a comparison of the knowledge of chronic pain and its management between final year physiotherapy...

European Journal of Pain 13 (2009) 38–50

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European Journal of Pain

journal homepage: www.EuropeanJournalPain.com

A comparison of the knowledge of chronic pain and its management betweenfinal year physiotherapy and medical students

Nada Ali, Di Thomson *

Institute of Origin, Kings College, London University, Academic Department of Physiotherapy, School of Biomedical Sciences, Kings College, Shepherd’s House, Guy’sCampus, London SE1 1UL, United Kingdom

a r t i c l e i n f o

Article history:Received 2 August 2007Received in revised form 15 January 2008Accepted 14 February 2008Available online 23 April 2008

Keywords:Chronic painMedical studentsPhysiotherapy studentsEducationUndergraduateSurveyKnowledgeManagement

1090-3801/$34.00 � 2008 European Federation of Chdoi:10.1016/j.ejpain.2008.02.005

* Corresponding author. Tel.: +44 0207 848 6336 (O+44 0207 848 6325.

a b s t r a c t

The scientific literature reveals a surprising lack of knowledge of chronic pain mechanisms and its man-agement amongst health care professionals, including physicians and physiotherapists. There is littleinformation directly related to a comparison between medical and physiotherapy students’ knowledgeof chronic pain. This study aimed to determine and compare the level of knowledge of chronic painand its management between final year medical (n = 126) and physiotherapy students (n = 62). A chronicpain questionnaire which included two sections on knowledge and one section on management was usedto gather quantitative and qualitative data. Final year physiotherapy students were found to have statis-tically greater knowledge of chronic pain than final year medical students (p = 0.01 and p = 0.002). In con-trast, medical students were found to have statistically significantly greater understanding of themanagement of patients with chronic pain (p = 0.001). Male students from both groups scored signifi-cantly higher in the management section (p = 0.008) as did older students (p = 0.01). There was a lackof understanding, in varying degrees, of central sensitization, opioid addition, fear-avoidance and a num-ber of students from both cohorts appeared to bring a curative focus to the treatment of chronic pain. Oneway forward could be found in the interprofessional agenda. This will offer students from different dis-ciplines opportunities to understand their different roles and enhance each others’ learning base so that abiopsychosocial framework of care can be implemented. In this way, physiotherapists could learn moreabout the drug management of chronic pain and medical students could explore more collaborativepatient-centred paradigms that address issues such as self-efficacy, self-management and patientempowerment. More focus needs to be paid to the education of the health professionals regarding theirassumptions and understanding what ‘vulnerable’ means in a tissue in comparison to a person.� 2008 European Federation of Chapters of the International Association for the Study of Pain. Published

by Elsevier Ltd. All rights reserved.

1. Introduction

Pain is among the most common complaints for which peopleseek medical care, yet pain is also among the most under treatedpatient complaints (Heit, 2003). Despite extensive progress in thescientific understanding of pain over the last decade, patients ap-pear to continue to suffer needlessly (Weinstein et al., 2000) andare paying a heavy price for the reduced quality of life, and eco-nomic costs (Glajchen, 2001). Expertise in treating chronic pain isscarce; typically, there is an under provision of services, and signif-icant unexpressed demand (CSAG, 2000). One reason for this maybe found in the education of the health professionals in whose carethese patients lie. It is possible that adequate pain management ishindered by lack of knowledge in the subject area of pain (Pharm

apters of the International Associa

)/+44 01727 838530 (H); fax:

et al., 1999; Weinstein et al., 2000). This may be because effectivepain management can be complex, requiring approaches that ex-ceed the expertise of one profession. It is a multidimensional phe-nomenon that cuts across professional boundaries, pharmacists,nurses, psychologists, occupational therapists, doctors and physio-therapists all having an input into its management (Carr et al.,2003). Pharmacists are key to the appropriate use of pharmacolog-ical interventions, nurses co-ordinate the care, education and med-ical therapy, psychologists focus on the use of active coping skills,doctors concentrate on potential medical or surgical interventionsand therapists manage the physical rehabilitation process (Ash-burn and Staats, 1999).

The most common research methods for ascertaining healthprofessionals’ knowledge of pain and its management is by utiliz-ing a self-report questionnaire on different populations of healthprofessionals. Some have tested the basic factual knowledge offinal year nurses (Chiu et al., 2003), others have included boththe knowledge and beliefs of different health care professionals

tion for the Study of Pain. Published by Elsevier Ltd. All rights reserved.

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N. Ali, D. Thomson / European Journal of Pain 13 (2009) 38–50 39

(Lebovits et al., 1997) and Rochman (1998) used a questionnairewhich cited 10 common myths about pain to test occupationaltherapists.

