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. 2016 Feb 10;25(1):11–21. doi: 10.1080/10669817.2015.1122308

An abbreviated therapeutic neuroscience education session improves pain knowledge in first-year physical therapy students but does not change attitudes or beliefs

Terry Cox 1,*, Adriaan Louw 2, Emilio J Puentedura 3
PMCID: PMC5539573  PMID: 28855788

Abstract

Objective

To determine if a 3-hour therapeutic neuroscience education session alters physical therapy student’s knowledge of pain and effects their attitudes and beliefs regarding treating chronic pain.

Methods

Seventy-seven entry-level doctoral physical therapy students participated in the study. Following consent, demographic data were obtained and then the subjects completed the Neuroscience of Pain Questionnaire, the Health Care Provider’s Pain and Impairment Relationship Scale and an additional questionnaire designed by the researchers. The subjects then received a 3-hour educational session developed by the researchers, focusing on the neurobiology and physiology of pain. The questionnaires were re-administered immediately after the educational session and at 6 months post-education.

Results

Seventy-seven subjects (mean age = 24.7 years, 57.1% female and 81.8% white) completed the questionnaires pre- and post-educational session with 75 completing the questionnaires at 6 months. To assess the effect of the education on the scores of the questionnaires, a repeated measures ANOVA was conducted. Students demonstrated significantly higher scores on the neuroscience of pain questionnaire (p < 0.001) with no significant effect found on the attitudes and beliefs questionnaire at any of the time points. There were significant differences found on some of the individual questions that were part of the additional questionnaire.

Discussion

An educational session on the neuroscience of pain is beneficial for educating entry-level doctoral physical therapy students immediately post-education and at 6 months. This educational session had no effect on the student’s attitudes and beliefs regarding treating the chronic pain population. There were additional significant findings regarding individual questions posed to the subjects.

Keywords: Therapeutic neuroscience education, TNE, Pain education, Pain neuroscience education, Physical therapy student, Neuroscience of pain questionnaire, Health care provider’s pain and impairment relationship scale, Chronic pain

Introduction

Recent research into educational strategies for patients with musculoskeletal pain shows an increased use of therapeutic neuroscience education (TNE).1–4 TNE aims to reduce pain and disability by helping patients gain an increased understanding of the biological and physiological processes involved in their pain experience.5,6 TNE differs from traditional patient education strategies by not focusing on anatomical or biomechanical explanations for pain, but rather on neurophysiology, neurobiology, processing and the representation and meaning of pain.3,5,7

To date, studies on TNE have focused primarily on patients with various forms of musculoskeletal pain, such as chronic low back pain (LBP),4,6,8 whiplash associated disorders,9 acute LBP,10 chronic fatigue syndrome7 and lumbar surgery.11 In contrast to patient-centered studies, Moseley demonstrated that a 3-hour TNE session increased the knowledge of pain in various health care providers (physical therapists, nurses, psychologists, etc.).12 In regard to physical therapy students, very little information is available on the use and benefits of TNE. Latimer et al., demonstrated that a 16-hour pain module specific to chronic LBP, taught to 618 physical therapy students, had a positive effect on the attitudes and beliefs regarding the treatment of chronic LBP.13 There has been no study of TNE in United States physical therapy programs despite the identified need for improved patient education related to pain.14 With the increased clinical use of, and research associated with TNE, physical therapy students will likely experience a greater need for training in TNE to be able to better educate patients on their pain experiences.14 With the increased rates of chronic pain globally15–18 and the well-documented struggles that physical therapists have treating patients with chronic pain13,19,20, there is clearly a need for an efficient method for educating physical therapists who are charged with treating this population. Therefore, this study developed and utilized an abbreviated, 3-hr. TNE session to determine if it had the ability to alter physical therapy students’ knowledge of pain, as well as their attitudes and beliefs regarding the treatment of patients with chronic pain.

