Development of learning material to complement pain education of physiotherapists in Indian universities

Authors: Mathew J, Rashid M, Shirsath P, Raja K / Submitted: 02 February 2020.

This article is undergoing peer review.


Abstract

Background and purpose: It is necessary to bring the current understanding of pain to undergraduate, postgraduate, and staff of physiotherapy in all the universities and institutions in India. Approximately 15,000 (minimum) students are graduated every year from different institutions in India. More than 20,000 physiotherapists teach or practice in various institutions, hospitals, and universities. The current pain curriculum of the universities is outdated and scanty. Physiotherapists are first-line managers of pain and it is important for them to understand the current advances in pain management to effect competent practice. Methods: With this objective in mind, missing areas of pain science have been identified from the curricula of universities of India and instructional Digital Versatile Discs (DVD) were developed in these areas by experts. The DVDs were sent to all the universities and institutions by post and recommended to incorporate the information in the undergraduate and postgraduate curricula. Results and discussion: The impact and reachability of the study were evaluated through Google forms and email responses received from the participating institutions. This project is expected to have a snowball effect by imparting current understanding and knowledge in young therapists and teaching faculty as the lectures are available perpetually on the website of the participating institution. Cultural and other characteristics are similar across the countries of South Asia (India, Pakistan, Sri Lanka, Nepal, Bhutan, Bangladesh, Maldives, and Myanmar) and all of these countries use English as the medium of higher education. Hence a regional impact is also anticipated.

Keywords: pain curriculum; pain education; pain learning; pain lecture series


Introduction

Pain, a symptom with the potential to alter the quality of life of an individual, often restricts daily activities that bring a person to a health care professional, seeking relief (Dueñas, Ojeda, Salazar, Mico, & Failde 2016). Physiotherapists (PTs) are often primary contact clinicians in pain management (Holm, Ljungman, Åsenlöf, Linton, & Söderlund 2016; Mills, Torrance, & Smith 2016). Inadequately managed pain can lead to physical and psychological adverse outcomes in individuals and families (Sinatra 2010). The pain experience is shaped by biomedical, psychosocial and behavioural factors. Comprehensive evaluation and critical thinking of these three domains are required to identify the underlying cause, which is essential to plan treatment and to facilitate better outcomes (Jones, Edwards, & Gifford 2002). A clear understanding of current concepts of pain and related areas is required for establishing a standardized and consistent assessment, and formulation of an appropriate treatment plan. The International Association for the Study of Pain (IASP) has developed a well-explained pain curriculum for physiotherapy education, revised in 2012 (Slater, Sluka, Söderlund, & Watson 2015). The content and construct of pain education in PT curricula vary across countries and institutions (Vijayanand 2016; Raja 2017). Education on the topic of pain is still fragmented and inadequate in the undergraduate and postgraduate physiotherapy curriculum in India (Bhatnagar, Patel, & Raja 2018). According to the Indian Association of Physiotherapists (IAP), there are 223 recognized institutions that offer undergraduate (UG) and postgraduate (PG) in physiotherapy, under various private and government universities (Physiotherapyindia.org. 2016). The current understanding of pain is not adequately represented in the teaching curriculum of most of these universities. The absence of a central statutory council for the profession makes it difficult to establish standard curricula nationally (Raja 2017). Changing concepts and understanding of pain are covered only in a limited fashion in both UG and PG levels of education in many universities. Integration of a pain education curriculum would expose UG and PG students to current concepts in pain assessment and management, and potentially improve their competence, thereby benefiting their patients and clientele. We received an IASP project in 2015, through which we conducted a one-year intensive mixed-methods coaching through online and residential methods. Although well-received, this was able to reach only a fraction of the physiotherapist community (Mani, Engheepi, Gupta, & Raja 2016). We apprehend that this intensive online education or a face to face webinar is neither adequate nor feasible to bring about meaningful changes at a national level. Hence a more far reaching method of instruction was required. One of the limitation of the program was inconsistency of internet in various parts of India. A method to overcome these difficulties was envisaged as pre-recorded lectures.  Hence the objectives of this study was to assess the reach of pre-recorded learning material on the current understanding of pain which will be made available to colleges and universities free of cost is expected to be more far-reaching. This will also be given to the board of studies (BOS) of universities, to effect changes in the curriculum design and delivery.

Methods

Phase 1 – Curriculum review and topic identification

Undergraduate and postgraduate physiotherapy pain curricula of all the universities across India were identified and stored in the institutional central library data sharing system under the guidance of the senior subject librarian. The curriculum was critically analysed by comparing it with the IASP curriculum for physiotherapy by the Institutional Review Committee (IRC). The IRC included 10 senior academic faculties and two research associates from the research institution. Missing areas of pain science were identified and listed by a consensus of the IRC. On approval of the project from IASP, an invitation to participate in the project was sent to all the universities and colleges of India.  Interested colleges and universities were included in the project. An external expert review committee (EERC) of 10 members was established from the selected members of the board of studies (BOS) of participant universities. The previously identified topics and estimated hours were circulated to the EERC members for validation through institutional email using a Google form. Expert speakers for each topic were identified and invited for lecture recording. All the identified experts had a minimum of 10 years of clinical, academic and research expertise in the specified topic.

