisaram a inserção de uma única estratégia pedagógica sem um grupo controle ou observaram o conhecimento do aluno mediante a grade curricular acadêmica existente. O objetivo deste estudo foi comparar a efetividade de dois modelos educacionais sobre neurociência da dor em graduandos de um curso de fisioterapia, contribuindo para a promoção do conhecimento e de atitudes relacionados à dor. Foi realizado um estudo experimental, longitudinal prospectivo, com randomização aleatória simples dos participantes em dois grupos: grupo aulas e grupo texto. O conhecimento foi avaliado por meio do questionário neurofisiológico da dor (QND). As variáveis quantitativas foram descritas com a média e o desvio-padrão. As variáveis qualitativas foram descritas por meio do número absoluto e da frequência (%). O teste T foi aplicado para análises univariadas estratificadas com um nível de significância de 5%. O grupo aulas participou de aulas expositivas e o grupo texto recebeu materiais informativos para estudo orientado. Os programas tiveram duração de cinco semanas, com follow-up após 30 dias da exposição. Comparando os grupos nos períodos pré e pós-intervenção (grupo aulas: média=4,5, DP±1,94; e grupo texto: média=3,34, DP±1,46), verificou-se uma diferença significativa favorável ao grupo aulas (p<0,001). Não houve diferença significativa entre os tempos pré e 30 dias após de intervenção entre os grupos (p<0.082). Os dois modelos educacionais sobre neurociência da dor melhoram o conhecimento em graduandos de um curso de fisioterapia, sendo o programa de aulas expositivas mais efetivo que o programa de estudo orientado.
Descritores
Educação em Saúde; Dor Crônica; Dor Musculoesquelética
RESUMEN
La adaptación de los profesionales de la salud a los nuevos conceptos de dolor se ha vuelto fundamental. Estudios anteriores analizaron la inserción de una única estrategia pedagógica sin un grupo control o observaron el conocimiento del estudiante a través del plan de estudios académico existente. Este estudio tuvo el objetivo de comparar la efectividad de dos modelos educativos sobre la neurociencia del dolor en estudiantes de grado de la carrera de fisioterapia, y contribuyó a la promoción de conocimientos y actitudes relacionados con el dolor. Se realizó un estudio experimental, longitudinal prospectivo, con aleatorización simple de los participantes en dos grupos: grupo clases y grupo texto. Se evaluó el conocimiento a través del cuestionario de neurofisiología del dolor (NPQ). La variables cuantitativas se describieron con la media y la desviación estándar. Las variables cualitativas se describieron mediante número absoluto y frecuencia (%). Se aplicó la prueba T para los análisis univariados estratificados con un nivel de significación del 5%. El grupo clases participó en clases expositivas y el grupo texto recibió materiales informativos para estudio guiado. Los programas duraron cinco semanas, con follow-up tras 30 días de la exposición. Al comparar los grupos en los períodos previos y posteriores a la intervención (grupo clases: media=4,5, DP±1,94; y grupo texto: media=3,34, DP±1,46), se observó una diferencia significativa favorable al grupo clases (p<0,001). No hubo diferencia significativa entre el período previo y los 30 días tras la intervención entre los grupos (p<0.082). Los dos modelos educativos sobre la neurociencia del dolor mejoraron el conocimiento de los estudiantes de grado de la carrera de fisioterapia, y el programa de clases expositivas fue más efectivo que el programa de estudio guiado.
Palabras-clave
Educación para la Salud; Dolor Crónico; Dolor Musculoesquelético
INTRODUCTION
The discussion about the biopsychosocial model in health has existed for some time. It was proposed by psychiatrist Engel in 1977, when the predominant model was biomedical1. The biopsychosocial model presents a new paradigm on the understanding of the health/disease process1 and represents a broad perspective, establishing an integration between the biological, psychological, and social spheres in approaches to health care2.
Interventions for chronic musculoskeletal pain were previously established and associated only with an actual injury3. Now, adapted to the new known characteristics, pain is understood as an unpleasant sensitive and emotional experience, associated, or an experience similar to that associated, with an actual or potential tissue injury4. This update of concepts defines pain as a dynamic phenomenon, in which linear neurophysiological mechanisms are abandoned and open space to care in a multidimensional context extremely dependent on the interaction of various endogenous and exogenous factors4,5.
Given this scenario, it is not uncommon to observe situations in which health professionals are faced with implemented approaches that do not result in clinical improvement according to traditional outcomes. This may be justified by the need for strategies that consider the various factors that interfere with this clinical evolution, not limited, therefore, to the health and disease process, but encompassing the biopsychosocial model for the maintenance and/or improvement of pain, especially when characterized as chronic6,7.