The previous studies included questions on both acute andchronic pain whereas others with a focus on chronic pain have ar-gued that apart from knowledge the attitudes of health profession-als play an important role in the treatment of patients and haveutilised questionnaires with this in mind. Three such instrumentsused by Houben et al. (2005a) are the Pain Attitudes and BeliefsScale for physiotherapists (PABS-PT) (Ostelo et al., 2003) which dif-ferentiates between a biomedical and a biopsychosocial treatmentorientation to low back pain, the Pain and Impairment RelationshipScale (HC-PAIRS) (Rainville et al., 1995) originally designed for pa-tients but adapted for health professionals and the Tampa Scale forKinesiophobia (TSK) (Kori et al., 1990) designed to measure fear ofmovement.

The limitations of these scales are invariably those associatedwith questionnaires generally, that is, to what extent do the resultsof questionnaires correspond with actual treatment behaviour? Insome respects Houben et al. (2005b) addressed this by also show-ing videos of patient/therapists interactions. They also offset thereasoned responses asked for by the PABS-PT with a measure ofautomatically activated attitudes (the Extrinsic Affective SimonTask – EAST).

The results of questionnaires, videos or indeed paper patientsmay in the end have few implications for practice and arguablythe only way to assess health providers’ attitudes and behaviouris by making use of direct observation of treatment sessions as theyoccur. However, limitations of this qualitative approach lie in theproblems inherent in the transferability of insights from one con-text to another, the effect of the observer on the observed andthe number of observations that would be required to give arounded picture of practice.

Both physicians and physiotherapists play an important andmajor part in the management of pain (Ihlebaek and Eriksen,2004). Pain is one of the most common reasons for seeing a physi-cian in primary care and one-fifth of pain patients have sufferedfrom pain for more than 6 months (Mantyselka et al., 2001). Thereis evidence that doctors have difficulty with patients with backpain (Chaudhary et al., 2004; Breen et al., 2007) and that GPs’ con-fidence in their own abilities to assess and supply evidence-basedcare for back pain is lacking (McIntosh and Shaw, 2003; Breenet al., 2004) making this an important area for improved education(Skelton et al., 1995). A recent study (Breen et al., 2007) found thatGPs did not explicitly express a lack of knowledge regarding thepossible influence of psychosocial factors in patients with low backpain but this belied their responses on the subject.

According to previous studies the teaching of pain related topicsin medical schools is fragmented, important topics are poorly cov-ered and specific curricula for pain are uncommon (Turner andWeiner, 2002; Poyhia and Kalso, 1999; Watt-Watson et al., 2004;Poyhia et al., 2005). There still continue to be concerns about clini-cians’ reluctance to prescribe and support the use of opioids forchronic non-malignant pain (Heit, 2003; Vallerand, 2003; Cowanet al., 2003; Glajchen, 2001). This points to a continuing lack ofknowledge with respect to the pharmacology of opioid therapy(Weinstein et al., 2002b). Green et al. (2002) found that a largenumber of physician respondents selected a poor treatment optionfor the chronic pain vignettes they studied and prescribed opioidanalgesics infrequently. On the other hand, current thought maybe filtering through because the younger respondents and thosewho had received education in pain were more likely to choosethe optimum responses to the vignettes.

Physical therapists also play a vital role in the management ofpain. Wolff et al. (1991) surveyed practicing orthopaedic physicaltherapists on their knowledge of pain mechanisms and pain man-

agement and found that their pain knowledge scores were low, andthe scores on positive attitudes toward treating patients withchronic pain were even lower. However, these results must beviewed with caution as only 23.8% of the questionnaires returnedwere useable. More recently Scudds et al. (2001) surveyed 169physiotherapy programmes in North America and found thatalthough a large proportion of the programme leaders felt that painwas adequately covered the few hours spent on it were inconsis-tent with this belief.

The IASP curriculum for physical therapists stresses the multidi-mensional nature of pain and the need for adequate assessment(Scudds and Solomon, 1995). In spite of this it is of concern thatDaykin and Richardson (2004) found that the physiotherapists’treatments for patients with chronic low back pain were basedon the medical model of acute pain. Similarly, Foster et al. (1999)found that physiotherapists in Britain and Ireland were not incor-porating current-best evidence into their practice as advocated bya biopsychosocial approach.

Bonica (1990), the founder of the movement toward specializedpain clinics, contends that ‘‘no medical school has a pain curricu-lum” and this is echoed by the literature (Poyhia and Kalso,1999; Watt-Watson et al., 2004; Poyhia et al., 2005; Niemi-Murolaet al., 2006). The teaching of pain continues to be disorganized,unstructured, fragmented, and inadequate (Unruh, 1995; Field,1996; Poyhia et al., 2005; Niemi-Murola et al., 2006). Moreover,medical education may even reinforce negative orientation to pa-tients with complex biopsychosocial problems and may contributeto irrational attitudes and beliefs about pain (Weinstein et al.,2000a). Consequently, negative attitudes and misconceptions rein-forced as undergraduates are more difficult to change later (Watt-Watson et al., 2004). It is clear from the extant literature that aconcerted effort is needed not only to fill the gap in undergraduateeducation of chronic pain but also to bridge the gap between painresearch and pain management practices (Watt-Watson et al.,2004).

