Toward consensus on pain-related content in the pre-registration, undergraduate physical therapy curriculum: a Delphi-study

ABSTRACT

Background

Access to pain education for healthcare professionals is an International Association for the Study of Pain's key recommendation to improve pain care. The content of preregistration and undergraduate physical therapy pain curricula, however, is highly variable.

Objective

This study aimed to develop a list, by consensus, of essential pain-related topics for the undergraduate physical therapy curriculum.

Methods

A modified Delphi study was conducted in four rounds, including a Delphi Panel (N = 22) consisting of in pain experienced lecturers of preregistration undergraduate physical therapy of Universities of Applied Sciences in the Netherlands, and five Validation Panels. Round 1: topics were provided by the Delphi Panel, postgraduate pain educators, and a literature search. Rounds 2–4: the Delphi Panel rated the topics and commented. All topics were analyzed in terms of importance and degree of consensus. Validation Panels rated the outcome of Round 2.

Results

The Delphi Panel rated 257, 146, and 90 topics in Rounds 2, 3, and 4, respectively. This resulted in 71 topics judged as “not important,” 97 as “important,” and 89 as “highly important.” In total, 63 topics were rated as “highly important” by the Delphi Panel and Validation Panels.

Conclusion

A list was developed and can serve as a foundation for the development of comprehensive physical therapy pain curricula.

KEYWORDS:

• Physical therapy curriculum
• pain curriculum
• education
• preregistration
• undergraduate

Introduction

The widespread prevalence and also the large global burden of musculoskeletal (MSK) pain (i.e., four MSK-related diseases in top 11 ranking among 354 diseases) demonstrate the need for comprehensive education in pain for all healthcare professionals (HCPs) (Briggs, Carr, and Whittaker, 2011; Goldberg and McGee, 2011; Institute for Health Metrics and Evaluation, 2019; International Association for the Study of Pain, 2011; Jackson et al., 2015; Rice, Smith, and Blyth, 2016). The major deficits in knowledge, attitudes, and skills of (student) HCPs about the mechanisms and management of pain are one of the reasons that pain management is inadequate worldwide (Giordano and Boswell, 2011; International Association for the Study of Pain, 2010; Miles, Kellett, and Leinster, 2017; Thompson, 2009; Thompson, Johnson, Milligan, and Briggs, 2018). To counteract this, education in pain is one of the cornerstones advocated in the National Pain Strategies of the International Association for the study of Pain (International Association for the Study of Pain, 2011). Education in pain for HCPs in general is often limited, fragmented, inadequately addressed, and inconsistent in the preregistration undergraduate health curricula of medicine, nursing, and physical therapy (Briggs, Carr, and Whittaker, 2011; Doorenbos et al., 2013; Gallagher et al., 2000; Institute of Medicine, 2011; Jones, 2009; Shipton et al., 2018). The documented content of these pain curricula is highly variable and often dominated by the biomedical model (Briggs et al., 2015; Briggs, Carr, and Whittaker, 2011; Doorenbos et al., 2013; Ehrström, Kettunen, and Salo, 2018; Giordano and Boswell, 2011; Hoeger Bement et al., 2014; Leegaard, Valeberg, Haugstad, and Utne, 2014; Mezei and Murinson, 2011; Murinson, Mezei, and Nenortas, 2011; Pöyhiä, Niemi-Murola, and Kalso, 2005; Shipton et al., 2018; Thompson, Johnson, Milligan, and Briggs, 2018; Watt-Watson et al., 2009), and often lacking essential content related to current pain (neuro)science (Briggs et al., 2015; Briggs, Carr, and Whittaker, 2011; Ehrström, Kettunen, and Salo, 2018). Education about pain tends to ignore the biopsychosocial framework; despite being advocated in clinical guidelines, cognitive-behavioral methods and multidisciplinary management receive limited or no attention (Ehrström, Kettunen, and Salo, 2018; Loeser, 2015; Scudds, Scudds, and Simmonds, 2001; Sessle, 2012).

