Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Abstract

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Keywords

International Association for the Study of Pain multidisciplinary pain science teaching resources active learning

Introduction

Over 50 million Americans suffer from daily chronic pain (CP) that impacts functioning, quality of life,¹ and mental health.² CP has also been linked to depression/anxiety symptoms,³ and suicidal behavior.⁴ Pharmacological treatments including opioids have been generally unsuccessful at treating CP,^5,6 and have contributed to the opioid crisis.⁷ Opioid treatment is associated with an increased risk of opioid use disorder,⁸ suicide risk,⁹ overdose events, and drug-related death.^10,11 With the decline of opioid treatment for CP since 2012 and a rising fentanyl crisis,¹² there is an urgent need to optimize nonpharmacological treatment of CP,⁵ and those treatments have been highlighted in the most recent guidelines from the Centers for Disease Control and Prevention (CDC).¹³ Unfortunately, patients with CP often prioritize the need for surgery and pain medications in contrast to best-practice recommendations advocating for interprofessional healthcare self-management strategies like exercise.^14,15 That disconnect can leave providers feeling uncertain about how to treat patients with CP and frustrated with the lack of an interdisciplinary pain management strategy.^16,17 One recent survey of primary care physicians (PCPs) treating patients with CP found that only 31% were satisfied with their ability to provide care to patients with CP, with 43% feeling pressured to prescribe pain medicine.¹⁸ Even when the provider understands what may be useful for a patient, successfully connecting that message to the patient can be a challenge.¹⁹

One potential reason these conversations are difficult is the comparative lack of time spent in healthcare education, across disciplines, in both teaching and, but more importantly practicing, how to evaluate and treat patients with CP.^20‐22 The purpose of this article is to share 5 interdisciplinary evidence-based messages and related learning activities that interprofessional health educators could use with their students to improve their skills to evaluate and treat patients in CP. These messages should form the basis for interprofessional learning experiences that allow students to develop and demonstrate competency in evaluating and treating CP.

A recent systematic review of pain content in medical schools found that American medical schools devoted an average of only 11 h of curricular time to pain, with 96% of schools having no required pain medicine content for students.^22,23 Physical therapy (PT) schools reported an increase in average pain curricular content from only 4 h²⁴ to 31 h.²⁰ Despite CP being an important part of any treatment specialty, medical students report feeling unprepared to treat patients with CP due to insufficient education.^25,26 A study of pain education content in schools of pharmacy concluded that coverage of the topic was fragmented and inadequate.²⁷

Due in part to the opioid crisis,^28,29 a shortage of pain physicians,³⁰ and a plethora of expensive yet ineffective treatments for CP,¹⁵ providers are looking for more effective ways to collaboratively treat patients with CP. For example, including a pharmacist as part of the interprofessional team has demonstrated improved functionality and symptom management, increased use of nonopioid pain medications, and a decrease in both opioid dose and opioid misuse risks.^31,32 For patients undergoing arthroscopic hip surgery, simply initiating a PT referral prior to opioid prescribing, compared to opioids before PT, resulted in reductions in total health care costs ($16 995 vs $18 806), total opioid supply (44 days vs 90 days), and percentage of patients that transitioned to chronic long-term opioid use (53%-70%).³³

Other nonopioid and nonsurgical treatment options for patients in CP include exercise,^34,35 cognitive behavioral therapy,³⁶ and sleep hygiene interventions.³⁷ Another promising treatment is pain neuroscience education (PNE), which involves educating patients about the neurophysiology of CP.³⁸ Recent systematic reviews have shown PNE to be effective at decreasing kinesiophobia/pain catastrophizing,³⁹ healthcare utilization,⁴⁰ and disability.⁴¹ These beneficial effects are amplified when combined with exercise interventions.⁴² These evidence-based approaches may contrast with students’ understanding of the biomedical treatment model, which teaches that all pain is directly due to tissue pathology.^43,44 Educators are tasked with giving students evidence for and examples of the effectiveness of biopsychosocial interdisciplinary care for patients with CP.

Fortunately, even brief interventions aimed at changing healthcare provider beliefs away from biomedical and towards biopsychosocial principles of CP appear to be effective.^45‐51 Despite encouraging clinical evidence for educating providers about pain, interprofessional health students are likely the most important audience,⁵² because clinician beliefs and abilities around pain management are shaped early in their clinical training.⁵²

Educators in medicine⁵³ and physical therapy⁵⁴ have called for students to be assessed in their ability to evaluate and treat pain in practice-based learning simulations that mirror clinical practice, similar to a competency-based educational model.⁵⁵ Unfortunately, the majority of medical schools that assess CP knowledge do so at the cognitive level as opposed to the application level.⁵³ Students who have only been asked to answer multiple choice questions on CP during school will likely not be well prepared to clinically apply skills like motivational interviewing,⁵⁶ active listening,⁵⁷ developing a strong therapeutic alliance (TA) with patients,⁵⁸ and communicating with other members of the healthcare team.⁵⁹ Each of these skills is vital to successfully connecting to patients with CP and supporting behavior change.

While momentum is building to include CP patient management skills into doctor of physical therapy (DPT) program accreditation through the Commission on Accreditation in Physical Therapy Education,⁴³ this is not currently the case. By using backward design learning theory,⁶⁰ educators can design and apply learning experiences that prepare students to meet the ultimate objective, which is to graduate students who are competent in applying the principles of CP management.

Fortunately, medical school, physical therapy, psychology, and pharmacy educators now have access to a growing number of resources to help plan curricular content around CP treatment and practice. Educators in physical therapy,^61,62 medicine,^63,64 and pharmacy^65,66 have outlined courses and activities devoted to pain based on both interprofessional and profession-specific guidelines. The American Association of Colleges of Pharmacy (2023) developed a searchable database of activities conducted at pharmacy institutions as a resource for educators and a method to inform stakeholders about the efforts of schools of pharmacy to address the opioid crisis. There are also a multitude of free resources available to educators to assist in the design of active learning activities, such as Oregon Pain Guidance,⁶⁷ the NIH Pain Consortium,⁶⁸ and Boston University's SCOPE of Pain podcast series.⁶⁹

An interprofessional group representing 10 different health professions⁷⁰ outlined core competencies that students should be able to demonstrate to treat patients in pain.⁴³ Those competencies were expounded further specific to PT students⁷¹ which were then used as a foundation to develop the recent PT profession-wide Pain Education Manual.⁷² More broadly, the International Association for the Study of Pain (IASP) has published pain curricula to assist educators from medical schools,⁷³ physical therapy,⁷⁴ occupational therapy,⁷⁵ pharmacy,⁷⁶ interprofessional education,⁷⁷ and undergraduates.⁷⁸ Educators also have access to pain curricula at specific medical schools^79‐81 to structure their classes. A central tenet of all those curricular models is a strong focus on interprofessional collaboration and knowledge application practice to treat patients with CP.

Multiple brief interprofessional student educational interventions have been detailed in the literature demonstrating that they can be effective at changing student beliefs around pain and understanding of the roles of other professions in CP management. Many focus on improving interprofessional communication between providers which is important for the management of these patients with CP.⁸² Others have focused on better understanding opioids/pain physiology, hearing from patients in CP,⁸³ and developing interprofessional treatment plans.^84,85 It is important to continue to highlight the knowledge and competencies that students will need to use during their conversations with patients in CP throughout the curriculum for students to prepare them to be effective clinicians.

Building on the work of Langford et al⁸⁶ who asked students to self-report their competency in pain management after an interprofessional learning activity using the Interprofessional Collaborative Competency Scale,⁸⁷ educators should attempt to assess students’ postlearning competencies and abilities around treating CP. By assessing competency and not simply recalling knowledge, educators will best prepare interprofessional students for the reality of complex clinical practice.^53,54 Unfortunately, both developing and assessing interprofessional active learning application activities that mimic clinical practice is more time-consuming than developing lecture content. Educators who have not taught content related to CP may be unsure which topics and activities are most appropriate for an active learning approach. Our goal is that the 5 interdisciplinary evidence-based messages and related learning activities can be used by interprofessional health educators to improve student skills in the evaluation and treatment of patients in CP. These messages should form the basis for interprofessional learning experiences that allow students to develop and demonstrate competency in evaluating and treating CP.

Process to identify interdisciplinary messages

The nature of this approach was an evidence-based interprofessional CP curricular development narrative review. An interprofessional team of educators representing medicine, pharmacy, physical therapy, and psychology convened over 10 separate meetings in 2022 and 2023 to determine 5 interprofessional CP messages deemed most important for students to learn at the application level. Those messages were based on a contemporary understanding of CP and both interprofessional and profession-specific curricular guidelines such as those created by the IASP. The team then developed active learning educational activities designed to reinforce each message (Supplemental Appendices I-V). Each learning activity included formative/summative assessments, synchronous/asynchronous didactic resources, and a detailed description of the activity designed to reinforce the message. Learning messages were discussed with a medical student graphic artist who created images that reflect the 5 core educational messages; the draft images were shared with the interprofessional team and edited to accurately capture the message of the article.