The International Association for the Study of Pain (IASP) hadpreviously noted this deficit and appointed a subcommittee onMedical School Courses and Curriculum in 1985 (Pilowsky,1988). Their subsequent report concluded that pain was not wellintegrated into the medical curriculum (Strong et al., 1999). As aresult, the IASP published guidelines on desirable standards withregard to general pain knowledge for various health professionalsat undergraduate and specialist levels (Pilowsky, 1988; Scuddsand Solomon, 1995). Despite these efforts, the content in mostundergraduate courses continues to be minimal with respect topain and many authors feel that this requires serious attention(Poyhia and Kalso, 1999; Turner and Weiner, 2002; Watt-Watsonet al., 2004; Poyhia et al., 2005; Niemi-Murola et al., 2006).

The aim of this study is to investigate and compare the knowl-edge of chronic pain and its management between final year phys-iotherapy students and final year medical students at a CityUniversity college with the view of informing the pre-registrationeducation in this area. It also attempts to identify the determiningfactors that might influence the students’ knowledge and manage-ment of chronic pain.

2. Methods

This is a survey-based research design. Ethical approval wasgranted by the College Research Ethics Committee prior to com-mencement of the study. Final year medical and physiotherapystudents were approached separately by the researcher followingtheir respective lectures. After an oral and written explanation ofthe purpose of the study the students were invited to fill in thequestionnaire. Voluntary participation and confidentiality wereguaranteed as well as an assurance that refusing to participate

1 Chartered Society of Physiotherapy 2005 Personal communication.2 Royal College of Physicians: briefing on women in medicine August 2004

www.rcplondon.ac.uk/college/statements/briefingwomenmed.asp.

40 N. Ali, D. Thomson / European Journal of Pain 13 (2009) 38–50

would in no way jeopardize their education. They were allowed totake as long as they wished, no effort was made to aid them andthey were requested not to confer or discuss answers. They werenot given the option of taking the questionnaire away becausethe answers to the questions testing their knowledge could becompromised and this would be a confounding factor to the study.The tick box questionnaire was developed based on a review of theliterature on chronic pain, published questionnaires, discussionswith experts in the field and a statistician.

There are few recently published questionnaires specificallyfor student health professionals’ knowledge and beliefs aboutchronic pain. However those consulted were the HC-PAIRS scale(Rainville et al., 1995), a questionnaire listing 10 common myths(Rochman, 1998) and the Pain Attitudes and Beliefs Scale forphysiotherapists PABS-PT (Ostelo et al., 2003) and a 23-item painknowledge questionnaire (Trinca, 1998). In total the question-naire used in this study consisted of 16 questions. The first threequestions elicited demographical data. Questions 4–8 exploredthe students’ academic, clinical, and personal experiences ofchronic pain in order to determine and consider the influenceof these factors on their knowledge and management. Questions9 and 10 presented statements of facts and asked for a level ofagreement from true, false or don’t know (Q. 9) and from‘strongly agree’ to ‘strongly disagree’ (Q. 10). The responseoption’don’t know’ was included in Q. 9 to avoid guessing theanswer. Questions 9 and 10 covered areas of physiology, pathol-ogy, psychology and sociology of chronic pain and issues of opioidaddiction and disability. Question 11 asked for a level ofagreement from ‘strongly agree’ to ‘strongly disagree’ regardingapproaches to the management of patients with chronic painand question 12 on the health professionals involved in the man-agement of these patients. The final part of the questionnaire (Q.13–16) invited comments from the students about this area ofpractice. The questionnaire was piloted on seven health profes-sionals (currently undertaking a MSc in Pain) not involved inthe study to check for the clarity of the instructions, ambiguityand to determine the time needed to complete the survey. Inaddition face validity, content validity, construct validity andcriterion-related validity were all addressed (Portney andWatkins, 2000).

2.1. Data analysis

Data were analysed using the statistical package SPSS v 12 forWindows. Descriptive statistics were used where possible to de-scribe data (mean, median, frequencies, etc.) Data were otherwiseordinal; non-parametric tests were thus used for analysis. This ap-proach was also appropriate as participants were not randomlysampled.

A Mann–Whitney U-test was used to compare the mean re-sponses between the two groups, that is, the medical studentsand the physiotherapy students. A Kruskal–Wallis test was usedto compare responses across several independent areas. The Spear-man’s rank correlation coefficient was used to identify relation-ships between two variables. The v2 test was used to look forsignificant differences between the two groups. Statistical signifi-cance was set at p < 0.05. Further information provided verbatimwas analysed by a content analysis approach and categories andthemes were identified (Burnard, 1991).