Phase 2 – Video recording of the lecture series

Efforts were made to ensure that the demonstration and didactic classes were recorded with the best available video recording system. A high definition (HD) video conferencing system (EVC150 point-to-point) by Aver Information Inc. was used for recording. The Aver EVC150 system offered a full HD 720P content with a Pan-Tilt-Zoom camera and a microphone array. The lecture series was recorded according to a pre-set time table over a period of two months in the organising institution. Video editing was done under the guidance of the experts to identify and cross verify the content. Necessary editing and rerecording were done. A master copy of the lecture series was made for commercial duplication and handed over to a professional audio-visual expert for associated labelling and commercial production for 469 colleges offering both UG and PG courses in physiotherapy (IAP).

Phase 3 – Distribution and institutional depository management

The lecture series consisting of 4 DVD of various classes were produced. Under the guidance of IRC and institutional clerical staff, the DVDs were sent to all the 469 colleges (registered-223 and non-registered-246 institutions with IAP) and BOS heads through India Post registered parcel services with a return to sender service. The institutional office staff was instructed to record any return of undelivered DVDs. The set of DVDs was sent with a letter of appreciation for participating in the project, the importance of the project, and the recommendation of including the material in their teaching curriculum of pain science.  All institutional heads were requested to keep the DVD set in the library, accessible to all the faculty and students of the institution as self-learning material. This is expected to enhance professional education through independent learning even before the expected curricular changes are effected. We foresaw the importance of understanding the ‘multidimensional nature of the pain’ and requested the institutional heads to conduct a small workshop on the ‘multidimensional nature of pain’ based on the information included in the DVDs.

A simple Google form survey was incorporated to measure the effectiveness and acceptance of the lecture series from two institutions of Southern India prior to circulating the DVDs. The form consist of 10 ‘yes’ or ‘no’ questions assessing the acceptance, effectiveness and attitude towards a new method of learning experience.

The lecture series was also uploaded in the project associated online data drive (Microsoft OneDrive) with a sharable link for future distribution and research purposes. Online link to the lecture series was made freely available from the institutional website (Jssphysiotherapy.edu.in.  2019).

Data analysis

Descriptive statistical methods were used for constructing tables of means and quantiles, measures of variance and cross-tabulations included hours of each pain topic.

Results

The areas of pain education missing from mainstream curricula have been identified and learning resources developed. Eight major topics were identified by the IRC as gaps after the review process, which required an estimated 22 hrs of video lecturing. Identified topics and estimated hours for each topic are described in table 1. 

Table 1: Topics identified as necessary.

Sl. NoIdentified topicsEstimated hours
1Introduction to pain2
2Multi-dimensional nature of pain3
3Pain assessment and measurement4
4Management of pain5
5Cognitive-behavioural approach2
6Pain ergonomics1
7Electrotherapy in pain management1
8Low back pain and neck pain2
9CRPS and neuropathic pain2

Based on the comments and recommendations received from the EERC members, the topics were modified and subdivided, and recorded as per the decided methodology. A summary of the pain lecture series are illustrated in Figure 1.

Figure 1: Pain topics and duration of the lecture recording.

The overall response rate for the initial invitation to participate in the study across the country was 58.2 percentage. Five universities responded to the email in the first instance within a period of one month from email circulation time. Twenty five institutions under these universities and other universities also responded with their interest in participating in the study (figure 2). Other colleges have evinced interest but will consider only during their next scheduled curriculum review. The board of studies of three universities have included the course in their curriculum. Based on the recommendations four institutions conducted a pain workshop using the provided lecture series.

Figure 2: Initial response received within a month of email circulation.

A 500 students and 50 academicians responded to the Google form survey evaluating the effectiveness an acceptance of the lecture series. A majority (88.2 %) responded ‘yes’ to all the 10 questions.

Discussion

The conception and conduction of the program were feasible in terms of time and human resources. We have received a significant response for the invitation sent to the universities and physiotherapy institutions across the country.  Approximately 15,000 (minimum) students are graduated every year from different institutions in India. More than 20,000 faculty and practicing physiotherapists teach or practice in various colleges, hospitals, and universities (Raja 2017; Grafton & Gordon 2016). This project is expected to have a snowball effect by imparting current understanding and knowledge in young therapists and teaching faculty. Moreover, cultural and other characteristics are similar across the countries of South Asia (India, Pakistan, Sri Lanka, Nepal, Bhutan, Bangladesh, Maldives, and Myanmar) and all of these countries use English as the medium of higher education. Hence a regional impact is anticipated.