Five interdisciplinary messages for CP treatment

The 5 interdisciplinary evidence-based messages concerning CP along with a summary of their importance to didactic education are detailed in Table 1.

Table 1.

Five interdisciplinary evidenced-based messages concerning chronic nonmalignant pain.

MESSAGE	SUMMARY OF IMPORTANT DIDACTIC EDUCATION
Therapeutic alliance (TA)	TA is the connection and sense of support that a patient feels between themselves and a clinician Patients with chronic pain often report poor TA with their clinicians A strong TA appears to be predictive of improved clinical outcomes for those with chronic pain
Consistent terminology	Patients with chronic pain place a high priority on biomedical (anatomical) diagnostic information but may struggle to understand the meaning of that terminology A lack of understanding of biomedical diagnostic information (eg, MRI results) can lead patients to worry about their prognosis for recovery Research demonstrates measurable changes in clinical outcomes when biopsychosocial as opposed to biomedical terminology is used Confusion over their condition and prognosis for recovery is heightened when the interdisciplinary team does not provide consistent biopsychosocial messaging
Importance of positive prognosis	Most patients with chronic pain do not expect their condition to improve Patient expectation of recovery has been independently linked to improved clinical outcomes Having patients hear what to expect during the recovery process can improve clinical outcomes Clinicians should use caution to refrain from nocebo messaging during interactions with patients and provide evidenced-based reassurance that injuries will heal
Surgery, opioids, and imaging	Despite many patients seeing opioids as beneficial for chronic pain, no level 1 evidence exists that shows opioids are effective at treating chronic pain Weaning patients from opioids improves risk factors for multiple injury risks but in many cases results in either unchanged or improved pain scores Absent specific patient presentations, clinical practice guidelines do not recommend surgeries for patients with chronic pain as a first-line treatment Lumbar fusions appear to be expensive and ineffective for patients with chronic pain Recent studies that show pathology on imaging in the absence of pain underscores the importance of correlating imaging findings with symptoms and not simply treating imaging findings
Importance of early referral	Few patients with chronic pain are referred to the interprofessional team early within entering the medical system as recommended by clinical practice guidelines Early compared to late referral to physical therapy has been linked with a reduction in opioid dosage, overall cost, and need for additional surgery Providers from all disciplines can help reinforce the importance of exercise

Message 1: The importance of TA: Trust, empathy, and humility

TA focuses on the connection, warmth, and sense of support created between clinician and patient that empowers the 2 to work collaboratively.^57,58 In other words, TA is an indirect measurement of the trust the patient places in a provider to work in a collaborative and connected manner. Unfortunately, patients with CP frequently report a poor TA with their providers.⁸⁸ A strong TA enhances the provider's ability to initiate difficult conversations around behavior change and self-management⁸⁹ that may run counter to other interventions that a patient might initially prefer. Similarly, patients with CP who felt understood and perceived mutual trust with their providers had higher satisfaction and switched providers less frequently.⁹⁰ Figure 1 depicts the importance of the therapeutic alliance.

Figure 1.

Therapeutic alliance: scenes from a therapeutic relationship.

A systematic review of the influence of the TA on outcomes for patients with chronic musculoskeletal pain treated by a variety of providers showed a reduction in pain and improvement in physical functioning with higher-rated TA.⁹¹ For physical therapists treating patients with CP, TA is moderately correlated with satisfaction with treatment and the likelihood of recommending that treatment.⁹² A study of 3 different treatments for low back pain delivered by physical therapists showed that TA strongly predicted perceived efficacy, pain reduction, and improvement in functioning and disability.⁹³

Patients in CP unfortunately report that finding providers that both empathize and understand their pain is challenging.⁹⁰ There is further evidence that women and individuals from minoritized racial groups with CP may feel particularly misunderstood by their providers,⁹⁴ with evidence of racial and gender disparities in pain assessment and treatment.^95,96 A lack of focused training for students in all health disciplines in the development of TA and cultural humility may be partially to blame. It is also possible that poor TA is related in part to the challenges that both patients⁹⁷ and providers,⁹⁸ including students,⁹⁹ report in discussing and addressing mental and behavioral health concerns that often accompany CP. With more evidence supporting the importance of TA in improving outcomes for patients with CP,⁵⁸ it is important to incorporate TA training, including developing TA when working with diverse patients and comorbid mental health concerns, into health professional education.

Regardless of their specific discipline, health students should be trained to both listen⁵⁷ and communicate effectively with patients with CP.¹⁹ Students are highly unlikely to learn how to effectively build TA and utilize patient-centered communication strategies through didactic teaching alone.

Supplemental Appendix I outlines an evidence-based^67,100‐107 suggested active learning experience centered on TA. Students work with a simulated patient or lab partner to practice a subjective evaluation, with a special focus on appropriate verbal and nonverbal language that helps the patient feel connected to the clinician. Formative feedback is provided by the simulated patient or classmate to prepare for a summative practical assessment in which the faculty member can ensure students can effectively connect with patients.

Summary of important didactic information: TA

TA is the connection and sense of support that a patient feels between themselves and a clinician.

Patients with CP often report poor TA with their clinicians.

A strong TA appears to be predictive of improved clinical outcomes for those with CP.

Message 2: Interdisciplinary terminology describing pathology: Consistency, language, hope

While best practice recommendations for CP call for a shift from the biomedical model to the biopsychosocial model,^108,109 patients still place a high emphasis on biomedical diagnostic information.¹¹⁰ Unfortunately biomedical diagnostic terminology used to describe pathology can be confusing for patients without a medical background to understand and can vary widely between members of the interdisciplinary team.¹¹¹ For example, the diagnostic terminology found in provider notes and imaging results impacts the words patients choose to describe their pain and in turn their perceived prognosis.¹¹² Figure 2 depicts the importance of consistent terminology to describe pathology.

Figure 2.

Consistent terminology for pathology: lost in un-translation.

Words such as “tear,” “bulging,” and “herniated,” while anatomically accurate, can inadvertently increase patient fear, while minimally affecting intervention choices from other members of the team.^111,112 Patient confusion over different explanations from different providers about the cause of their pain can increase anxiety about their condition and prognosis. For example, giving patients evidence-based information about back pain rather than imaging their lower back can improve their perceptions of their pain.¹¹³ Likewise, a randomized controlled trial (RCT) that compared medical reassurance to reading magnetic resonance imaging (MRI) results found that reading the specific MRI terminology resulted in patients believing that they were less likely to improve.⁹⁷

Confusion is only made worse when there is poor communication between members of the interdisciplinary team. For example, only 16.7% of PCPs reported being satisfied with transition notes from other services where patients received CP care.¹⁸ Ideal communication requires 2 components: (1) providers need to communicate with each other to provide consistent messaging to patients and (2) the interprofessional team must choose accurate patient terminology that minimizes jargon and improves patients’ understanding of their condition and its ability to improve.

Patients with CP benefit from biopsychosocial messaging from providers, and even more so when all providers are communicating the same message. However, switching from the biomedical, pathology-focused language typically used in documentation and interprofessional communication to a biopsychosocial message that does not induce fear can be challenging. Students need the opportunity to practice those patient conversations and hear the perspectives of other disciplines.

Supplemental Appendix II outlines an evidence-based^{97‐99,111,114‐116} suggested active learning experience centered on using consistent terminology to describe a patient's condition from all members of the interdisciplinary team. Students work as a team to convert biomedical language on an MRI report to biopsychosocial language more appropriate for patient communication. Formative feedback is provided by other student members of the team to prepare for a summative practical assessment where the faculty member can model potential patient responses to communication both with and without biopsychosocial language.

Summary of important didactic information: Consistent terminology

Patients with CP place a high priority on biomedical (anatomical) diagnostic information but may struggle to understand the meaning of that terminology.

A lack of understanding of biomedical diagnostic information (eg, MRI results) can lead patients to worry about their prognosis for recovery.

Research demonstrates measurable changes in clinical outcomes when biopsychosocial as opposed to biomedical terminology is used.

Confusion over their condition and prognosis for recovery is heightened when the interdisciplinary team does not provide patients with consistent biopsychosocial messaging.