3. Results

3.1. The response rate

The response rate was final year physiotherapy students 89%(62) and final year medical students 79% (126). This response rate

was sufficient to provide statistically meaningful results. 82% (51)of the physiotherapy students were female which is broadly repre-sentative of the UK physiotherapy student population1 59% (74) ofthe medical students were female. This figure is slightly lower thanthe national average number of women accepted for training in theUK which is 61%.2 The distribution of age is positively skewed in thetwo groups of students. The mean age is 24.57 years (range = 22–33)for medical students and 23.06 years (range = 21–36) for physiother-apy students, indicating that final year physiotherapy students arerelatively younger than final year medical students.

3.2. The teaching of chronic pain

All physiotherapy and medical students (n = 188) had reportedreceiving teaching on chronic pain. Seventy-three percent of phys-iotherapy students reported receiving their teaching within 0–11months ago, whereas 50% of the medical students reported receiv-ing their teaching within 1 year to 1 year to 11 months ago.

3.3. Context of received teaching

Interestingly, only 38% of medical students and 31% of the phys-iotherapy students reported receiving teaching on chronic pain inneuroscience lectures. Thirty-four percent of medical studentscompared to 8% of physiotherapy students reported receivingteaching on chronic pain in pharmacology lectures. Twenty-fourpercent of medical students compared to 84% of physiotherapystudents reported receiving teaching on chronic pain in psychologylectures. Eighty percent of medical students compared to 42% ofphysiotherapy students reported receiving teaching on chronicpain while on clinical placements.

4. Knowledge of chronic pain

4.1. Knowledge-1

This item was comprised of eight questions. The range of totalscores of students of both groups (n = 186) was from �2 to 8. Onaverage, students’ total scores fell in the range 4 where possiblerange of scores is �8 to 8. This means that their knowledge levelis higher than the average score of zero. However, only 4% of allthe students answered all the 8 knowledge-1 questions correctly(Table 1).

Distribution of the overall knowledge-1 scores of the twogroups are presented by box plot (Fig. 1) and Table 2. In Fig. 1,the horizontal line within each box indicates the median scoreand the upper and lower boundaries of the box represent the in-ter-quartile range. The whiskers represent the extreme range ofscores. Differences in total knowledge-1 scores between the twogroups of students were calculated using a Mann–Whitney U-test.Table 2 reveals that physiotherapy students scored significantlyhigher than medical students in the knowledge-1 item (p = 0.01).

4.2. Knowledge-2 (Likert scale)

There were a total of 186 responses to this knowledge-2 itembecause two students failed to respond. On average, students’ totalscores fell in the range 19 where the possible range of scores is 5–25. This minimum score of 5 was the lowest score obtainable in the5-question knowledge-2 item Fig. 2.

http://www.rcplondon.ac.uk/college/statements/briefingwomenmed.asp

Table 1Knowledge of chronic pain comparison of knowledge-1 between cohorts

Incorrect Don’t know Correct Total

Count % Count % Count % Count %

Medicine1. Chronic pain is closely related to tissue damage 20 16 10 8 94 76 124 1002. Pathology is often identifiable 17 14 3 2 104 84 124 1003. It results in changes in Central Nervous System 27 22 19 15 78 63 124 1004. Repeated unsuccessful attempts to relieve the pain may result in hypervigilance (high alert) to pain 19 15 13 10 92 74 124 1005. Chronic pain can be cured 61 49 16 13 47 38 124 1006. Psychological factors play a major role in its development 15 12 7 6 102 82 124 1007. Psychological factors play a major role in its maintenance 7 6 7 6 110 89 124 1008. Risk of addiction to prescribed opioid analgesics to chronic pain patients is quite high 64 52 11 9 49 40 124 100

Physiotherapy1. Chronic pain is closely related to tissue damage 10 16 7 11 45 73 62 1002. Pathology is often identifiable 11 18 0 0 51 82 62 1003. It results in changes in Central Nervous System 5 8 4 6 53 85 62 1004. Repeated unsuccessful attempts to relieve the pain may result in hypervigilance (high alert) to pain 3 5 11 18 48 77 62 1005. Chronic pain can be cured 22 35 15 24 25 40 62 1006. Psychological factors play a major role in its development 2 3 0 0 60 97 62 1007. Psychological factors play a major role in its maintenance 1 2 1 2 60 97 62 1008. Risk of addiction to prescribed opioid analgesics to chronic pain patients is quite high 20 32 36 58 6 10 62 100

Frequency distribution of individual knowledge items between the two groups.

Medicine Physiotherapy

-2

0

2

4

6

8

Kn

ow

led

ge-

1

Fig. 1. Comparison of total knowledge-1 scores.