Methodology

Participants

Seventy-seven entry-level doctoral physical therapy (DPT) students in the first year of their curriculum were asked to participate in the study. These students were in the summer term of their first year, which began the previous fall. Their first year of study consisted mostly of foundational education preparing them for more specific, advanced education in physical therapy. All 77 of the students agreed to participate in the study and each signed an informed consent prior to the study.

Questionnaires

The research review board of Southwest Baptist University approved this study. Study participants completed a demographic survey asking for age; gender; race; highest degree obtained; pain rating if they were currently in pain; identifying if they had ever had surgery before; and if they or any family member were currently in or had ever been in chronic pain (defined as being in pain for 6 months or more at any one time). Following this, they completed the Neuroscience of Pain Questionnaire (NPQ).12,21 This test/questionnaire was designed to assess an individual’s knowledge regarding pain and is based upon postgraduate medical student examination papers on the subject of pain and consists of 19 true/false questions. The NPQ has been used in both the health care worker population and the patient population with some modifications for clarity.12,21 The questions and answers have been checked for accuracy based upon a classic, seminal textbook on pain.22

Study participants then completed the Health Care Provider’s Pain and Impairment Relationship Scale (HC-PAIRS).13 This survey was used to assess the participant’s attitudes and beliefs regarding adults with chronic low back pain. Although specifically designed to assess attitudes and beliefs about chronic low back pain, the HC-PAIRS was used in this study as an assessment of attitudes and beliefs regarding chronic pain not necessarily specific to the low back, with the low back provided as one example of chronic pain. The HC-PAIRS consists of 15 questions where the respondent marked a response on a seven-point Likert scale anchored on one end with “Completely Disagree” and on the other end with “Completely Agree”.13,23 When used to measure attitudes and beliefs of health care providers regarding chronic low back pain, this scale has been shown to have high reliability, internal consistency, and discriminant validity.23 In addition, another study found the HC-PAIRS to be a reliable and valid measure of health care provider’s attitudes and beliefs about the relationship between pain and impairment.24 This survey has been previously used in the physical therapy student population.13 Interestingly, a student’s year in professional training has been shown to make a difference in the scores on the HC-PAIRS with students in the latter years of training scoring more positively than those early on in their training.25–28

Participants then completed a final survey with 14 questions designed by the researchers in line with the research question. These questions asked the participants to rank which health care providers, in their opinion, are most ideally situated to treat patients with chronic pain. It also included questions designed to elicit information about their attitudes and beliefs regarding the treatment of the chronic pain population that were not included in the HC-PAIRS. Additionally, it included questions regarding the participants’ perceived preparedness for treating this patient population. These questions were all scored on a 10-point Likert scale anchored by “Strongly Disagree” on one end and “Strongly Agree” on the other (Appendix 1).

Prior to, immediately after, and 6 months after the TNE session, participants completed the NPQ, HC-PAIRS and the additional survey. During this 6-month period, the participants had some of the material interspersed in the musculoskeletal lectures during their normal course work but questions on the NPQ or the surveys were not specifically addressed. At the 6 month data collection period, there were only 75 subjects as 2 subjects were dismissed from the program for academic reasons during the 6 months after initial data collection.

Educational protocol

TNE was provided in a 3-hr. lecture focusing on the neurobiology and physiology of pain, with no particular reference to any of the questions in the NPQ.4,6,29 This lecture was presented by one of the researchers (TC) utilizing a Power Point presentation and the participants were given lecture handouts, allowing the ability to take notes. Questions were encouraged and answered based on the TNE lecture.

Statistical analysis

To assess the effect of TNE on scores on the NPQ and HC-PAIRS, two separate repeated measures ANOVAs were conducted, with time (pre-, post- and 6 months post-) as the within-subject variables. To assess the relationship of gender, presence of current pain, surgical history, pain lasting more than 6 months, and family history of pain lasting more than 6 months, on scores on the NPQ and HC-PAIRS, these were added one at a time (using a stepwise approach) as the between-subjects variables in the aforementioned ANOVAs.