Message 3: Assessing and intervening to improve the patient's own prognosis of condition: expectancies, fear, and hope

Most patients with CP do not expect their condition to improve over time either with or without medical care.¹¹⁰ That is problematic because poor expectations have been linked with lingering pain after surgery,¹¹⁷ pain during a diagnostic injection,¹¹⁸ as well as long-term pain intensity and function.¹¹⁹ Interestingly, patient expectation of recovery was more predictive of shoulder pain recovery for patients referred to PT than physical exam findings or even the physical therapist's expectation of recovery.¹²⁰ Advances in understanding of neurobiological underpinnings of CP have highlighted the role of predictive processing in maintaining CP, in that the pain is made worse or sometimes even generated by neurocognitive predictions of pain and bodily harm.^121‐123 These predictions contribute to affective states such as fear that can further exacerbate pain via persistent sympathetic activation, contribute to kinesiophobia, and lead to innocuous somatosensory input being perceived and experienced as painful.¹²⁴ This predictive pain cycle can become self-reinforcing and may be a primary driver for the chronicity of pain, especially for individuals with centralized pain conditions. Figure 3 depicts the importance of improving a patient’s understanding of a prognosis that includes recovery.

Figure 3.

Improving patient's prognosis: the road to recovery.

Indeed, pain catastrophizing, or the cognitive tendency to magnify the threat value of pain and feel helpless in the face of pain, has been consistently linked to higher pain severity, depression, and disability.¹²⁵ Providers may inadvertently reinforce these maladaptive processes by emphasizing the role of structural damage, which is often not the driver of CP, or communicating that the patient has an intractable and debilitating condition, which can, unfortunately, become a self-fulfilling prophecy. It is important to ensure that all members of the interprofessional team not only use consistent terminology, but also work collaboratively to provide hope as they describe the patient's prognosis. Inconsistent messaging around prognosis from different team members confuses patients and can negatively impact patient expectations around recovery.

With research showing that educating patients about pain being potentially linked to improving patient expectation of recovery,¹²⁶ it is important that patients receive honest yet encouraging messaging from all members of the healthcare team. Consistent, hopeful, and honest feedback from all members of the interdisciplinary team about the recovery process from CP can give patients more adaptive expectations of their functional improvements over time. Practically for a provider referring to another interdisciplinary team member, this might come from how imaging results are discussed,⁹⁷ setting realistic expectations for therapy,¹²⁷ describing the role of the brain versus structural damage in CP,^{110,126,128,129} and describing success stories of other patients to improve hope.^127,130 For the provider, this may also mean modifying their evaluation away from biomedical, and anatomical diagnoses and instead focusing on measuring function to demonstrate objective progress and continue to optimize expectations of future recovery.¹²⁸

To improve patient expectations, providers can use videos that outline the recovery process and what to expect over time. For example, patients with acute whiplash neck pain after a motor vehicle accident who watched a short 10-minute video in the ER reported decreased pain, imaging utilization, pain medicine prescriptions, and incidence of bed rest compared to a group that did not watch the video.¹³¹

Students are highly unlikely to learn how to effectively outline an expected recovery process refraining from nocebo messaging with didactic content alone.

Supplemental Appendix III outlines an evidence-based^{85,127,132‐135} suggested active learning experience centered on providing a positive prognosis to patients in CP. Students work individually creating discipline-specific messaging to share with a patient in pain regarding their expected recovery. They then meet as an interprofessional team to determine how that messaging can be best shared with a patient and practice that conversation with a simulated patient. Formative feedback is provided by the simulated patient or faculty member to prepare for a summative practical assessment where the faculty member can ensure students can effectively outline an expected recovery process for a patient in pain.

Summary of important didactic information: Importance of positive prognosis

Most patients with CP do not expect their condition to improve.

Patient expectation of recovery has been independently linked to improved clinical outcomes.

Having patients hear what to expect during the recovery process can improve clinical outcomes.

Clinicians should use caution to refrain from nocebo messaging during interactions with patients and provide evidence-based reassurance that injuries will heal.

Message 4: Evidence-based discussion: Pain medications, surgery, and imaging

Pain medications, surgery, and imaging all have important targeted roles to play in our medical system. Unfortunately, in current clinical practice, those 3 interventions are often overused for patients with CP, resulting in poor outcomes when more effective and cheaper treatment options are available but under-utilized.^15,136,137 Figure 4 depicts how unnecessary surgery, imaging, and opioids can leave patients trapped without physical therapy and behavioral health.

Figure 4.

Pain medications, surgery, imaging: the chronic pain rotary.

Pain medications

The 2016 CDC Guideline for Prescribing Opioids for CP recommended nonopioid therapies as a first-line treatment.¹³⁸ However, the updated 2022 CDC guidelines note possible misapplication of those recommendations to create biased, inflexible, and harmful policies for patients experiencing and living with CP.¹³ The 2022 guidelines stressed individualized person-centered care practices and interprofessional care of CP whenever possible. The guidelines stress again that opioid therapy for CP comes with risks. Opioid use has been associated with an increased risk of cardiovascular events,⁵ clinical depression,¹³⁹ motor vehicle accidents,⁵ suicide,¹⁴⁰ and fractures.¹⁴¹ Despite those risk factors, many patients perceive opioid medications as necessary to decrease their CP. However, the link between increased opioid medications and CP relief is not supported in the literature. Chen et al¹⁴² demonstrated that for many patients with CP, a reduction in opioid dosage led to a reduction in pain intensity, not an increase in pain intensity. More recently, Fishbain and Pulikal¹⁴³ studied the effects of opioid tapering regimens for patients with CP and found that 97% of studies showed that decreasing opioid dosage was associated with either no change in reported pain or an improvement in pain. That study also showed that patients who offered multidisciplinary treatment did better than those who were not.

Surgery

Surgery is an effective and important tool to help manage a variety of conditions; however, surgeries for CP are often used contrary to clinical practice guidelines. For example, despite a multidisciplinary call to action in 2018 to transform how surgery is used to treat low back pain,¹⁴⁴ patients with low back pain continue to be offered low-value spinal fusion surgeries at high rates.¹³⁷ Those surgeries are expensive,¹⁴⁵ have high failure rates,¹⁴⁶ and have minimal evidence supporting their use¹⁵ absent neurological findings.

Placebo surgeries have been studied for a variety of health conditions¹⁴⁷ in an attempt to differentiate the biomedical effects of surgeries compared to placebo improvements. While surgical procedures often improve pain and function, their benefits over conservative interventions like placebo surgery, and PT have been minimal to nonexistent for pain arising from labral tears,¹⁴⁸ knee meniscal tears,¹⁴⁹ and tendinopathy.¹⁵⁰ A recent systematic review showed statistically significant but minimal functional improvements in pain and function at 6, 12, and 24 months after a rotator cuff repair compared to conservative care.¹⁵¹ In fact, a surprisingly high number of patients who are satisfied with their shoulder pain and function after a rotator cuff tear demonstrate a retearing of the surgical site despite being satisfied with their overall function.¹⁵²

The purpose of presenting students with evidence that calls into question the efficacy of surgeries is not an attempt to convince students that surgery has no role for patients with CP; rather, it helps reinforce the importance of the evidence-based, biopsychosocial treatment approach. Students can understand how “fixing” the biomedical problem that appears on imaging is not guaranteed to alleviate the problem, highlighting the importance of a more interdisciplinary, patient-centered approach. While more research on placebo surgery needs to be conducted,¹⁴⁷ these studies help reinforce the importance of assessing for and attempting to modify patient treatment expectations, regardless of healthcare discipline. Due to the difficulty of conversations around surgery, both with patients and other members of the interprofessional team, it is imperative that students have an opportunity to practice those discussions prior to entering the clinical setting.

Imaging

Patients consider imaging an important component of the diagnostic and treatment process¹⁵³ and may request advanced imaging in the belief that it will change treatment interventions. However, patients with spine pain who receive imaging miss more work, utilize health services more often, and spend more on medical costs than those who do not receive imaging.¹⁵⁴ Furthermore, imaging findings may not depict an accurate representation of the amount of pain someone is experiencing. A prospective study examining lumbar MRIs for patients without low back pain found that when patients did develop low back pain at a later date 84% of the follow-up MRIs were unchanged or improved compared to baseline imaging when the patient was pain-free.¹⁵⁵ Clinicians can use that research to help reassure patients about their prognosis despite findings that may initially appear worrisome. In fact, in a recent RCT, reassuring patients with low back pain that their MRI findings were normal led to improvements in pain intensity, catastrophizing, function, and subjective perception of their condition compared to patients who heard their MRI results without that reassurance.⁹⁷

Healthcare providers should not mislead or ignore imaging findings; however, they should carefully consider the language and messaging they use with patients to minimize inadvertent nocebo messaging.¹¹¹ One strategy is to review the results of advanced imaging but immediately put results in the context of how often those specific results appear in scans of patients with no pain. Simply including prevalence data on spine imaging findings within a patient's MRI report significantly decreases opioid use one year later.¹⁵⁶ Reviewing imaging findings that do demonstrate pathology for patients with low back pain can give patients a feeling of closure and validate the veracity of their pain complaints.¹⁵⁷ However, that conversation should attempt to leave the patient with a feeling of hope that despite their imaging results, improvement is possible through active interventions.