Whereas the International Association for the Study of Pain (IASP) Curriculum Outline on Pain for Physical Therapy targets all levels of physical therapy training, the European Pain Federation (EFIC) targets postgraduates (European Pain Federation, 2019; Fishman et al., 2013; Hoeger Bement et al., 2014; International Association for the Study of Pain, 2018). Additionally, most research is into the postgraduate area (Hush, Nicholas, and Dean, 2018). Although the IASP core curriculum is helpful for curriculum designers of physical therapy programs, the outline is limited to describing competences and learning objectives, and guidance is lacking on the specific content (Hunter et al., 2008; Jones, 2009; Watt-Watson et al.,2004). Considerable variation exists in the content of education about pain for physical therapy between countries (Hoeger Bement and Sluka, 2015; Scudds, Scudds, and Simmonds, 2001). An unpublished pilot inventory of pain content in physical therapy courses at the Universities of Applied Sciences (UAS) in the Netherlands revealed substantial differences in content, volume, and competence levels even within the country.

Even though increasingly more physical therapists recognize the multidimensional nature of chronic pain and the importance of self-management, systematically and adequately addressing psychological factors remains challenging (Cowell et al., 2018; Denneny et al., 2020; Singla, Jones, Edwards, and Kumar, 2015; Verwoerd et al., 2022). Given that physical therapists are frontline clinicians in pain management (Beswick et al., 2012; Edgerton et al., 2019; Kehlet, Jensen, and Woolf, 2006; Pendergast, Kliethermes, Freburger, and Duffy, 2012; Van Gorp et al., 2015; Wylde et al., 2015), preregistration undergraduate courses must integrate specific knowledge and skills and contain the latest evidence to prepare them to manage pain effectively (Briggs, Carr, and Whittaker, 2011; Cowell et al., 2018; Hoeger Bement et al., 2014; International Association for the Study of Pain, 2011; Synnott et al., 2015). Because the importance of education in pain is widely recognized, a description based on consensus of required content on a preregistration undergraduate level is needed.

This study aimed to identify a widely consented set of essential topics in the preregistration, undergraduate pain curriculum of the Dutch physical therapy program by consulting experts in the field of higher education and pain. The research question was: “What are the essential pain-related topics in pain evaluation and management that should be integrated within the curriculum of preregistration undergraduate physical therapy students to enable them to treat patients with pain according to applicable guidelines?”

Methods

Design

A modified Delphi study was administered online from February 2020 to May 2021. Four rounds were used to generate consensus between experts (Becker and Roberts, 2009; Hasson, Keeney, and McKenna, 2000; Keeney and McKenna, 2005; Okoli and Pawlowski, 2004; Skulmoski, Hartman, and Krahn, 2007; Thompson, 2009; Wilson, Averis, and Walsh, 2003). Feedback was collected and was forwarded to the next round, including a summary of comments and statistical measures (Murphy et al., 1998). In order to prevent group bias, national bias, and bandwagon effects, five special interest group Validation Panels were used in a single round. The results of the Validation Panels were combined with the results of the Delphi Panel to compose a consented set of essential pain-related topics for the preregistration undergraduate curriculum of physical therapists. Formal ethical review was not needed as judged by the medical ethics committee at the University Medical Center of Groningen (M21.289289). All participants provided written informed consent prior to the beginning of the survey. Guidance on Conducting and Reporting Delphi Studies was followed (O’Brien et al., 2014).

Participants Delphi Panel

The Delphi Panel experts were recruited from pain experienced physical therapy lecturers from all UAS in the Netherlands. Participants were eligible if they met the predetermined criteria: (1) have a minimum of 5 years of professional educational experience on the topic of pain; (2) involvement in pain-related curriculum development and teaching in it; and (3) willing and able to dedicate the time required for Delphi rounds. We aimed to form a panel of at least 20 experts to include sufficient expertise and diversity to cover pain’s multidimensional aspects and derive representative results (Jorm, 2015). Potential participants were informed by e-mail about the purpose and procedure of contributing as experts.