To assess the effect of TNE on student beliefs about study specific additional pain questions (Appendix 1), mean scores for the answers were calculated for each time period and repeated measures ANOVAs were conducted for each question with time as the within-subject variables. An alpha level of 0.05 (a = 0.05) was selected prior to the study, and we used a Bonferroni adjusted alpha for multiple comparisons.

Results

Participants

Seventy-seven students participated in the study (75 at the 6-month data collection). Mean age of the group was 24.7 ± 2.5 years and 44 (57.1%) were female. The group was comprised of 63 whites (81.8%); 4 African-Americans (5.2%); and 10 Asians (13.0%). Twenty of the students (26%) reported current pain with a mean pain rating of 2.7 ± 0.2. Forty-five (58.4%) reported a history of surgery; sixteen (20.8%) reported having pain longer than 6 months; and twenty-five (32.9%) reported a family history of pain lasting longer than 6 months.

NPQ and HC-PAIRS

There was a significant interaction observed for NPQ over time, F(1, 73) = 367.53, p < 0.001 (Partial Eta Squared = 0.832, Observed Power = 1.000). Pairwise comparisons showed that students demonstrated significantly higher scores on the NPQ immediately following TNE, as well as 6 months later (Ps < 0.05). There was also a decline in scores between immediately after TNE and 6 months later which was significant at the 0.05 level (Fig. 1).

Figure 1.

Figure 1

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Mean scores on the NPQ pre-education, immediately post-education and 6 months post-education.

Gender, presence of current pain, surgical history, pain lasting more than 6 months and family history of pain lasting more than 6 months had no significant effect on scores on the NPQ (p > 0.05).

There was no significant interaction observed for HC-PAIRS over time, F(1, 73) = 0.772, p = 0.464 indicating that TNE had no significant effect on HC-PAIRS scores at any time point (Fig. 2).

Figure 2.

Figure 2

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Mean scores on HC-PAIRS pre-education, immediately post-education and 6 months post-education.

Study specific additional attitudes and beliefs questions

Rankings of the health care providers thought by students to be best suited to treat chronic pain were ordered (lowest number representing top choice) and means calculated for each time period. The Pain Management Doctor was consistently ranked as the profession most ideally suited to treat chronic pain (grand mean = 1.61), with Physical Therapists close behind them (grand mean = 1.98). For the Pain Management Doctor, there was a significant difference in ranking from pre (1.48) to post (1.99) (p = 0.008) and from post (1.99) to 6 months (1.36) (p = 0.001) but no significant difference between pre and 6 months (p = 1.000). The effect size (η2) was moderate at 0.08 (Fig. 3). For all other professions, there were no significant differences in rankings over time.

Figure 3.

Figure 3

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Ranking of health care providers ideally suited to treat chronic pain.

The results of the changes between pre-TNE, immediate post-TNE and 6-month post TNE regarding the various study specific additional attitudes and beliefs questions (Appendix 1, questions 3–14) can be found in Table 1.

Table 1.

Mean scores pre-, immediate post- and 6-month after TNE regarding level of agreement with the various study specific additional attitudes and beliefs questions