Conversations around imaging findings can be difficult for students to lead early in their training. Almost like learning a second language, students need to master both biomedical and biopsychosocial vocabulary to describe the same pathology and understand when to use each one.¹¹¹ An overly biomedical vocabulary with patients with minimal biopsychosocial understanding can lead to a nocebo effect and cyberchondria¹⁵⁸ where a patient searches online for content and becomes more worried. However, exclusively using biopsychosocial language with patients and providers can lead to decreased confidence that the student understands the pathology. Students of all disciplines should be given opportunities to practice describing imaging findings in different ways to be prepared for the realities of clinical practice.

Supplemental Appendix IV outlines an evidence-based^{5,15,67‐69,136,143,146,147,156} suggested active learning experience centered on effective evidence-based discussions with patients with CP regarding opioids, surgery, and imaging. Students prepare discipline-specific messaging that they would share with a patient in CP and discuss that messaging as an interdisciplinary team prior to interacting with the simulated patient. Those discussions focused on sharing research about the effectiveness of opioid tapering along with the minimal evidence supporting its use for patients with CP. Students also practice discussing when imaging and surgery are indicated for patients with CP. Formative feedback is provided by the simulated patient and any observers to prepare for a summative practical assessment where the faculty member can roleplay a patient in CP who is convinced that opioids, additional imaging, and surgery are the only ways to “fix” their pain.

Summary of important didactic information: Surgery, opioids, imaging

Despite many patients seeing opioids as beneficial for CP, no level 1 evidence exists that shows opioids are effective at treating CP.

Weaning patients from opioids improves risk factors for multiple injury risks but in many cases results in either unchanged or improved pain scores.

Absent specific patient presentations, clinical practice guidelines do not recommend surgeries for patients with CP as a first-line treatment

Lumbar fusions appear to be expensive and ineffective for patients with CP.

Recent studies that show pathology on imaging in the absence of pain underscore the importance of correlating imaging findings with symptoms and not simply treating imaging findings.

Message 5: Importance of early referral to the interprofessional team: Access, collaboration, and patient communication

Convincing a patient to attend PT or to start exercising when they believe that movement will only make the pain worse is hard to do, especially when patients are requesting other treatment options. Part of the disconnect is that referring providers tend to prioritize improving patient function and minimizing medication side effects, while patients prioritize decreasing pain and receiving a definitive diagnosis of their problem.¹⁵⁹ Unfortunately, contrary to clinical practice guidelines,¹³ only a small percentage of patients with CP are referred to PT or psychology despite evidence that shows the importance of early referrals.¹⁶⁰ There are insurance barriers, access barriers, and long-standing historical barriers that limit access and availability of multimodal therapies for patients living with CP. Among individuals with risk factors for CP, engaging in exercise and cognitive behavioral therapy earlier (ie, within 4-8 weeks) appears to reduce the likelihood of chronicity of pain.¹⁶¹ Figure 5 shows the importance of an early referral.

Figure 5.

Early referral: now that's what I call a quick referral.

A scoping review of pharmacists engaged in opioid management activities in primary care settings found an improvement in functionality and symptom management for patients and reduced opioid doses. Changes in prescriber behaviors were also noted including improved adherence to pain management protocols, increased initiation of nonopioid therapies, and increased engagement in risk-mitigating strategies such as prescribing naloxone, accessing prescription monitoring programs, and reduced concomitant prescribing of benzodiazepines.³¹ Another scoping review of the pharmacist's role in opioid stewardship highlighted the educational contributions of the pharmacist as a member of the interprofessional healthcare team. Pharmacists’ education of patients and other healthcare professionals was associated with improved pain scores, enhanced knowledge and understanding as well as reducing opioid use.³²

A 2013-2015 survey of PCP referral patterns for patients with knee osteoarthritis (OA) found that out of 1000 visits, only 46 received PT referrals, and 221 received lifestyle counseling, while 498 received NSAIDs and 316 received opioids.¹⁶² Pain medication referrals for knee OA increased from 2007 to 2015 with PT and lifestyle coaching appearing to be under-utilized according to clinical guidelines.¹⁶² Sun et al¹⁶³ found a similar under-utilization of PT, with only 29.3% of patients with new-onset musculoskeletal pain receiving physical therapy in < 90 days after their initial medical appointment. Despite low referral rates relative to best practice guidelines, physical therapy remains a low-cost effective treatment for patients in pain, but its effectiveness improves greatly the earlier a patient can begin formal PT.

A systematic review for patients with low back pain found that initiating a PT referral within 30 days of a medical appointment resulted in significant reductions in opioid use, future healthcare utilization, spinal injections, and spine surgery.¹⁶⁴ Even PT within 90 days of a medical appointment is correlated with a 10% reduction in opioid use for shoulder, neck, back, or knee pain and decreased dosage amounts for those who do use opioids.¹⁶³

Unfortunately, not all healthcare providers have immediate referral access to other members of the interprofessional team. That is especially true in rural areas where other providers may be located far away. In those situations, clinicians can recommend early referral to telehealth services^165‐167 which grew in popularity during the COVID-19 pandemic.¹⁶⁸ Clinicians can also utilize programs like the Project for the Extension for Community Healthcare Outcomes (Project ECHO)¹⁶⁹ to connect with other interprofessional providers to reinforce IASP didactic pain content from an interprofessional approach.¹⁷⁰

All members of the healthcare team whether in the same geographic location or connected electronically can help support the message of exercising and early referral to active patient-centered treatment approaches like PT and psychology. Patients with CP often identify the need for extra support when initiating an exercise program,¹⁷¹ and that support should be reinforced with consistent messaging from the entire team. Educators should give students an understanding of the research supporting early referrals but more importantly, the opportunity to practice talking with diverse patients about how they can support that behavior change.

Supplemental Appendix V outlines an evidence-based^{33,101,102,104,105,135,163,164} suggested active learning experience centered on the importance of early referral to the interdisciplinary healthcare team and safe, effective interventions such as exercise. Students prepare discipline-specific reports to the rest of the interprofessional health care team to share and better understand how other disciplines would care for that patient. Those discussions will focus on sharing research about the importance of early referral to all members of the healthcare team and practice discussing both with patients and payers the importance of early referral to both other providers but also encouragement for increasing physical activity. Formative feedback is provided by other student classmates and faculty observing those discussions to prepare for a summative practical assessment where the faculty member can roleplay a patient or payor who is unwilling to try conservative management options like psychology or physical therapy.

Summary of important didactic information: Importance of early referral

Few patients with CP are referred to the interprofessional team early within entering the medical system as recommended by clinical practice guidelines.

Early compared to late referral to physical therapy has been linked with a reduction in opioid dosage, overall cost, and need for additional surgery.

Providers from all disciplines can help reinforce the importance of exercise.

Limitations

This approach had several limitations. First, the authors do not represent all health professions that play a role in interprofessional CP management. Additionally, the messages in this article were developed by a small team of clinician educators without a systematic external review process (other than manuscript peer review) by other providers or patients. All authors were affiliated with the same university so there is potential bias on conclusions that may not be generalizable to all American health professional schools.

Summary

Preparing health science students to evaluate and treat patients with CP requires formative, active learning opportunities that provide an opportunity to receive constructive feedback prior to clinical practice. To prepare students for those assessments, educators should design didactic content built on resources like the IASP curricular guidelines^{73‐75,77,78} and profession-specific resources.⁷² The 5 interprofessional messages presented in this viewpoint aim to highlight learning areas that should be prioritized when teaching healthcare students about CP.

From that didactic foundation, a healthcare educator aiming to redesign their content to utilize active learning within a competency-based educational model⁵⁵ should give students opportunities for formative evaluations to enhance preparedness for competency assessment. Competency-based education translates the competencies needed for effective pain treatment into active skills by providing students opportunities to progress from simply observing a faculty member completing a task to eventually doing that task on their own with no supervision. Along the way, supervision needed to perform those “Entrustable Professional Activities” reduces as students demonstrate the ability to perform competencies with less and less supervision.¹⁷² Educators from PT,^173‐175 pharmacy,¹⁷⁶ psychology,¹⁷⁷ and medicine¹⁷⁸ have all advocated for an educational shift towards assessing student competency and not simply knowledge recall.