Participants Validation Panels

Five special interest group Validation Panels were used as a bias-reducing filter: Panel (1) early career physical therapists; 4th-year Bachelor physical therapy students with minimally 20-week internship experience and physical therapists up until 1-year work experience (i.e., reference for the prospective curriculum “consumers”); Panel (2) physical therapists with a minimum of 5 years working experience (i.e., reference for the broader work field of physical therapy); Panel (3) non-pain lecturers in the field of higher education of physical therapy (i.e., reference for less pain oriented, but higher education focused lecturers); Panel (4) postgraduate pain educators: educators of accredited postgraduate pain courses that are commercially accessible, including general practitioners, physician assistants, psychologists, occupational therapists, psychosomatic physical therapists, pediatric physical therapists, and manual therapists; and Panel (5) IASP and EFIC representatives: physical therapy pain curriculum committee members (i.e., international reference and content experts in the field of pain curricula). The national Validation Panels were recruited by Delphi Panel members, the associated UAS, social media, and a message in the online newsletter of the Dutch Physical Therapy Association. Pain educators in postgraduate pain courses were recruited using a database of accredited courses from the Dutch Physical Therapy Association. EFIC and IASP representatives were contacted by e-mail.

Procedures, Rating, and Analysis

A web-based survey (Survey Monkey Company, Palo Alto, CA, USA) was used for all four rounds of the Delphi Panel and a single round of each Validation Panel. The invitation included instructions to take in mind preceding participation in the round: (1) the general level of competence of physical therapy education is on a preregistration undergraduate level; (2) what is minimal necessary (i.e., the curriculum space is limited); and (3) indicate the importance of the pain topic itself free of competence sublevel (i.e., degree of expertise) within the undergraduate level (Bergsmann et al., 2015). Members had four weeks to fill in the survey in every round, and a reminder was sent halfway through. All Delphi Panel members participated independently and anonymously. A total of four rounds were determined a priori (Figure 1).

Figure 1. Flowchart of the Delphi process.

IASP: International Association for the Study of Pain, EFIC: European Pain Federation

Delphi Panel

First round

The aim was to collect and define as many relevant pain topics as possible. The first round was an open consultation round in three steps: (1) the Delphi Panel was asked to liberally list as many pain topics as possible. The topics submitted by the individual participants were taken together and combined into one list by the first two authors (RR and AB); (2) the Delphi Panel was asked to verify the list and add topics if necessary; and (3) the list was provided to pain educators of accredited postgraduate pain courses (Validation Panel 4), who were asked to add omitted topics (Keeney and McKenna, 2005; Trevelyan and Robinson, 2015; Wilson, Averis, and Walsh, 2003). For completeness, existing IASP and EFIC curricula literature was screened to identify any additional topics. After data collection, duplicates between topics derived in steps 2 and 3 were removed, and the first two authors categorized all topics.

Second round

The aim was to rate and possibly reduce the number of First Round topics. Participants of the Delphi Panel were asked which topics are important for a starting physical therapist to treat patients with pain in daily practice according to applicable guidelines and state-of-the-art knowledge. For each topic, the panelists were asked “Rate per topic to what extent you consider this topic important for the preregistration undergraduate physical therapy pain curriculum.” The participants rated each topic on a 5-point Likert scale: (1) very unimportant; (2) unimportant; (3) important; (4) very important; and (5) extremely important. There was an additional “no opinion” option that could be used when the participant could not judge it to prevent uninformed response bias (Becker and Roberts, 2009; Trevelyan and Robinson, 2015). To avoid ceiling effects, a 5-point Likert scale was used with three positive choices (i.e., extremely important, very important, and important) and two negative choices (i.e., very unimportant and unimportant) (Crow et al., 2002; Lozano, García-Cueto, and Muñiz, 2008; Moret et al., 2007). For each category, comments could be left.

Third round

The aim was to reach consensus on Second Round topics emphasizing those topics on which no consensus had been reached. Summarized comments per cluster were presented together with statistical information (i.e., percentages and bar charts) to inform the Delphi Panel on topics that have gained collective opinion (see analysis). The Delphi Panel members were asked to rerate the topics based on the group’s opinion (i.e., statistical information and comments). During the round, Delphi panel members were asked to comment on all ambivalent topics next to general comments.