Question Pre score Post score 6-mths score p-value pre-post p-value post-6-mths p-value Pre-6-mths
Question 3: Physical therapy is the ideal profession to treat chronic pain 6.91 7.67 7.68 0.001* (η2 = 0.08) 1.00 0.010* (η2 = 0.08)
Question 4: There is a lot that physical therapists can offer chronic pain patients 7.61 8.01 7.85 0.091 1.00 1.00
Question 5: Therapists should stop any/all treatments of chronic pain patients short of pain to avoid unnecessary flare-up of symptoms 4.84 4.36 5.11 0.424 0.023* (η2 = 0.03) 1.00
Question 6: Movement is essential in treating chronic pain 6.37 5.91 7.21 0.225 0.000* (η2 = 0.12) 0.006* (η2 = 0.12)
Question 7: I am nervous about treating chronic pain patients in clinical practice/clinical rotations 5.24 5.35 5.72 1.000 0.427 0.313
Question 8: I feel prepared to treat chronic pain patients in clinical practice/clinical rotations 2.61 4.39 4.32 0.000* (η2 = 0.21) 1.000 0.000* (η2 = 0.21)
Question 9: The mantra “no pain, no gain” should apply to the treatment of chronic pain patients 1.76 1.96 1.04 1.000 0.000* (η2 = 0.07) 0.010* (η2 = 0.07)
Question 10: The mantra “let pain be your guide” should apply to the treatment of chronic pain patients 5.19 4.39 5.03 0.024* (η2 = 0.03) 0.213 1.000
Question 11: Chronic pain patients should not be expected to engage in aerobic exercise as part of their treatment plan 2.55 2.97 1.68 0.498 0.067 0.001* (η2 = 0.08)
Question 12: Patients in chronic pain will likely require a great deal of passive treatments such as physical agents (modalities), manual stretching and massage 5.99 5.78 6.39 1.000 0.063 0.470
Question 13: Once educated about their pain, the chronic pain patient can be treated like any other treatment by seeking out and correcting physical impairments 5.03 4.72 5.09 0.898 0.624 1.000
Question 14: Chronic pain can only be managed by physical therapy and cannot really be “treated” 3.59 3.43 3.93 1.000 0.499 1.000
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Notes: Effect sizes are given as Eta squared (η2) values and Cohen’s guidelines suggest small = 0.01; medium = 0.059; and large = 0.138.

*

Mean difference is significant at 0.05 level with Bonferroni adjustment for multiple comparisons.

Comparing the pre-TNE to immediate post-TNE values, there was statistical significance found for 4 of the 11 questions, indicating a positive change regarding these items. There were other questions that were found to be statistically significant pre-TNE to 6-month post-TNE and post-TNE to 6-month post-TNE (Please see Table 1 for these results).

Discussion

The results from this study indicate a brief, 3-hr. TNE session on the neurophysiology and neurobiology of pain can increase the knowledge of pain and change some specific beliefs regarding therapy and pain in DPT students, not only immediately after education, but also 6 months later.

The results regarding the immediate increase in NPQ scores by the DPT students concur with the study by Moseley.12 Prior to TNE, the students averaged a correct NPQ score of 41.3%, while Moseley’s untrained health care professionals averaged 61%.12 This lower starting score could likely be attributed to the comparison of first-year physical therapy students in this study population to already trained and qualified health care professionals in the Moseley study. Following TNE, the students improved to an average correct score on the NPQ of 84.2%, which is very comparable to the Moseley study showing a post TNE-average score of 78% in health care professionals.12 This result is meaningful, showing that DPT students, even early in their educational training, are able to increase their understanding of pain neurophysiology and neurobiology, similar to already-trained health care providers. This result concurs with the overall premise of the study by Moseley on patients’ ability to improve their NPQ score, indicating TNE can be understood by patients, students and health care providers.12 This study, however, helps to clarify the use of TNE for educating future and perhaps current physical therapists by being the first published study identifying the lasting effect of a single TNE session, 6-months later.14

In health care educational models, degradation of information is well documented.30,31 Unless educational material is revisited and reinforced, information decay occurs.30,31 In health care literacy, it is thus encouraged to provide additional strategies to maintain gained health care knowledge, such as providing refresher educational sessions, booklets, follow-up phone calls or electronic mail.32–34 This study, however, demonstrates a maintained, albeit slightly lower, NPQ score (76.9%) at 6-month follow-up. It could be argued that the ongoing classes during the 6-months after the TNE, which contained biological and physiological information likely pertaining to the TNE presentation, could have helped with the maintenance of knowledge as described before. Nevertheless, this study is the first exploring and showing the lasting effect of TNE on NPQ scores after initial exposure.