Conclusion

To treat a problem as prevalent and complex as CP, it is imperative that students are given the opportunity early in their education to practice the competencies they will need to demonstrate to effectively manage patients in CP. The 5 messages and active learning activities presented in this viewpoint and Supplemental Appendices serve as a flexible foundation for interprofessional educators to meet their specific educational goals related to teaching students to treat patients with CP. The activities provide a framework on which educators can build, while considering variations needed to accommodate for access to resources such as synchronous access to students of other disciplines and simulated patients.

Supplemental Material

sj-docx-1-mde-10.1177_23821205231221950 - Supplemental material for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Supplemental material, sj-docx-1-mde-10.1177_23821205231221950 for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application by Jeb Helms, Laura Frankart, Melissa Bradner, Jonathan Ebersole, Beck Regan and Taylor Crouch in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-2-mde-10.1177_23821205231221950 - Supplemental material for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Supplemental material, sj-docx-2-mde-10.1177_23821205231221950 for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application by Jeb Helms, Laura Frankart, Melissa Bradner, Jonathan Ebersole, Beck Regan and Taylor Crouch in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-3-mde-10.1177_23821205231221950 - Supplemental material for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Supplemental material, sj-docx-3-mde-10.1177_23821205231221950 for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application by Jeb Helms, Laura Frankart, Melissa Bradner, Jonathan Ebersole, Beck Regan and Taylor Crouch in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-4-mde-10.1177_23821205231221950 - Supplemental material for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Supplemental material, sj-docx-4-mde-10.1177_23821205231221950 for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application by Jeb Helms, Laura Frankart, Melissa Bradner, Jonathan Ebersole, Beck Regan and Taylor Crouch in Journal of Medical Education and Curricular Development

Supplemental Material

sj-docx-5-mde-10.1177_23821205231221950 - Supplemental material for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Supplemental material, sj-docx-5-mde-10.1177_23821205231221950 for Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application by Jeb Helms, Laura Frankart, Melissa Bradner, Jonathan Ebersole, Beck Regan and Taylor Crouch in Journal of Medical Education and Curricular Development

Footnotes

Authors’ contributions

Jeb Helms—conceptualization, methodology, resources, writing–original draft, writing–review and editing, supervision, and project administration. Laura Frankart—conceptualization, methodology, resources, writing–original draft, writing–review and editing. Melissa Bradner—conceptualization, methodology, resources, writing–original draft, writing–review and editing. Jonathan Ebersole—conceptualization, methodology, resources, writing–original draft, writing–review and editing, and visualization. Beck Regan—visualization and artwork creation. Taylor Crouch—conceptualization, methodology, resources, writing–original draft, writing–review and editing.

FUNDING

The author(s) received no financial support for the research, authorship, and/or publication of this article.

DECLARATION OF CONFLICTING INTERESTS

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ORCID iDs

Jeb Helms

Melissa Bradner

Supplemental material

Supplemental material for this article is available online.

References

Yong

Mullins

Bhattacharyya

. Prevalence of chronic pain among adults in the United States. Pain (Amsterdam). 2022;163(2):e328‐e332.

Gjerde

Skurtveit

Handal

, et al. Mental disorder prevalence in chronic pain patients using opioid versus non-opioid analgesics: a registry-linkage study. Eur J Pain. 2023;27(7):884‐895.

Gómez Penedo

Rubel

Blättler

, et al. The complex interplay of pain, depression, and anxiety symptoms in patients with chronic pain: a network approach. Clin J Pain. 2020;36(4):249‐259.

Chen

Pettersson

Summit

, et al. Chronic pain conditions and risk of suicidal behavior: a 10-year longitudinal co-twin control study. BMC Med. 2023;21(1):9‐9.

Chou

Turner

Devine

, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for national institutes of health pathways to prevention workshop. Ann Intern Med. 2015;162(4):276‐286.

Krebs

Gravely

Nugent

, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. J Am Med Assoc. 2018;319(9):872‐882.

Jones

Viswanath

Peck

Kaye

Gill

Simopoulos

. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther. 2018;7(1):13‐21.

Edlund

Martin

Russo

DeVries

Braden

Sullivan

. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014;30(7):557‐564.

Olfson

Waidmann

King

Pancini

Schoenbaum

. Opioid prescribing and suicide risk in the United States. Am J Psychiatry. 2023;180(6):418‐425.

10.

Gomes

Mamdani

Dhalla

Paterson

Juurlink

. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686‐691.

11.

Dunn

Saunders

Von Korff

, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152(2):85‐92.

12.

Han

Yan

Zheng

Khan

Yuan

. The rising crisis of illicit fentanyl use, overdose, and potential therapeutic strategies. Transl Psychiatry. 2019;9(1):282‐289.

13.

Dowell

Ragan

Jones

Baldwin

Chou

. CDC clinical practice guideline for prescribing opioids for pain – United States. Morb Mortal Wkly Rep. 2022;71(3):1‐95.

14.

Christe

Pizzolato

Meyer

Nzamba

Pichonnaz

. Unhelpful beliefs and attitudes about low back pain in the general population: a cross-sectional survey. Musculoskelet Sci Pract. 2021;52:102342.

15.

Lewis

Cook

Hoffmann

O'Sullivan

. The elephant in the room: too much medicine in musculoskeletal practice. J Orthop Sports Phys Ther. 2020;50(1):1‐4.

16.

Militello

Anders

Downs

, et al. Understanding how primary care clinicians make sense of chronic pain. Cogn Technol Work. 2018;20(4):575‐584.

17.

Cate Polacek

Christopher

Mann

Udall

. Healthcare professionals’ perceptions of challenges to chronic pain management. Am J Manag Care. 2020;26(4):e135‐e139.

18.

Roper

Jones

Rowland

Thomas-Eapen

Cardarelli

. Mixed methods study of patient and primary care provider perceptions of chronic pain treatment. Patient Educ Couns. 2021;104(3):585‐594.

19.

Chapman

Woo

Maluf

. Preferred communication strategies used by physical therapists in chronic pain rehabilitation: a qualitative systematic review and meta-synthesis. Phys Ther. 2022;102(9).

20.

Bement

Sluka

. The current state of physical therapy pain curricula in the United States: a faculty survey. J Pain. 2015;16(2):144‐152.

21.

Reyes

Brown

. Occupational therapists’ pain knowledge: a national survey. Disabil Rehabil. 2016;38(13):1309‐1317.

22.

Shipton

Bate

Garrick

Steketee

Shipton

Visser

. Systematic review of pain medicine content, teaching, and assessment in medical school curricula internationally. Pain Ther. 2018;7(2):139‐161.

23.

Hernández-Sánchez

Poveda-Pagán

Toledo-Marhuenda

Lozano-Quijada

. Dealing with chronic pain: tips to teach undergraduate health sciences students. J Pain Res. 2022;15:3223‐3232.

24.

Scudds

Simmonds

. Pain in the physical therapy (PT) curriculum: a faculty survey. Physiother Theory Pract. 2001;17(4):239‐256.

25.

Malik

Ahn

Thompson

Palma

. A systematic review of pain management education in graduate medical education. J Grad Med Educ. 2022;14(2):178‐190.

26.

Yanni

McKinney-Ketchum

Harrington

, et al. Preparation, confidence, and attitudes about chronic noncancer pain in graduate medical education. J Grad Med Educ. 2010;2(2):260‐268.

27.

Singh

Wyant

. Pain management content in curricula of US schools of pharmacy. J Am Pharm Assoc. 2003;43(1):34‐40.

28.

Baker

. History of the joint commission’s pain standards: lessons for today’s prescription opioid epidemic. Jama. 2017;317(11):1117‐1118.

29.

Clarke

Skoufalos

Scranton

. The American opioid epidemic: population health implications and potential solutions. Report from the national stakeholder panel. Popul Health Manag. 2016;19(Suppl 1):S1‐S10.

30.

Mukhdomi

Vanzant

Harris

, et al. The pain medicine fellowship landscape, an observational analysis. Interv Pain Med. 2022;1(2):100086.

31.

Jordan

Latif

Mullan

Chen

. Opioid medicines management in primary care settings: a scoping review of quantitative studies of pharmacist activities. Br J Clin Pharmacol. 2021;87(12):4504‐4533.

32.

Gondora

Versteeg

Carter

, et al. The role of pharmacists in opioid stewardship: a scoping review. Res Social Adm Pharm. 2022;18(5):2714‐2747.

33.

Rhon

Snodgrass

Cleland

Greenlee

Sissel

Cook

. Comparison of downstream health care utilization, costs, and long-term opioid use: physical therapist management versus opioid therapy management after arthroscopic hip surgery. Phys Ther. 2018;98(5):348‐356.

34.

Ambrose

Golightly

. Physical exercise as non-pharmacological treatment of chronic pain: why and when. Best Pract Res Clin Rheumatol. 2015;29(1):120‐130.