Table 2Mann–Whitney U-test results for the comparison of the total knowledge-1 scoresbetween cohorts

Background Ranks

N Mean rank Sum of ranks

Knowledge-1Medicine 124 86.41 10715.00Physiotherapy 62 107.68 6676.00Total 186

Mann–Whitney U = 2965, sig. (2-sided) p = 0.01.


14

16

18

20

22

24

26K

no

wle

dg

e-2

Fig. 2. Comparison of total knowledge-2 scores.

Table 3Mann–Whitney U-test for comparing differences in total knowledge-2 scoresbetween cohorts

Background Ranks


Knowledge-2Medicine 124 85.10 10552.00Physiotherapy 62 110.31 6839.00Total 186

Mann–Whitney U = 2802.00, sig. (2-sided) p = 0.002.


4.3. Comparison of Knowledge-2

The distribution of the total k2: Physiotherapy students hadslightly better knowledge-2 scores compared to medical studentson the 5-point scale. However, this difference was significantly lar-ger (p = 0.002) when a 3 point-scale was used for hypothesis test-

ing. The differences in total knowledge-2 scores between cohortswere tested using a Mann–Whitney U-test (Table 3).

4.4. Comparison of management

Fig. 3 shows that medical students have higher managementscores compared physiotherapy students, and Mann–Whitney

Table 4Mann–Whitney U-test results for testing the differences in total management scoresbetween cohorts (3-point scale)

Background Ranks


ManagementMedicine 125 111.14 13892.50Physiotherapy 62 59.44 3685.50Total 187

Mann–Whitney U: 1732.5, sig. p < 0.001.

Table 5Correlation of age with knowledge and management

Age

N Spearman’s q Sig. p (2-sided)

Knowledge-1 186 0.02 0.77Knowledge-2 186 �0.5 0.51Management 187 0.18 0.01

Table 6Qualitative analysis results showing different themes, responses and examples to open qu(n = 126) and final year physiotherapy students (n = 62)

Themes Number of responses Exemplar response

Medicalstudents

Physiotherapystudents

Medical students

Nos % Nos %

Time 110 59 44 23 Long-term pain >6Medical model dilemma 57 30 0 0 Unresponsive to thDisability 13 7 0 0 Hugely disablingPsychological disturbance 6 3 0 0 It has a large psych

often ignored by mCNS disturbance 4 2 5 3 PlasticityTissue healing 0 0 13 7 –Pathology 0 0 20 11 –Biopsychosocial view 0 0 15 8 –Nature of pain 0 0 11 6 –Contemptuous responses 2 1 0 0 8 h of lectures


25

30

35

40

45

Man

agem

ent

Fig. 3. Comparison of management of chronic pain between cohorts.


U-test in Table 4 shows that this difference is highly significant(p < 0.001).

4.5. The relationship between age and gender and knowledge andmanagement scores

Mann–Whitney U-test was used to test the relationship be-tween students’ gender and the knowledge and managementitems. The test revealed that male students from both groupsscored significantly higher in the management item (U = 2906,male = 61, female = 125, sig. p = 0.008) compared to femalestudents. However, there were no significant differences betweenthe two sexes and the two knowledge items.

The relationship between age and both knowledge and manage-ment were calculated using the Spearman’s rank correlation coef-ficient. The results are presented in Table 7 which show that onlythe management item was significantly (p = 0.01) positively corre-lated with age. This means, the older the student the higher themanagement scores (Table 5).

4.6. Qualitative analysis

See Tables 6 and 7.

5. Discussion

The results of this study showed there were nine statisticallysignificant differences between the two groups of students whichmay be the result of differences in teaching and practice. Scrutinyof the data showed that the questionnaire appeared to be sensitiveenough to detect these differences.

5.1. Comparison of knowledge

Overall physiotherapy students scored significantly higher thanthe medical students on both knowledge scales. The responses onindividual questions within the knowledge sections of the ques-tionnaire showed some interesting variations indicating a discrep-ancy in knowledge of particular concepts. Physiotherapy studentsscored significantly higher (p = 0.006) than medical students onthe question ‘chronic pain results in changes in the CNS’ despitethe fact that more medical students reported receiving teachingon chronic pain in their neuroscience lectures. This lack of knowl-edge of the concept of central sensitization was previously re-ported among nurses by Chiu et al. (2003) although this resultwas felt to be more a result of a limited exposure to information

estion 1 ‘‘What do you understand by chronic pain?” by final year medical students

s

Physiotherapy students

weeks for me pain for more than 6 monthserapeutic interventions –

–ological componentedical services.