In contrast to the NPQ results, the student’s scores on the HC-PAIRS did not change significantly immediately after, or at 6-months following the TNE session. These results are seemingly contrary to the findings of the Latimer study, measuring the attitudes and beliefs of physiotherapy students to CLBP.11 The Latimer study, however used students who had already progressed through more than half of their training to become qualified PT’s, thus exposing them to clinical scenarios, clinical rotations and increased knowledge and experience as to the functional difficulties patients with chronic pain face, which is in contrast to the entry-level DPT students used in this study. The HC-PAIRS specifically examines the attitudes and beliefs in regard to impairments and disability, which are likely developed during clinical exposure to patients.23 Additionally, professional health care student training year impacts the results of the HC-PAIRS with fourth-year students scoring lower than those in their first year of study (lower scores indicates a more positive belief and attitude),25,26 and third-year physical therapy students have been shown to have more positive attitudes regarding fear avoidant beliefs than do first-year students.27 Furthermore, the Latimer study provided a 16-hr. pain module specific to chronic LBP, while this study provided a 3-hr. abbreviated TNE lecture, not specific to CLBP. The contrasting findings from this study and the Latimer study, however, do highlight questions regarding optimal duration and timing in the curriculum of TNE material.13

An analysis of the results of the additional questions yielded interesting and important findings. Some significant shifts occurred immediately following the TNE session, including seeing PT as an ideal profession to treat chronic pain (Question 3); feeling more prepared to treat people with chronic pain (Question 8); and beliefs that pain should serve as a guide to treatment for patients with chronic pain (Question 10). These shifts reflect a positive view in the role of PTs treating people in chronic pain, including the student’s future role and thus feeling more prepared. These short-term shifts in attitudes were maintained at 6-months for DPT students viewing PT as the ideal profession to treat chronic pain and feeling prepared (as students) to treat people with chronic pain. Interestingly, there was a return to pre-TNE level beliefs about pain serving as a guide in the management of patients with chronic pain. In the light of the evidence that PT’s often struggle treating people with chronic pain,13,19,20 these findings provide evidence that TNE may shift DPT students’ attitudes regarding the role of a PT in treating people with persistent pain. This finding concurs with a recent study35 where a single TNE session provided to patients with fibromyalgia resulted in a significant positive shift in the patient’s view and ability of PT helping people with persistent pain. TNE focuses on the neurobiology and neurophysiology of a patient’s pain experience.4,14 Viewing treatments from a biological movement perspective may indeed allow a reappraisal of a movement/biological profession such as PT to help people in pain. This concurs with the DPT students’ significant shift from pre-TNE to 6-months later view of movement being essential in treating chronic pain (Question 6) and disagreement that aerobic exercise should be discontinued in people with pain (Questions 11). This reappraisal of movement, especially aerobic exercise, concurs with current best-evidence treatment for people in pain necessitating aerobic exercise and movement.36–38 Supporting this overall increased positive view of PT’s role in treating people with chronic pain, it is noteworthy that immediately after and 6-months after the TNE session, students did not express any change in nervousness when treating people suffering from chronic pain (Question 7).

Questions 5, 6 and 9 were only found to be statistically significant comparing post-TNE values with 6-month post-TNE values but not immediately post-TNE. There may be many factors that account for this. It may be explained by the students becoming more exposed to the musculoskeletal curriculum during the 6-month time period and thus some of the concepts may have been reinforced, although not specifically. But it may also be explained by the students becoming more mature and processing the information over the 6-month time period, and it becoming more meaningful to them as they move closer to being exposed to chronic pain patients in their clinical rotations.

Conclusions

The results of this study indicate that a 3-h TNE session regarding basic pain neuroscience principles as measured by the NPQ is beneficial in educating entry-level DPT students early on in the DPT program. The results also indicated no changes in the attitudes and beliefs of the entry-level students in regard to the chronic pain population as measured by the HC-PAIRS. These results are encouraging for the use of a brief TNE program in physical therapy entry-level curricula to help fill a perceived gap regarding the education of the students in the area of pain neuroscience and treating the chronic pain population.

Appendix 1.

Appendix 1.

Appendix 1.

Appendix 1.

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