Health professionals’ training directly impacts the preparation for the management of patients with chronic pain. The education model in Brazil is based on acquiring technical qualifications, not on solving problems and applying knowledge based on the best evidence8. This creates a deficit of understanding and critical analysis of the clinical scenario by students8. Moreover, some barriers—such as the hierarchy of teaching, professors being the sole holders of the knowledge to be transmitted, prior knowledge seen as certain and immutable—encourage superficial teaching, memorization of content and lack of critical reflection, the adoption of standardized intervention models, in addition to the lack of team participation and cooperation9.
The important role of the university in the implementation of these concepts in pain is carried out by active pedagogical methodologies that include the neuroscience of pain and its multiple aspects. The contact and practice of therapeutic strategies based on the biopsychosocial model for chronic pain during health professionals’ training is an alternative to change this panorama in the long term. Recently graduated health professionals can develop a broader approach in the evaluation and therapeutic conduct, increasing the efficiency of their results9. It also has repercussions in a more humanized approach, as well as tends to decrease the chances of reinforcing negative beliefs to patients, improving pain coping and its prognosis as a consequence10.
Reflecting on this scenario, the adoption of teaching programs is valid, as well as the updating of the academic curriculum in higher education institutions with the adequacy and maintenance of knowledge about pain. This study aims to analyze and compare the effectiveness of two educational models on pain neuroscience for undergraduate students of a physical therapy course. The hypothesis tested is that educational programs improve knowledge about pain neuroscience, with better results by the classes program.
METHODOLOGY
Study design
An experimental longitudinal prospective study was conducted in accordance with the CONSORT 2010 statement11. A researcher performed simple randomization with random allocation of individuals into two groups: Group 1 (classes) and Group 2 (textual information). Three other researchers were responsible for the evaluation procedures carried out with the participants. A researcher, with training in physical therapy and experience in the studies and clinical practice focused on chronic pain area, taught the classes of the educational program on pain neurosciences proposed for the participants.
Participants
The study population consisted of undergraduate students of a physical therapy course of both sexes. The following inclusion criteria were adopted: (1) minimum age of 18 years old; (2) being able to read and understand Portuguese; (3) being in the 3rd and 4th periods of the course. Individuals were exclude for lacking internet access or personal email and those who were not present at all scheduled activities.
Initially, 121 individuals were evaluated for inclusion in the study. However, 10 were excluded for personal reasons, and 11 withdrawn from the study . As per Figure 1, the other volunteers were randomized into two distinct groups: Group 1 and Group 2. Group 1 (n=50) and Group 2 (n=50) (Figure 1).
No withdrawals occurred throughout the five weeks of intervention. Nevertheless, at the four-week follow-up after the experiment, four volunteers dropped out in the classes group and nine dropped out in the text group. All withdrawals occurred for personal reasons.
Procedures
After confirming the information, three researchers made formal and individualized contact with participants via the contact channels provided during the completion of the personal characteristics questionnaire. The following information was collected: age; whether they have dealt with people with a history of chronic pain; whether they have dealt with chronic pain treatment; whether they have participated in classes on chronic pain; whether they have performed extracurricular activities involving chronic pain; whether they have had previous experiences in chronic pain care. Thus, volunteers were guided about all the procedures that would be performed, having been duly clarified about the research, its objectives and its characteristics.
Group 1 was characterized by a pain educational program model conducted for five consecutive weeks, with one class per week, in synchronous online format by the digital platform Google Meet. The classes were structured in an expository format, taught by a professor with experience in research on chronic pain, with pre-programmed content, based on new evidence from studies related to pain. The classes add problematizations about both clinical and academic reality, stimulating students to reflect on concepts already overcome and to participate with their experiences and personal knowledge on the subject. The content was divided into five blocks, each equivalent to a class lasting four hours, one class per week. The content of the classes was presented via slides, based on pain neuroscience and biopsychosocial factors12-14, focusing on a proposed pain education strategy15. The themes of each class were defined as follows:
Class 1: Multidimensional approach to chronic pain – understanding concepts about pain; the impact of pain in the world and the importance of studying and understanding its aspects; kinesiopathological model versus dynamic systems; biopsychosocial model and new paradigms; cognitive and behavioral factors.
Class 2: Neurosciences in the multidimensional approach to chronic pain – neurophysiological study of pain and internal and external factors influencing it; neurotags/neuronal networks related to the pain process; correlation with cognitive and behavioral factors.
Class 3: Neuroscience-based multidimensional assessment of pain – classification and mechanisms of pain; assessment strategies; available resources and tools.
Class 4: Understanding the stages of pain education based on neuroscience – lecture based on material made available openly and free of charge by the Pesquisa em Dor® (PED - Pain Research) group;
Class 5: Strategies for multidimensional approach to chronic pain – dynamic class aiming to associate the previously exposed contents with the presentation of extra resources from international study groups on pain to complement the knowledge and guide the management of patients with chronic pain.