–

Changes within nervous systemPain that continues beyond normal tissue healing timesThere is no organic pathology foundA combination of physical and psychosocial factors.Unpleasant–


about this important concept. This is surprising since it has ap-peared in the literature since the early nineties and has had consid-erable influence on medicine and the pharmaceutical industry.Woolf and Salter (2000) have argued that an important part ofany therapeutic approach to chronic pain is to treat or prevent cen-tral sensitization. The lack of early recognition and treatment of apatient’s acute pain does not automatically lead to sensitizationof the CNS but it is certainly a risk factor. It is especially importantfor medical students who arguably should be aware that blockingnoxious afferent input could decrease the level of CNS sensitizationand reduce the likelihood of patients developing chronic pain(Yezierski et al., 2004).

One important area of knowledge least understood by bothgroups of students was the issue of opioid addiction. Surprisingly52% (64) of the medical students thought it to be quite high and9% (11) reported ‘not knowing’, while the actual incidence is aslow as less than 1 in 1000 (Heit, 2003). Under prescribing due tounjustified fear of addiction (Turner and Weiner, 2002), a lack ofbasic knowledge and poor assessment and reassessment (Glajchen,2001) have for many years been cited as major weaknesses andresponsible for inadequate pain management. However, it is alsoimportant to realise that even the most knowledgeable health pro-fessional will not be able to change their practice without their pa-tients involvement and Mahowald et al. (2005), Galicia-Castilloand Mcelhaney (2003) and McCarberg and Barkin (2001) foundthat fear of addiction, tolerance and side effects have been de-scribed by patients. Interestingly Ward et al. (1998) also foundfatalism and the desire to please the clinician as additional con-cerns. Given that this situation has been unchanged for a consider-able number of years it is timely to consider a new model ofhealthcare that empowers patients and facilitates the effectivenessof their management. Edwards et al. (2004) cite two models, a col-laborative one in which both patient and clinician contribute theirknowledge to the encounter resulting in jointly planned and nego-tiated goals and strategies and another in which clinicians explorein greater depth their patients’ previous experiences and presentattributions to increase their understanding of their (patients’) sit-uation. At the same time they actively seek all evidence that sup-ports or challenges their own ideas about their patients and theirpractice and encourage their patients to do the same (Edwardset al., 2004; Trede et al., 2003). The future of such practice meansthat both health professionals and patients will both be requiredto reflect on their role as in any equal relationship.

Understandably given their presumed greater knowledge ofpharmacy far more of the medical students answered this questioncorrectly than the physiotherapy students.

One of the statements that received a very poor response byboth groups of students was ‘can chronic pain be cured?’ 61(49%) of the medical students and 22 (35%) of the physiotherapystudents all stated it can be cured and a further 16 (13%) and 15(24%), respectively said they did not know. On the one hand, thisstatement may have been ambiguous and therefore misinterpretedaccording to the students’ perception of the word ‘cure’. However,it was notable that although the physiotherapy students statedthat chronic pain extends beyond 6 months the medical studentsquoted 6 weeks which indicates a time limiting condition. It is ofconcern that these cohorts of prospective physicians and physio-therapists could bring this ‘curative’ focus on chronic pain intothe clinical setting. The result may have negative consequenceson both patient and health professional and carry an additional po-tential for chronic pain patients to become stigmatised as ‘problempatients’. Moreover, if patients with chronic pain are given themessage that their pain is curable it may lead to a search for a med-ical cure (McCracken et al., 2004).

Physiotherapy for patients with chronic pain incorporates aprocess of facilitating patients’ active coping strategies in order

to increase their self-efficacy and self-management and thereforetherapists in this area have become less reliant on their ‘tool box‘of technical skills and more reliant on their interpersonal skillsin adopting a patient-centred model. Not surprisingly given this fo-cus of physiotherapy the physiotherapy students commendablymentioned a ‘combination of physical and psychosocial factors’,‘changes in the nervous system’, ‘there is no organic pathology tobe found’ and there is a ‘combination of physical and psychosocialfactors’. However, despite this Daykin and Richardson (2004) foundthat biomedical pain orientated beliefs influenced the clinical rea-soning of the qualified therapists in their study. This begs manyquestions as to what has happened since they completed their edu-cation at college. Richardson (1996) suggests that the workingenvironment and senior physiotherapists’ beliefs can have a strongsocializing influence over the actions of newly qualified or novicephysiotherapists.

From a physicians’ perspective Breen et al. (2007) cite the diffi-culties GPs have in the successful management of back pain. Theimplementation of a biopsychosocial approach appeared at oddswith frequent inappropriate referrals for imaging and secondarycare interventions (Breen et al., 2007). The authors recommend amove away from education focussed on a biomedical model to-wards a more biopsychosocial framework which includes assess-ment and strategies to reduce a patient’s anxiety and distress.Additionally, a work-based learning approach could also be ad-dressed in students’ clinical education (Breen et al., 2007).