Fourth round

The aim and organization of the Fourth Round were identical to the Third Round and can be seen as a further iteration of the process. Extra information was added when comments revealed a misunderstanding of the ambivalent topics.

Validation Panels

In a single round, all Validation Panels were asked to judge the topics rated as important, very important, and extremely important, based on the analysis of Round 2 of the Delphi Panel. Unimportant topics were removed to reduce the completion time, consequently increasing the potential number of responses in the Validation Panels and reducing attention bias. Incomplete lists defined as missing three ratings or more consecutively and lists with a fill-in time smaller than 5 min were excluded to prevent careless responding (Goldammer, Annen, Stöckli, and Jonas, 2020; Huang et al., 2012).

Analysis

A response rate of 70% for each round of the Delphi Panel was considered sufficient (Sumsion, 1998). After the First Round, the collected topics were content analyzed, and duplicates were removed and pragmatically categorized into nine categories, partly overlapping the categorization used in the IASP and EFIC curricula (Table S2) (Keeney, Hasson, and McKenna, 2010; Keeney and McKenna, 2005). Authors (RR & AB) independently aggregated and identified responses. A consensus meeting took place to resolve any disagreements. A stepwise procedure was followed in all rounds to analyze the importance based on group position and degree of consensus (i.e., agreement or certainty based on group dispersion) of all topics (Table 1). Criteria for importance were based on the median, whereas criteria for consensus were based on percentage agreement and the interquartile range (IQR), rather than the mean and standard deviations, to reduce the influence of outliers in judgment (Trevelyan and Robinson, 2015). The choice of “no opinion” was excluded in all calculations.

Table 1. Importance and degree of consensus of topics.

Judgment	Explanation
Highly important, high degree of consensus	Rated “very important” and “extreme important” by ≥ 75% of the participants or a median within these levels with low dispersion (IQR ≤ 0.75)
Highly important, low degree of consensus	Rated with a median within “very important” and “extreme important” with high dispersion (0.75 ≤ IQR ≤2.5)
Important, high degree of consensus	Rated “important” by ≥ 75% of the participants or a median within this level with low dispersion (IQR ≤ 0.75)
Important, low degree of consensus	Rated with a median within “important” with high dispersion (0.75 ≤ IQR ≤2.5)
Unimportant	Rated important by < 75% of the participants
Ambivalent	Rated highly important, important or unimportant with very high dispersion (IQR ≥ 2.5)

Judgment of topics is based on importance and degree of consensus using a Likert scale, where the amount (in percentage) and dispersion of ratings is considered. IQR: Interquartile Range

Initially, all topics with highly variable ratings (IQR ≥ 2.5) were categorized as ambivalent and remained for the next round for reevaluation (Hasson, Keeney, and McKenna, 2000; Keeney and McKenna, 2005; Sumsion, 1998). Then, topics were categorized as unimportant, important, or highly important: unimportant when rated as important (3 or higher on the Likert Scale) by less than 75% of the participants, and highly important when rated 4 or 5 on the Likert Scale by minimally 75% of the participants. Further, the topic was categorized according to the median if not categorized by the former steps (1 or 2: unimportant; 3: important; 4 or 5: highly important) (Diamond et al., 2014; Trevelyan and Robinson, 2015; Von der Gracht, 2012). Second, consensus was assumed when IQR ≤ 0.75. Consequently, topics were taken out of the procedure when consensus was assumed or when topics were rated as unimportant, leaving the (highly) important topics without consensus for reevaluation (Figure 2). After Round 4, all topics were categorized according to their importance and degree of consensus. Finally, all topics deemed “highly important” by all Panels (i.e., Delphi and Validation Panels) were presented as consented topics. The judgments of all topics in their respective categories, including the Validation panels’ judgments, is presented separately in Table S2.

Figure 2. Flowchart of topic analysis after Delphi and Validation Panels judgments. Topics judged as “not important” were taken out of the procedure, as were the topics judged as “highly important” or “important,” with a high degree of consensus. Validation Panels judged the “highly important,” “important,” and “ambivalent” topics based on Round 2. Finally, all topics judged as “highly important” by both the Delphi and all Validation panels were presented as a consented list. IASP: International Association for the Study of Pain, EFIC: European Pain Federation.