Parallel to the classes, content fixation exercises were applied by a virtual platform that enabled students to interact. These exercises aimed to reinforce critical thinking from clinical cases, and stimulate the understanding of new concepts on pain.
Group 2, called text group, was followed for five weeks. The guided study methodology was used in this group, with active learning. Various study materials, such as texts and videos, and complementary materials, such as summaries and mind maps, were sent by a messaging application. Submissions were made once a week, and students studied according to their schedule availability. These materials were aligned with the weekly theme of the classes group. Group 2 also had access to the same interactive virtual platform as Group 1, to perform the exercises and solve possible questions.
Outcomes
Knowledge about pain neurophysiology was the primary outcome of the study; it was evaluated by the Neurophysiology of Pain Questionnaire (NPQ), a measurement tool recorded by a reliable and validated questionnaire for the Portuguese language16,17. The NPQ is a self-applied instrument, originally developed with 19 items that evaluate knowledge related to the neurophysiology of pain, in which each item can be answered as: true, false, and undecided. After evaluating the psychometric properties of the NPQ, it was found that only 12 items are needed to achieve the same results as the original questionnaire17. The revised questionnaire, composed of 12 items, was adapted to Portuguese16. The result is described in absolute and relative values of correctly answered items. Scores equal to or greater than 65% correct on the NPQ, in 90% of the participants, are considered satisfactory to evaluate the acquisition of neurophysiological knowledge of pain17.
Thus, the NPQ was applied in three moments, as shown in Figure 2: A1, prior to the beginning of the program; A2, after the immediate end of the program; and A3, 30 days after the end of the program.
Data analysis
The Statistical Package for the Social Sciences (SPSS) was used for statistical analysis. The sample size (n=100) was based on similar studies conducted previously10,18. Considering the division into two groups, the sample size of each group (n=50) still exceeds the number already established in the cited studies.
Initially, the normality analysis of quantitative variables was performed. In it, the asymmetry and kurtosis coefficients were calculated and evaluated. When both coefficients are within the range between −3 and +3, the variable is considered to have a distribution sufficiently close to normal for parametric tests to be used. Additionally, the variables were also evaluated with the Shapiro-Wilk normality test. The next step included descriptive data analysis along with univariate analyses. Quantitative variables were described as mean and standard deviation. Qualitative (categorical) variables were described by absolute number and frequency (%). To perform the univariate analyses stratified by the study groups, the t-test was used with a significance level of 5%19.
Ethical aspects
The participating volunteers had access to the informed consent form (ICF) in digital format. All participants, after reading, gave their consent to participate in the research. The volunteers answered the personal characteristics questionnaire, containing the following information: age, course, period they are currently attending, institution in which they are taking the course, email, phone number, and questions about previous experiences with chronic pain. All marked responses, including the ICF and consent to participate in the research, were sent to the email indicated by the volunteer.
RESULTS
Regarding the characteristics of the study population (Table 1), 24% had already dealt with a history of chronic pain, 24% had treatment for chronic pain, 86% participated in classes with the theme chronic pain, 87% had already performed extracurricular activities involving chronic pain, and 16% had previous experiences in chronic pain care. No statistically significant difference was found for any of these variables when Groups 1 and 2 were compared.
Concerning the general performance of the application of the NPQ prior to the intervention, the participants had an average of 2.93±1.7 correct answers. Group 1 had a mean of 3.7±1.6 and Group 2 had a mean of 2.0±1.2, showing a statistically significant difference between the groups (p<0.001).
Comparing by stratified analysis the NPQ scores at different times in the two study groups (Table 2), Group 1 had a mean of 4.5±1.94 and Group 2 had a mean of 3.34±1.46 for the pre-intervention (A1) and post-intervention (A2) periods, conferring a significant difference favorable to Group 1 (p<0.001). In the comparison of the post-intervention period (A2) and the period after 30 days after the end of the intervention (A3), Group 1 had a mean of −1.61±1.27, while Group 2 reached a mean of −0.98±1.15, showing a significant difference between the groups (p<0.018). The difference between the pre-intervention period (A1) and the period 30 days after intervention (A3) was not significant (p<0.082); the mean for Group 1 was 2.93±1.70 and for Group 2, 2.32±1.55.
DISCUSSION
Our study revealed that this sample of undergraduate students of a physical therapy course obtained improvement in the knowledge acquired about pain neuroscience by two proposed educational models. We observed that the improvement in knowledge was favorable to the classes group compared to the text group. These results confirm our hypothesis that educational programs improve knowledge about pain neuroscience, with better results by the classes program.