35.

Belavy

Van Oosterwijck

Clarkson

, et al. Pain sensitivity is reduced by exercise training: evidence from a systematic review and meta-analysis. Neurosci Biobehav Rev. 2021;120:100‐108.

36.

DeBar

Mayhew

Benes

, et al. A primary care-based cognitive behavioral therapy intervention for long-term opioid users with chronic pain: a randomized pragmatic trial. Ann Intern Med. 2022;175(1):46‐55.

37.

Whale

Dennis

Wylde

Beswick

Gooberman-Hill

. The effectiveness of non-pharmacological sleep interventions for people with chronic pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2022;23(1):1‐33.

38.

O’Connor

Sillevis

Erickson

. Pain neuroscience education delivered by a student physical therapist for a patient with persistent musculoskeletal pain. Am J Case Rep. 2021;22:e932212–e932211.

39.

Watson

Ryan

Cooper

, et al. Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. J Pain. 2019;20(10):1140. e1141-1140. e1122.

40.

Louw

Zimney

Puentedura

Diener

. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2016;32(5):332‐355.

41.

Wood

Hendrick

. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short- and long-term outcomes of pain and disability. Eur J Pain. 2019;23(2):234‐249.

42.

Siddall

Ram

Jones

Booth

Perriman

Summers

. Short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: a systematic review and meta-analysis. Pain. 2022;163(1):e20‐e30.

43.

Shepherd

Zimney

Bement

Wassinger

Courtney

. Empowering physical therapist professional education programs to deliver modern pain content. Phys Ther. 2022.

44.

Mardian

Villarroel

Quist

, et al. Flipping the hidden curriculum to transform pain education and culture. Frontiers Pain Res. 2023;4:1197374‐1197374.

45.

Louw

Vogsland

Marth

Marshall

Cox

Landers

. Interdisciplinary pain neuroscience continuing education in the veterans affairs: live training and live-stream with 1-year follow-up. Clin J Pain. 2019;35(11):901‐907.

46.

Mankelow

Ryan

Taylor

Martin

. The effect of pain neurophysiology education on healthcare students’ knowledge, attitudes and behaviours towards pain: a mixed-methods randomised controlled trial. Musculoskelet Sci Pract. 2020;50:102249.

47.

Zimney

Louw

Johnson

Peppers

Farrell

. Effects of pain neuroscience education on physician assistant students’ understanding of pain and attitudes and beliefs about chronic pain. S D Med. 2018;71(11).

48.

Gyurcsik

Tupper

Brittain

, et al. A proof-of-concept study on the impact of a chronic pain and physical activity training workshop for exercise professionals. Scand J Pain. 2021;21(1):112‐120.

49.

Cardarelli

Elder

Weatherford

, et al. An examination of the perceived impact of a continuing interprofessional education experience on opiate prescribing practices. J Interprof Care. 2018;32(5):556‐565.

50.

Arnstein

Conly

Shelat

Williamson

. Interprofessional chronic pain and addiction training on an emergency department observation unit. Pain Medicine. 2021;22(10):2148‐2152.

51.

Hassan

Carlin

Zhao

Taenzer

Furlan

. Promoting an interprofessional approach to chronic pain management in primary care using project ECHO. J Interprof Care. 2021;35(3):464‐467.

52.

Louw

Sluka

Nijs

Courtney

Zimney

. Revisiting the provision of pain neuroscience education: an adjunct intervention for patients but a primary focus of clinician education. J Orthop Sports Phys Ther. 2021;51(2):57‐59.

53.

Shipton

Steketee

Bate

Visser

. Exploring assessment of medical students’ competencies in pain medicine—a review. Pain Rep. 2019;4(1).

54.

Jensen

Nordstrom

Mostrom

Hack

Gwyer

. National study of excellence and innovation in physical therapist education: part 1—design, method, and results. Phys Ther. 2017;97(9):857‐874.

55.

Timmerberg

Chesbro

Jensen

Dole

Jette

. Competency-based education and practice in physical therapy: it’s time to act!. Phys Ther. 2022;102(5):pzac018.

56.

Nijs

Wijma

Willaert

, et al. Integrating motivational interviewing in pain neuroscience education for people with chronic pain: a practical guide for clinicians. Phys Ther. 2020;100(5):846‐859.

57.

Diener

Kargela

Louw

. Listening is therapy: patient interviewing from a pain science perspective. Physiother Theory Pract. 2016;32(5):356‐367.

58.

Kinney

Seider

Beaty

Coughlin

Dyal

Clewley

. The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract. 2020;36(8):886‐898.

59.

Payton

. Improving communication skills within the nephrology unit. Nephrol Nurs J. 2018;45(3):269‐280.

60.

Belleza

Johnson

. Using the backward design process to integrate interprofessional education utilizing simulation in OT and PT educational curricula. 2019.

61.

Wassinger

. Pain knowledge, attitudes and beliefs of doctor of physical therapy students: changes across the curriculum and the role of an elective pain science course. J Man Manip Ther. 2021;29(5):288-296.

62.

Helms

Mayhew

Zimney

. The effectiveness of active learning approaches in a pain education curriculum within a physical therapy program. J Phys Ther Edu. 2021;35(3):218‐226.

63.

Mirman

Mukhdomi

Rajaguru

, et al. Pain education during the coronavirus pandemic: the introduction of pain medicine during the pre-clinical years. Pain Med. 2022;23(4):609‐613.

64.

Shipton

Steketee

Visser

. The pain medicine curriculum framework-structured integration of pain medicine education into the medical curriculum. Frontiers Pain Res. 2023;3:1057114‐1057114.

65.

Werremeyer

Skoy

Marvanova

, et al. A PharmD program curricular approach to addressing the opioid crisis. Curr Pharm Teach Learn. 2019;11(6):592‐602.

66.

American Association of Colleges of Pharmacy. Opioid Related Activities. 2023. https://www.aacp.org/opioid.

67.

Oregon Pain Guidance. Difficult Conversations. 2023. https://www.oregonpainguidance.org/clinics/difficult-conversations/.

68.

National Institute of Health. Centers of Excellence in Pain Education-Access Current Interactive Modules. NIH Pain Consortium, 2023. https://coepes.nih.gov/.

69.

Alford

. Safer Competent Opioid Prescribing Education of Pain Micro Cases. 2023. https://www.scopeofpain.org/micro-cases/.

70.

Fishman

Young

Lucas Arwood

, et al. Core competencies for pain management: results of an interprofessional consensus summit. Pain Med. 2013;14(7):971‐981.

71.

Hoeger Bement

St. Marie

Nordstrom

, et al. An interprofessional consensus of core competencies for prelicensure education in pain management: curriculum application for physical therapy. Phys Ther. 2014;94(4):451‐465.

72.

Shepherd

Wassinger

Rubine

, et al. Pain education manual. 2021. https://www.orthopt.org/uploads/content_files/files/Pain_Manual_Draft_FINAL_6.25.2021%281%29.pdf.

73.

Kopf

Treede

R-D

Graven-Nielsen

Cadavid

Rathmell

. IASP curriculum outline on pain for medicine. 2018. https://www.iasp-pain.org/education/curricula/iasp-curriculum-outline-on-pain-for-medicine/.

74.

Slater

HS, K

Soderlund

Watson

. Physical therapy curriculum: IASP curriculum outline on pain for physical therapy. 2018. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1580.

75.

Strong

Jones

Gollero

. IASP curriculum outline on pain for occupational therapy. 2018. https://www.iasp-pain.org/education/curricula/iasp-curriculum-outline-on-pain-for-occupational-therapy/.

76.

Herndon

Christrup

Battacharyya

Dickman

G, A

. . IASP Curriculum on Pain For Pharmacy. 2018. https://www.iasp-pain.org/education/curricula/iasp-curriculum-on-pain-for-pharmacy/.

77.

Watt-Watson

Baptista

Carr

. IASP interprofessional pain curriculum outline. 2019. https://www.iasp-pain.org/education/curricula/iasp-interprofessional-pain-curriculum-outline/.

78.

van Lankveld

Afram

Staal

van der Sande

. The IASP pain curriculum for undergraduate allied health professionals: educators defining competence level using Dublin descriptors. BMC Med Educ. 2020;20(1):60.

79.

Murinson

Nenortas

Mayer

, et al. A new program in pain medicine for medical students: integrating core curriculum knowledge with emotional and reflective development. Pain Med. 2011;12(2):186‐195.

80.

Stevens

King

Laponis

, et al. Medical students retain pain assessment and management skills long after an experiential curriculum: a controlled study. Pain (Amsterdam). 2009;145(3):319‐324.

81.