The inclusion of open questions in this study gave the respon-dents a chance to present their own understanding untroubledby the constraints of the pre-set questions. This freedom eliciteda relatively high number of medical students (30% n = 57) statingthat it is ‘unresponsive to therapeutic interventions’ and furthermore(7% n = 13) stated that it is ‘hugely disabling’ which clearly under-pinned their dependence on the medical model and their lack ofunderstanding of the nature of chronic pain. This is of course atodds with the 61 who responded that it was curable. Of course itis not possible to deduce that these two groups are different, itmay only emphasise the ambiguity of the word ‘cure’. However,whichever way one looks at it both suggest a biomedical paradigmhas been adopted albeit by a minority of medical students. The bio-medical model of pain is a single level construct which is appropri-ate where a problem’s cause can be established (such as an organicdysfunction) and which has a remedy available (Gifford, 2000).Intervention is then directed specifically toward correcting thedysfunction and if this fails the patients are frequently blamed(Gifford, 2000; Turk and Gatchel, 2002).

The medical students scored significantly higher (p = 0.001) inthe management section of the questionnaire. Conjecturally thismay be that they realise that as many drugs are not efficaciousfor chronic pain they have to be realistic and knowledgeable withthe management options whereas physiotherapist have far more‘tools’ to use and continue with a more interventionist approach.Fewer physiotherapy students compared with the medical stu-dents reported that TENS was considered effective in chronic pain.The physiotherapy students may have been more discriminatory intheir answer possibly indicating a stronger knowledge (as onewould expect given their profession) of a large variability in the lit-erature supporting its success (Moore et al., 2003).

More than a quarter of the physiotherapy students and nearly ahalf of the medical students answered that patients with chronicpain should avoid pain inducing activities. In all fairness it isimportant to note that these respondents were in the minorityand again this may have been a poorly worded statement. Never-theless health care provider’s beliefs and advice have a profoundimpact on patients’ beliefs and function and a vital message to pa-tients to maintain and improve their function despite their chronicpain is important. Fear of pain is known to be as disabling than

Table 7Table showing different themes, responses and examples to open question 2 ‘‘Do you think that some people are more prone to getting chronic pain? Please state briefly thereasons for your answer?” by final year medical students (n = 126) and final year physiotherapy students (n = 62)

Themes Number of responses Exemplar responses

Medical students Physiotherapy students Medical students Physiotherapy students

Nos % Nos %

Physical factors 12 6 0 0 Physical, pathological factors –Psychological factors 53 28 33 17 Poor coping strategies PersonalitySocio-cultural factors 26 13 12 6 Interaction of social and cultural factors Social and cultural factorsHypochondriacs 8 4 1 0.5 Neurotic Concerned for health and always visiting

the doctorMalingerers 9 5 4 2 People who want to benefit from playing

the sick roleTo get income benefits

Work status 8 4 6 3 Occupational hazards Work-related (physically hard)Pain experience 8 4 9 5 Pain thresholds vary Pain beliefsPast family history 4 2 0 0 Genetics, family history –Life experiences 2 1 5 3 Problems in other areas of life Life stressorsAge 1 0.5 1 0.5 Older people Older patientsLifestyle 0 0 7 4 – Sedentary lifestylePosture 0 0 1 0.5 – Abnormal postureEnvironment 0 0 1 0.5 – Environmental issuesNegative responses 4 2 7 4 No – it can affect anyone No – anyone is prone to itContemptuous responses 4 2 0 0 Fat women –


pain itself (Crombez et al., 1999). It has been reported that physi-cians often lack the skills and knowledge that are crucial to disabil-ity determination (Tollison et al., 2002). Interestingly, 23% (14) ofthe physiotherapy students believed that prolonged pain leads todisability and although they were in the minority this is in sharpcontrast to the fact that there is little direct relationship betweenpain and disability (Tollison et al., 2002). Consequently, the phys-iotherapy students who agreed with this statement may be lessambitious for their patients believing that disability is inevitable.This is in conflict with concepts of self-reliance and self-manage-ment and cognitive behavioural interventions which aim to im-prove patients’ self efficacy.

Despite the relatively low percentage of male students in bothmedical and physiotherapy groups they scored significantly higher(p = 0.008) than their female counterparts in the management ofchronic pain. These results are in direct contrast to the findingsof Green et al. (2003) who were unable to detect any significantgender differences in physicians. Older students in both groupswere found to perform significantly better in their understandingof the management of patients with chronic pain (p = 0.01). In lightof this finding subsequent analysis revealed significant relation-ships between age and experiences of chronic pain. This appearsto concur with Clarke et al. (1996) findings that personal painexperience correlated with high scores in pain management.