Comments of Delphi and Validation panels

The first two authors made a selection of the comments that were mentioned more than once by Delphi Panel members supporting the quantitative data and providing context for a better understanding of the results. These comments were forwarded to the next round as quotes preserving the original word usage as much as possible, without revealing the commenter’s identity due to writing style. The comments are presented in the Appendix.

Results

Participants in the Delphi Panel

A total of 22 lecturers participated in the Delphi Panel. Twelve out of 13 UAS in the Netherlands were represented. Ten UAS were represented by two lecturers in the Delphi Panel and two UAS by one lecturer. In the last round, there was one dropout (not responding). Descriptive characteristics of the participants are presented in Table 2.

Table 2. Sociodemographics of the Delphi Panel.

Characteristic	Delphi Panel (N = 22) Median (IQR) or n (%)
Gender, female	4 (18%)
Age (years)	52 (40–57)
Highest completed education level (%) Bachelor’s degree Master’s degree PhD	3 (13,6%) 16 (72,7%) 3 (13,6%)
Work experience as lecturer (years)	12,5 (8–22)
Working as lecturer in general (hours/week)	18 (12–28)
Working as lecturer in pain (hours/week)	2,5 (2–6,5)
Working experience as physical therapist (years)	17 (25–31)
Current working hours as physical therapist (hours/wk)	6 (0–8)
Work setting as physical therapist (%)^a Private practice Private practice (specialized in (chronic) pain) Hospital Rehabilitation center (pain rehabilitation team) Rehabilitation center (other teams) Nursing home/institution	73 32 32 23 14 18

^aTotal exceeds 100% due to panelists who work or have worked in multiple settings. IQR; Interquartile Range, PhD; Doctor of Philosophy

Participants in the Validation Panels

In Panel (1): the early career physical therapists, a total of 51 out of 91 (55%) completed their single round and were eligible based on their time to completion and completeness, and in Panel (2): physical therapists, 122/237 (51%) were eligible. For Panel (3): the non-pain lecturers, this was 81/100 (81%); Panel (4): the postgraduate pain educators, this was 17/19 (89%); and Panel (5): the EFIC/IASP representatives, this was 10/10 (100%). Descriptive characteristics of the Validation Panels are shown in Table S1.

First round

After an open consultation round, literature review, and duplicate removal, 257 topics were included in the initial list (Table S2). All topics were combined into nine categories: (1) taxonomy and defining pain (13 topics); (2) pain assessment and measurement (20 topics); (3) models and theories (i.e., health and psychosocial models, pain neurophysiology, and anatomy and biology models; 77 topics); (4) multidimensional nature of pain (47 topics); (5) management of pain (45 topics); (6) communication (15 topics); (7) beliefs and attitudes of patient and HCP including students (5 topics); (8) health policy and guidelines in pain (10 topics); and (9) pain subgroups/special populations (25 topics).

Second round

Of the total 257 topics rated in the Second Round, 36 were considered with a high degree of consensus as “highly important,” 16 as “important,” and 59 as “not important.” Additionally, 17 were categorized as ambivalent, resulting in 146 topics for the next round. See Figure 2 for the overview of judgment per round.

Third and fourth round

In Round 3, 146 topics were rated of which 90 remained to be rated in Round 4. After Round 3, only one topic (i.e., “mechanism-based approach”) was categorized as “ambivalent.” The comments revealed that not all panelists were familiar with this topic; consequently, additional information was given in the Fourth Round. After Round 4, the Delphi Panel rated 64 topics as “highly important and with a high degree of consensus,” 25 as “highly important with a low degree of consensus,” 53 as “important with a high degree of consensus,” 44 as “important with a low degree of consensus,” and 71 as being “not important.” A complete list of topics and judgments by the Delphi Panel and Validation Panels is reported in Table S2.