Tauben

Loeser

. Pain education at the university of Washington school of medicine. J Pain. 2013;14(5):431‐437.

82.

Cole

Adcock

Earl

, et al. Virtual interprofessional team care planning and communication for chronic pain management: an educational model. J Interprofession Educ Pract. 2022;29:100552.

83.

Hadjistavropoulos

Juckes

Dirkse

, et al. Student evaluations of an interprofessional education experience in pain management. J Interprof Care. 2015;29(1):73‐75.

84.

Dale

Cioffi

Murphy

Langlois

Musa

Stevens

. Ten-year mixed-method evaluation of prelicensure health professional student self-reported learning in an interfaculty pain curriculum. Pain Rep. 2022;7(5):e1030.

85.

Bishop

Waller

Sicat

, et al. Interprofessional team-based learning module: chronic non-cancer pain. MedEdPORTAL. 2015;1(2):43-47.

86.

Langford

Gordon

Loeseer

Tauben

Doorenbos

. Evaluation of an interprofessional active learning session on acute pain and opioid use disorder using the interprofessional collaborative competency attainment scale. J Interprof Care. 2020;34(2):193‐201.

87.

Archibald

Trumpower

MacDonald

. Validation of the interprofessional collaborative competency attainment survey (ICCAS). J Interprof Care. 2014;28(6):553‐558.

88.

Paap

Krops

Schiphorst Preuper

Geertzen

Dijkstra

Pool

. Participants’ unspoken thoughts and feelings negatively influence the therapeutic alliance; a qualitative study in a multidisciplinary pain rehabilitation setting. Disabil Rehabil. 2022;44(18):5090‐5100.

89.

Lewis

Ridehalgh

Moore

Hall

. This is the day your life must surely change: prioritising behavioural change in musculoskeletal practice. Physiotherapy. 2021;112:158‐162.

90.

Becker

. Tell me your dreams and goals: structuring communication exchanges to improve patient-centered care with chronic pain patients. Appl Nurs Res: ANR. 2020;53:151248.

91.

Lakke

Meerman

. Does working alliance have an influence on pain and physical functioning in patients with chronic musculoskeletal pain; a systematic review. J Compassionate Health Care. 2016;3(1):1‐10.

92.

Linares-Fernández

La Touche

Pardo-Montero

. Development and validation of the therapeutic alliance in physiotherapy questionnaire for patients with chronic musculoskeletal pain. Patient Educ Couns. 2021;104(3):524‐531.

93.

Ferreira

Maher

Refshauge

Latimer

Adams

. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013;93(4):470‐478.

94.

Samulowitz

Gremyr

Eriksson

Hensing

. “Brave Men” and “Emotional Women”: a theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Res Manag. 2018;2018:1‐14.

95.

Knoebel

Starck

Miller

. Treatment disparities among the Black population and their influence on the equitable management of chronic pain. Health Equity. 2021;5(1):596‐605.

96.

Hoffman

Trawalter

Axt

Oliver

. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci - PNAS. 2016;113(16):4296‐4301.

97.

Rajasekaran

Raja

SDC

Pushpa

Ananda

Prasad

Rishi

. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J. 2021;30:2069‐2081.

98.

Language

. Plain language in healthcare. 2023. https://www.plainlanguage.gov/resources/content-types/healthcare/.

99.

Gupta

Wood

Kumar

Misra

Turner

. No faculty required: use of a health literacy low inference self-assessment measure to promote behavior change. Acad Pediatr. 2020;20(5):712‐720.

100.

Babatunde

MacDermid

MacIntyre

. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health Serv Res. 2017;17(1):375‐375.

101.

Cheing

GLY

Lai

AKM

Vong

SKS

Chan

. Factorial structure of the pain rehabilitation expectations scale: a preliminary study. Int J Rehabil Res. 2010;33(1):88‐94.

102.

Fields

Mahan

Tillman

Harris

Maxwell

Hojat

. Measuring empathy in healthcare profession students using the Jefferson scale of physician empathy: health provider – student version. J Interprof Care. 2011;25(4):287‐293.

103.

Gang

Wilson

Garcia

Daher

Johnson

. The art of connection: a model for teaching therapeutic alliance to doctoral physical therapy students within an acute care course. J Phys Ther Educ. 2021;35(2):121‐127.

104.

Hatcher

Gillaspy

. Development and validation of a revised short version of the working alliance inventory. Psychother Res. 2006;16(1):12‐25.

105.

Mercer

Maxwell

Heaney

Watt

GCM

. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract. 2004;21(6):699‐705.

106.

Sulzer

Feinstein

Wendland

. Assessing empathy development in medical education: a systematic review. Med Educ. 2016;50(3):300‐310.

107.

Vargovich

Schumann

Xiang

Ginsberg

Palmer

Sperry

. Difficult conversations: training medical students to assess, educate, and treat the patient with chronic pain. Acad Psychiatry. 2019;43(5):494‐498.

108.

Miaskowski

Blyth

Nicosia

, et al. A biopsychosocial model of chronic pain for older adults. Pain Med. 2020;21(9):1793‐1805.

109.

Nuernberg Back

Liebano

Avila

. Perspectives of implementing the biopsychosocial model to treat chronic musculoskeletal pain in primary health care. Pain Manag. 2021;11(2):217‐225.

110.

da Silva Bonfim

Corrêa

Nogueira

LAC

Meziat-Filho

Reis

FJJ

de Almeida

. ‘Your spine is so worn out’—the influence of clinical diagnosis on beliefs in patients with non-specific chronic low back pain–a qualitative study. Braz J Phys Ther. 2021;25(6):811‐818.

111.

Stewart

Loftus

. Sticks and stones: the impact of language in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2018;48(7):519‐522.

112.

Sloan

Walsh

. Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine (Phila Pa 1976). 2010;35(21):E1120‐E1125.

113.

Karran

Medalian

Hillier

Moseley

. The impact of choosing words carefully: an online investigation into imaging reporting strategies and best practice care for low back pain. PeerJ. 2017;5:e4151‐e4151.

114.

Sagi

Spitzer-Shohat

Schuster

Daudi

Rudolf

MCJ

. Teaching plain language to medical students: improving communication with disadvantaged patients. BMC Med Educ. 2021;21(1):1‐407.

115.

Saunders

Palesy

Lewis

. Systematic review and conceptual framework for health literacy training in health professions education. Health Prof Educ. 2019;5(1):13‐29.

116.

Venktaramana

Loh

EKY

Wong

CJW

, et al. A systematic scoping review of communication skills training in medical schools between 2000 and 2020. Med Teach. 2022;44(9):997‐1006.

117.

Willingham

Vila

Ben Abdallah

Avidan

Haroutounian

. Factors contributing to lingering pain after surgery: the role of patient expectations. Anesthesiology. 2021;134(6):915‐924.

118.

Coppieters

Rehn

Plinsinga

. Patient expectations about a clinical diagnostic test may influence the clinician's test interpretation. Musculoskel Sci Pract. 2021;54:102387.

119.

Mohamed Mohamed

Joseph

Canby

Paungmali

Sitilertpisan

Pirunsan

. Are patient expectations associated with treatment outcomes in individuals with chronic low back pain? A systematic review of randomised controlled trials. Int J Clin Pract. 2020;74(11):e13680.

120.

Chester

Jerosch-Herold

Lewis

Shepstone

. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2018;52(4):269‐275.

121.

Kuner

Flor

. Structural plasticity and reorganisation in chronic pain. Nat Rev Neurosci. 2017;18(1):20‐30.

122.

Corder

Ahanonu

Grewe

Wang

Schnitzer

Scherrer

. An amygdalar neural ensemble that encodes the unpleasantness of pain. Science. 2019;363(6424):276‐281.

123.

Barrett

Simmons

. Interoceptive predictions in the brain. Nat Rev Neurosci. 2015;16(7):419‐429.

124.

Woolf

. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3):S2‐S15.

125.

Quartana

Campbell

Edwards

. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745‐758.

126.

Mittinty

Vanlint

Stocks

Mittinty

Moseley

. Exploring effect of pain education on chronic pain patients’ expectation of recovery and pain intensity. Scand J Pain. 2018;18(2):211‐219.

127.

Testa

Rossettini

. Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes. Man Ther. 2016;24:65‐74.

128.

Louw

Zimney

O'Hotto

Hilton

. The clinical application of teaching people about pain. Physiother Theory Pract. 2016;32(5):385‐395.

129.

Nijs

Clark

Malfliet

, et al. In the spine or in the brain? Recent advances in pain neuroscience applied in the intervention for low back pain. Clin Exp Rheumatol. 2017;35(Suppl 107(5)):108‐115.

130.

Evers

Colloca

Blease

, et al. Implications of placebo and nocebo effects for clinical practice: expert consensus. Psychother Psychosom. 2018;87(4):204‐210.