Patients with chronic pain are often the recipients of negativesocial evaluations which can lead to labeling and negative conse-quences for them and a disturbingly number of the students fromboth cohorts gave judgmental responses to the open question ‘doyou think there were some people more prone to getting chronicpain? 53 (28%) medical students thought that it was those peoplewith ‘poor coping strategies ‘ and 33 (17%) of the physiotherapythought patients’ personalities contributed to their condition. Itmust again be reiterated that these students were in the minorityalthough this does find resonance in the literature as Hahn (2001)found that ‘difficult’ patients were defined by doctors as, ‘frequentclinic attenders with chronic somatoform disorders’. More recentlyBreen et al. (2007) discovered that GPs felt that managing backpain was’ frustrating’, ‘a complete nightmare’, ‘hopeless’ and a‘complete waste of time’. As far back as 1998, Merril et al. arguedthat medical schools should prepare future physicians to managethe soma and psyche in the same individual and that those stu-dents who develop a negative orientation to psychological prob-

lems do not sketch a desirable portrait for the future. Likewisethe physiotherapists in Daykin and Richardson (2004) study statedthat difficult patients had ‘multiple areas of pain’.

Even more worrying were responses (albeit from a small sectionof both cohorts) who felt that patients with chronic pain were’malingerers’, ‘difficult to take these patients seriously’ or ‘hypno-tise them all’. Malingering is often discussed with reference tochronic pain patients (Fishbain et al., 1999). However, Jensenet al. (2003) found few studies related to malingering and painand concluded that malingering is rare in a chronic pain setting.

6. Conclusion

This study appears to concur with much of what has been writ-ten in the extant literature. There was a lack of understanding, invarying degrees, in the two groups of central sensitization, opioidaddition, fear-avoidance and a number of students from both co-horts appeared to bring a curative focus to the treatment of chronicpain. It is relevant to stress that although these students were inthe minority any negative misconceptions reinforced as under-graduates will be more difficult to change later (Watt-Watsonet al., 2004).

One way forward could be found in the interprofessional agen-da. Pain is a multidimensional problem that cuts across boundarieswith doctors, nurses, physiotherapists, occupational therapists andpsychologists all having an input into its management (Carr et al.,2003). It is generally recognized that chronic conditions whichhave many biopsychosocial implications cannot be met by theexpertise of any one discipline (Department of Health, 2001).Bringing students from different disciplines together may offeropportunities to understand their different roles and enhance eachothers’ learning base so that a holistic picture of care can be imple-mented. In this way, physiotherapists could learn more about thedrug management of chronic pain and medical students could ex-plore more collaborative patient-centred paradigms that addressissues such as self-efficacy, self-management and patient empow-erment. They could also learn more about counteracting fear-avoidance, hypervigilance and functional restoration programmes,all of which are to be found in the physiotherapists ‘tool box’. Forthis they might have to become aware of their own assumptionsabout fear-avoidance (Vlaeyen and Linton, 2000) and address thismore in their education. In this way referrals that undermine the

Appendices


self efficacy of the patient may be avoided. Too often the GP is leftout of the loop and unaware of the strategies that physiotherapistsuse when discussing patients’ long-term goals.

For many years the evidence base has highlighted the fact thatpain is a multifaceted phenomenon incorporating physical impair-ment, psychological distress, and social interruption. Thus, itsmanagement should embrace a wider framework than the medicalmodel and reflect its complex nature (Daykin and Richardson,2004).

It is disappointing and symptomatic that the knowledge is notfiltering down to clinical practice as evidence surfaces that aninterprofessional educational project implemented by Carr et al.(2003) in a general hospital did not attract participation from themedical staff. More focus needs to be paid to the education ofthe health professionals regarding their assumptions and under-standing what ‘vulnerable’ means in a tissue in comparison to aperson.

6.1. Limitations of the study

All questionnaire studies have inherent limitations because oftheir structured standardised format. The understanding of thequestions may not be the same for all the respondents and despitethe pilot study there may have been misinterpretations of thewording. The response rate was high and the ratios for both medical

and physiotherapy students reflected the ratios of males to femalesin both the medical and physiotherapy professions. The high re-sponse rate in all probability was due to the questionnaire beingdistributed and returned by hand which was purposely done toeliminate response bias although students were not obliged to an-swer it and were not under any time pressure. The medical studentsachieved better scores on the knowledge of management of painand this may have been confounded by two factors. Firstly, themedical students’ age profile indicated that the majority of themwere between 22 and 25 and the majority of the physiotherapy stu-dents were 20 years. Given that older students per se performedbetter in their understanding of the management of patients withchronic pain it is possible that the better performance of the med-ical students was due to their demographic characteristics. The re-sponses only pertain to one university although it must also be saidthat the education of medical and physiotherapy students is similarin all universities and there is no research that indicates that thissection of the population is any different from other areas of thecountry. However the findings may be viewed as an opportunityfor drawing into the light something that was always there, but hid-den in the prevailing approaches of professional practice.


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