Single round of the Validation Panels

All topics rated as highly important, important, and ambivalent in the Second Delphi Round were presented to all Validation Panels. Out of these 198 topics, a total of 70 topics were rated as “highly important” by all Validation Panels and were used as a filter after the final Fourth Delphi Round. Summarized ratings of each Validation Panel are presented in Table 3.

Table 3. Summarized ratings of the 198 items by the Validation Panels.

	Panel (1)	Panel (2)	Panel (3)	Panel (4)	Panel (5)
	Early career physical therapists	Physical Therapists	Non-pain lecturers	Post-graduate pain educators	EFIC and IASP representatives
Highly important	148	89	107	111	163
Important	46	103	79	67	25
Not important	4	6	12	20	10

Validation panelists judgment after their single round. IASP; International Association for the Study of Pain, EFIC; European Pain Federation

Comments from the Delphi and Validation Panels addressed the complexity, relevance, and specificity of the judged topics. Representative comments are presented in Appendix.

Final results

After four rounds, the Delphi Panel reached a consensus on a total of 89 topics as “highly important.” After cross checking this list with the 70 topics rated as “highly important” by the Validation Panels, it was determined that collective consensus was reached on 63 topics (Table 4). A complete overview of all ratings of both the Delphi Panel and all Validation Panels is presented in Table S2.

Table 4. Categories and topics with a collective consensus between Delphi panel and validation panels.

1. TAXONOMY AND DEFINING PAIN

[2] Chronic pain

[2] Nociceptive pain

[2] Acute Pain

[2] Nociplastic pain

[4] Referred pain

[2] Neuropathic pain

[3] Dimensions of pain (sensory, discriminative, affective, motivational, cognitive, evaluative)

2. PAIN ASSESSMENT AND MEASUREMENT

[2] Recognizing psychosocial factors

[2] Symptoms of chronic pain

[2] Evaluation of treatment effects

[2] Prognostics of transition from acute to chronic pain

[2] Pain perception

3. MODELS AND THEORIES

3.1 HEALTH AND PSYCHOSOCIAL MODELS/THEORIES

[2] Biopsychosocial model

[2] Pain-related mechanisms of physical therapy interventions (psychosocial)

[2] Self efficacy

3.2 PAIN NEUROPHYSIOLOGY, ANATOMY. AND BIOLOGY MODELS/THEORIES

[2] Central sensitization

[3] Plasticity and the brain

[2] Peripheral sensitization

[2] Pain-related mechanisms of physical therapy intervention (physiological)

[2] Neuroplasticity

[3] Neurophysiology of Nociceptive Pain

[4] The autonomic nervous system

[4] Physiology of stress

4. MULTIDIMENSIONAL NATURE OF PAIN

[3] Cognitions

[3] Illness Perception

[2] (Pain) behavior

[3] Influence of emotion on pain

[3] Fear

[2] Stress

[2] Complexity of pain

[3] Coping styles

[3] Influence of pain on movement (motor influence)

[4] Catastrophizing

[4] Risk factors for chronic dysfunction due to pain

[3] Influence of expectation on pain

[3] Contextual factors

[3] Influence of lifestyle on pain

[4] Kinesiophobia

[4] Influence of mood on pain

[4] Motivation

5. MANAGEMENT OF PAIN

[3] Self-management

[2] Physical Exercise Therapy

[4] Behavioral influence on pain

[3] Prevention of chronic pain

[2] Active lifestyle

[2] Graded exposure/exposure in vivo

[2] Lifestyle interventions

[2] Patiënt-centered approach

[2] Graded activity

[3] Adherence/compliance

[4] Working interdisciplinary

6. COMMUNICATION

[3] Shared decision-making

[2] Nocebo in practice

[2] Conversation techniques

[2] Motivational interviewing

[3] Coaching

[4] Empathy

[4] Dialogue and pain education (lecturing versus socratic style)

[4] Somatic, cognitive, emotions, behavior, social (SCEBS)/pain-SCEBS-motivation

7. BELIEFS AND ATTITUDES PATIENT & HEALTH CARE PROFESSIONAL INCL.THE STUDENT

[2] Attitude health-care professional /student

[2] Health beliefs health-care professional/student

8. HEALTH POLICY & GUIDELINES IN PAIN

No topics gained collective consensus

9. PAIN SUBGROUPS/SPECIAL PATIENT POPULATIONS

[3] Musculoskeletal pain

[4] Neck and back pain

All topics are ordered within the category on percentage agreement on “highly important” by the Delphi Panel. Number in brackets preceding the topic represents the round when the Delphi Panel determined the judgment of the topic.