Considering the acquisition of knowledge for both groups, the results are positive for the score levels presented in the two moments after exposure to the programs. These levels do not return to the initial pre-exposure values. The use of active teaching methodology used in both groups, in which the student shares with the professor the responsibility and commitment of the learning process, seems to facilitate the retention of knowledge. In addition to assisting in the construction of a critical professional, who is able to construct new meanings for the object of study, this professional tends to be more skilled in different geopolitical, social, and cultural contexts, either in collective or individual aspects of performance10.
From these results, when comparing the two groups between the pre-and post-intervention periods, we observed a statistically significant favorable difference for the classes group. However, when reassessed 30 days after the insertion of the programs, the score level for knowledge in the groups was not maintained. Although this score did not return to the initial pre-exposure levels, it did not confer a sufficient level to present a significant difference between the groups in the pre-intervention periods and after 30 days of the intervention.
This difference in the results of the knowledge acquired between the different methodologies of the groups corroborates Camilo’s20 observations. Targeted pedagogical actions with the use of images, sounds, body movements, challenges, etc. are suggested by the author as the best strategy for neurocognitive stimuli. This strategy was similar to the one we used to structure the educational program of the classes group, which had a more marked improvement in knowledge indicators. Although the text group had images and videos available for study, and even if both groups had access to the same virtual platform to ask questions, interact, and solve exercises, it seems that the interaction between a supervising professor and students in real time favors more knowledge retention than when a student studies alone.
Over the course of 30 days, the scores regarding knowledge of pain decrease, but do not return to the same levels as at the time of pre-exposure. Nevertheless, the difference between the groups did not remain. This shows that, regardless of the teaching methodology applied in the groups, if strategies to maintain the retained information are not used, the indicators can be reduced to levels close to the initial ones over time.
The strategy for maintaining this knowledge that can be adopted throughout graduation is proposed by DeSantana et al.8, with interdisciplinary work between professors of different subjects, in order to integrate the knowledge acquired instead of fragmenting them, always supported by current scientific evidence, stimulating the student to the habit of seeking updates from reliable sources. Continuing education is a strategy to be taken by students after their graduation, whether by specializations, courses, congresses, conferences, or discussions in groups and professional meetings8.
Our findings present scores similar to those found in other studies10,18,21 regarding the level of knowledge about neurophysiology of pain in students of the physical therapy course. After the submission of a group of physical therapy students to an active teaching structure, the results were positive for the acquisition of knowledge10, as observed in a 2013 study, which only measured the knowledge of pain in university students from the academic curriculum already existing in a physical therapy course18.
Our results also emphasize the results found by a systematic review21, showing that pain education strategies in the biopsychosocial model can promote improvements in knowledge and attitudes related to pain in students and health professionals.
We believe that these results can help educational institutions, professors, and future researchers in the academic curricular adequacy, adequacy of classes or extracurricular courses, as well as the adoption of active teaching methodologies, with the insertion of concepts and information aimed at pain management for academics and health professionals, especially understanding that continuous strategies must be implemented to maintain knowledge.
Our study presents a good methodological structure and, thus, good reliability of the data. Because it is a comparative study between groups, the risk of confounding bias for the analysis of teaching methodologies is reduced. The sample size adopted is the largest compared to other studies of similar themes previously conducted10,18, attenuating the level of heterogeneity of the sample and, thus, conferring greater representativeness of the study population. The use of follow-up also allowed a short to medium-term analysis of the effect of interventions, adding greater precision in this interpretation of data.
This study is limited by the scope of only one undergraduate area in health. New studies can expand the analysis of pain knowledge in different higher education courses in the health area, including the completeness of the disciplines regarding the contents related to pain knowledge as a strategy for maintaining the knowledge presented8. Simple randomization was a limitation of the study, without control of the difference between the groups of the initial score of the NPQ (p<0.001). Speculating that physical therapy academics have more positive beliefs than students in other health courses regarding chronic pain management15,22, and that knowledge and attitudes related to pain can be improved with the insertion of educational programs on pain neurosciences22, we suggest further studies with stratified randomization to control these variables.
Our results open alternatives for the development of new studies, especially with the insertion of new study groups stratified by time of training or different professions, as well as the comparison between face-to-face and remote classes. We suggest even the development of a five-week training course combining the two strategies used in this study, including an increase in follow-up time, with or without continuing education.
CONCLUSION
Two educational models on pain neuroscience improve knowledge in undergraduate students of a physical therapy course. The two groups showed favorable differences in the increase of knowledge about pain, with better results for the classes program compared to the guided study program. Although this knowledge remains higher than before the exposure with the studied content, the level of knowledge about pain acquired is not maintained 30 days after completion of the educational programs.
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Financing source:
São Paulo Research Foundation (FAPESP), 2022/02166-2, and Brazilian Federal Agency for Support and Evaluation of Graduate Education (CAPES)
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Approved by the Research Ethics Committee: Opinion no. 4.782.440, CAAE: (47657921.1.0000.5511)