The number of participants who attended the course as part of our last study (2015) was limited to 25 physiotherapist from all over India, representing different institutions or universities. The current study reached a wider population with a target audience of 500 students per year from the universities and 2500 from the 25 individual institutions every year. The lecture series and associated study materials are freely available from our institutional website, and will be available to many more. Thus this project has achieved much greater reach.  In the short term only reach could be evaluated.  

Future perspectives

As a part of this project, we have taken the pre-assessment of knowledge, attitudes, and beliefs (KAP) of the students, staff and BOS members from various institutions using validated questionnaires. These questionnaires will be administered again after one year to measure the changes which is expected to give an understanding of the impact of the program. Ongoing evaluation and updating of the course material will be done based on results from the impact data.

Practical implications

  • Imparting pain education through pre-recorded lecture series for physiotherapists
  • Promoting online, self-directed pain learning for improving pain education in physiotherapy students.

References

[1] Dueñas, M., Ojeda, B., Salazar, A., Mico, J.A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 9:457. doi: 10.2147/JPR.S105892

[2] Holm, S., Ljungman, G., Åsenlöf, P., Linton, S.J., & Söderlund, A. (2016). Treating youth in pain: Comparing tailored behavioural medicine treatment provided by physical therapists in primary care with physical exercises. European Journal of Pain, 20(4):626-38.  https://doi.org/10.1002/ejp.780

[3] Mills, S., Torrance, N., & Smith, B.H. (2016). Identification and management of chronic pain in primary care: a review. Current Psychiatry Reports, 18(2):22. https://doi.org/10.1007/s11920-015-0659-9

[4] Sinatra, R. (2010). Causes and consequences of inadequate management of acute pain. Pain Medicine, 1;11(12):1859-71. https://doi.org/10.1111/j.1526-4637.2010.00983.x

[5] Jones, M., Edwards, I., & Gifford, L. (2002). Conceptual models for implementing biopsychosocial theory in clinical practice. Manual Therapy, 7(1):2-9. https://doi.org/10.1054/math.2001.0426

[6] Slater, H., Sluka, K., Söderlund, A., & Watson, P.J. (2015). IASP Curriculum outline on pain for physical therapy. International Association for the Study of Pain, 2015 [cited 2016 Dec 25]. https://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=2055

[7] Vijayanand, P. (2016). Pain education in India. Indian Journal of Pain, 1;30(2):77. DOI: 10.4103/0970-5333.186460

[8] Raja, K. (2017). Physiotherapy-the state of the profession in India: an analysis. Physiotherapy-The Journal of Indian Association of Physiotherapists, 1;11(1):34. DOI: 10.4103/PJIAP.PJIAP_17_17

[9] Bhatnagar, S., Patel, A., & Raja, S.N. (2018). Aspiring pain practitioners in India: Assessing challenges and building opportunities. Indian Journal od  Palliative Care, 24(1):93. doi: 10.4103/IJPC.IJPC_148_17

[10] Physiotherapyindia.org. (2016). I.A.P :- Indian Association Of Physiotherapist – List of Recognized / Approved Under-Graduate Colleges By Indian Association Of Physiotherapist (IAP) In India. Available at: http://www.physiotherapyindia.org/education/approved-ug-colleges/3745-list-of-recognized-approved-under-graduate-colleges-by-indian-association-of-physiotherapist-iap-in-india.html [Accessed 13 Jan. 2020].

[11] Mani, R., Engheepi, F.B.P., Gupta, S., & Raja, K. (2016). Imparting the IASP Pain Curriculum to Physiotherapists through Distance Mode: A Study of Impact on Knowledge Attitudes and Beliefs about Pain.  16th World Congress on Pain, Japan2016.

[12] Jssphysiotherapy.edu.in. (2019). JSS Physiotherapy. [online] Available at: http://jssphysiotherapy.edu.in/Home/online_learning [Accessed 13 Jan. 2020].

[13] Grafton, K., & Gordon, F. (2019). A grounded theory study of the narrative behind Indian physiotherapists global migration. International Journal of Health Planning Management, 34(2):657-71. https://doi.org/10.1002/hpm.2725


Funding

This study has been funded by the 2019 IASP Developing Countries Project: Initiative for Improving Pain Education grant.

Acknowledgements

The authors acknowledge Dr. Akkamahadevi P, Dr. Prabhleen Jaggi Singh, Dr. Saumen Gupta, Dr. Twinkle Dabholkar, Ms. Anushee Narekuli, Mr. Vijay Samuel Raj and Mr. Nityal Kumar Alagingi for their expertise in creating the pain lecture series. We also acknowledge the office staffs, librarian and student council members (2018) of the institution for their active support and help throughout the project.

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