131.

Oliveira

Gevirtz

Hubbard

. A psycho-educational video used in the emergency department provides effective treatment for whiplash injuries. Spine (Phila Pa 1976). 2006;31(15):1652‐1657.

132.

Dineen-Griffin

Garcia-Cardenas

Williams

Benrimoj

. Helping patients help themselves: a systematic review of self-management support strategies in primary health care practice. PLoS One. 2019;14(8):e0220116‐e0220116.

133.

Evers

Hsu

Sherman

, et al. Patient perspectives on communication with primary care physicians about chronic low back pain. Perm J. 2017;21.

134.

Gill

Oster

Lawn

. Assessing competence in health professionals’ use of motivational interviewing: a systematic review of training and supervision tools. Patient Educ Couns. 2020;103(3):473‐483.

135.

Lane

Huws-Thomas

Hood

Rollnick

Edwards

Robling

. Measuring adaptations of motivational interviewing: the development and validation of the behavior change counseling index (BECCI). Patient Educ Couns. 2005;56(2):166‐173.

136.

Tamang

Wangdi

. High value and cheap musculoskeletal health care interventions: lessons for low-and middle-income countries. Bullet Faculty Phys Ther. 2022;27(1):1‐3.

137.

Buchbinder

Underwood

Hartvigsen

Maher

. The lancet series call to action to reduce low value care for low back pain: an update. Pain. 2020;161 Suppl 1(1):S57‐S64.

138.

Dowell

Haegerich

Chou

. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. Jama. 2016;315(15):1624‐1645.

139.

Scherrer

Salas

Copeland

, et al. Prescription opioid duration, dose, and increased risk of depression in 3 large patient populations. Ann Family Med. 2016;14(1):54‐62.

140.

Ilgen

Bohnert

Ganoczy

Bair

McCarthy

Blow

. Opioid dose and risk of suicide. Pain. 2016;157(5):1079.

141.

Miller

Stürmer

Azrael

Levin

Solomon

. Opioid analgesics and the risk of fractures in older adults with arthritis. J Am Geriatr Soc. 2011;59(3):430‐438.

142.

Chen

Seefeld

, et al. Lack of correlation between opioid dose adjustment and pain score change in a group of chronic pain patients. J Pain. 2013;14(4):384‐392.

143.

Fishbain

Pulikal

. Does opioid tapering in chronic pain patients result in improved pain or same pain vs increased pain at taper completion? A structured evidence-based systematic review. Pain Med. 2019;20(11):2179‐2197.

144.

Buchbinder

van Tulder

Öberg

, et al. Low back pain: a call for action. The Lancet (British Edition). 2018;391(10137):2384‐2388.

145.

Weir

Samnaliev

Kuo

T-C

, et al. The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the clinical practice research datalink (CPRD) and hospital episode statistics (HES). BMJ open. 2017;7(9):e017585‐e017585.

146.

Harris

Traeger

Stanford

Maher

Buchbinder

. Lumbar spine fusion: what is the evidence? Intern Med J. 2018;48(12):1430‐1434.

147.

Louw

Diener

Fernández-de-las-Peñas

Puentedura

. Sham surgery in orthopedics: a systematic review of the literature. Pain Medicine. 2017;18(4):736‐750.

148.

Schrøder

Skare

Reikerås

Mowinckel

Brox

. Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. Br J Sports Med. 2017;51(24):1759‐1766.

149.

Sihvonen

Paavola

Malmivaara

, et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis. 2018;77(2):188‐195.

150.

Challoumas

Clifford

Kirwan

Millar

. How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials. BMJ Open Sport Exer Med. 2019;5(1):e000528.

151.

Brindisino

Salomon

Giagio

Pastore

Innocenti

. Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis. J Shoulder Elbow Surg. 2021;30(11):2648‐2659.

152.

Spielmann

Forster

Kokan

Hawkins

Janzen

. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals—initial experience. Radiology. 1999;213(3):705‐708.

153.

Taylor

Bishop

. Patient and public beliefs about the role of imaging in the management of non-specific low back pain: a scoping review. Physiotherapy. 2020;107:224‐233.

154.

Lemmers

GPG

van Lankveld

Westert

van der Wees

Staal

. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019;28(5):937‐950.

155.

Carragee

Alamin

Cheng

Franklin

van den Haak

Hurwitz

. Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006;6(6):624‐635.

156.

Jarvik

Meier

James

, et al. The effect of including benchmark prevalence data of common imaging findings in spine image reports on health care utilization among adults undergoing spine imaging: a stepped-wedge randomized clinical trial. JAMA Netw Open. 2020;3(9):e2015713‐e2015713.

157.

Chou

Ranger

Peiris

, et al. Patients’ perceived needs for medical services for non-specific low back pain: a systematic scoping review. PLoS one. 2018;13(11):e0204885.

158.

Anandkumar

. Effect of pain neuroscience education and dry needling on chronic elbow pain as a result of cyberchondria: a case report. Physiother Theory Pract. 2015;31(3):207‐213.

159.

Henry

Bell

Fenton

Kravitz

. Goals of chronic pain management: do patients and primary care physicians agree and does it matter? Clin J Pain. 2017;33(11):955.

160.

Kazis

Ameli

Rothendler

, et al. Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ open. 2019;9(9):e028633.

161.

Chou

McCarberg

. Managing acute back pain patients to avoid the transition to chronic pain. Pain Manag. 2011;1(1):69‐79.

162.

Khoja

Almeida

Freburger

. Recommendation rates for physical therapy, lifestyle counseling, and pain medications for managing knee osteoarthritis in ambulatory care settings: a cross-sectional analysis of the national ambulatory care survey (2007–2015). Arthritis Care Res (Hoboken). 2020;72(2):184‐192.

163.

Sun

Moshfegh

Rishel

Cook

Goode

George

. Association of early physical therapy with long-term opioid use among opioid-naive patients with musculoskeletal pain. JAMA Netw Open. 2018;1(8):e185909‐e185909.

164.

Arnold

La Barrie

DaSilva

Patti

Goode

Clewley

. The effect of timing of physical therapy for acute low back pain on health services utilization: a systematic review. Arch Phys Med Rehabil. 2019;100(7):1324‐1338.

165.

Lee

Davenport

Randall

. Telehealth physical therapy in musculoskeletal practice. J Orthop Sports Phys Ther. 2018;48(10):736‐739.

166.

Gregory

Alexander

Satinsky

. Clinical telerehabilitation: applications for physiatrists. PMR. 2011;3(7):647‐656.

167.

Thomas

Burton

Withrow

Adkisson

. Impact of a preoperative education program via interactive telehealth network for rural patients having total joint replacement. Orthop Nurs. 2004;23(1):39‐44.

168.

Lee

. COVID-19 and the advancement of digital physical therapist practice and telehealth. Phys Ther. 2020;100(7):1054‐1057.

169.

Katzman

Comerci

Boyle

, et al. Innovative telementoring for pain management: project ECHO pain. J Contin Educ Health Prof. 2014;34(1):68‐75.

170.

Katzman

Bhatt

Krishnasamy

, et al. Project ECHO interprofessional telementoring: using a novel case-based approach for building the U.S public health service clinical response in pain and substance use disorder. J Interprof Educ Pract. 2022;29:100542.

171.

Joelsson

Bernhardsson

Larsson

. Patients with chronic pain may need extra support when prescribed physical activity in primary care: a qualitative study. Scand J Prim Health Care. 2017;35(1):64‐74.

172.

Ten Cate

. Competency-based education, entrustable professional activities, and the power of language. J Grad Med Educ. 2013;5(1):6‐7.

173.

Tovin

. Competency-based education: a framework for physical therapist education across the continuum. Phys Ther. 2022;102(5):1.

174.

American Physical Therapy Association. A vision for excellence in physical therapy education: culmination of the work of the education leadership partnership August 2021. J Phys Ther Educ. 2021;35(Supplement 1):1‐35.

175.

Chesbro

Jensen

Boissonnault

. Entrustable professional activities as a framework for continued professional competence: is now the time? Phys Ther. 2018;98(1):3‐7.

176.

Katoue

Schwinghammer

. Competency-based education in pharmacy: a review of its development, applications, and challenges. J Eval Clin Pract. 2020;26(4):1114‐1123.

177.

Hatcher

Fouad

Campbell

McCutcheon

Grus

Leahy

. Competency-based education for professional psychology: moving from concept to practice. Train Educ Prof Psychol. 2013;7(4):225‐234.

178.

Torralba

Jose

Katz

. Competency-based medical education for the clinician-educator: the coming of milestones version 2. Clin Rheumatol. 2020;39(6):1719‐1723.

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