Discussion

This study resulted in a list, by consensus, of 63 pain-related essential topics that preregistration undergraduate physical therapy students should learn in order to adequately treat patients with pain. Eight out of nine (at the start of this investigation addressed) categories are represented in the final list, showing the agreed broadness of pain education. Going more into detail, the results show that the topics should be seen from the perspective of hierarchy. Some topics resemble a broader area and can be considered a parent topic (e.g., “neurophysiology of modulation”), while others relate more in-depth to this topic as a child topic (e.g., “endogenous pain inhibition: conditioned pain modulation”). It is advised that this hierarchy is taken into account when developing a pain curriculum.

This study proposed a broad spectrum of biopsychosocial topics that could influence the patients’ experience and expression of pain related to current pain science. The agreed topics mainly represent understanding, assessing, and managing the complex multidimensional nature of pain. There is also consensus about a patient-centered approach to pain management, active interventions, and behavioral principles. In addition, Validation Panel (5) IASP/EFIC representatives commented to add the use of TENS and heat and cold as part of self-management strategy or manual therapy as a therapeutic strategy.

Topics such as “the biopsychosocial model,” “self-management,” and “patient-centered approach” are strategies that can be offered generically for several health problems, not only in pain rehabilitation. These general concepts create opportunities in the curriculum to develop competencies in general and more in-depth in specific areas such as pain. As pain is best approached using interdisciplinary collaboration, it has also been argued that students should learn about pain using interprofessional education (Carr and Watt-Watson, 2012; Gordon, Watt-Watson, and Hogans, 2018; Hoeger Bement et al., 2014; Van Lankveld, Afram, Staal, and Van der Sande, 2020). Therefore, cross-professional agreed competencies are needed to allow good collaboration. However, this also requires educators to adopt these strategies in their education and become competent in teaching them.

In “Management of pain,” some topics were commented on as “not suitable/too complex” and “knowing the concept but not supportive for practice.” For example, low consensus was reached on the topics “cognitive-behavioral methods” and “multi/interdisciplinary collaboration.” Nonetheless, these strategies may still be relevant for the preregistration undergraduate curriculum at a less advanced level. In fact, multiple studies support having competence in delivering psychologically informed interventions in physical therapy (Ballengee, Zullig, and George, 2021; Denneny et al., 2020; Main and George, 2011). At a preregistration undergraduate level, it is key that the student recognizes these management strategies as an option in chronic pain with a starting level of competence (Denneny et al., 2020). Comments of Delphi Panelists supported this: “Several concepts can at least be provided; they do not all have to be discussed with the same depth” and “Inter and multidisciplinary management; it is important to know when you have to work together and what the boundaries are.”

The current study results enable building curriculum outlines for education in pain, which shows considerable overlap with curriculum content described in earlier studies (Briggs, Carr, and Whittaker, 2011; Doorenbos et al., 2013; Hoeger Bement et al., 2014; Shipton et al., 2018) and by the IASP, EFIC, and the British Pain Society (British Pain Society, 2018; European Pain Federation, 2017; International Association for the Study of Pain, 2018). However, this study had a different focus: identifying content for education in pain for uniprofessional physical therapy education at a preregistration undergraduate level. The IASP provides a Curriculum Outline on Pain for Physical Therapy on competences and learning objectives. This study supplements this outline by providing guidance on the advised content required for treating patients with pain adequately.

Strengths

The composition of the Delphi Panel was representative of the target population of lecturers in pain in higher education. Additionally, a near-complete representation of all UAS in the Netherlands was achieved. Further, the liberal reporting of topics added topics from the IASP and EFIC literature and the verification of completeness by a Validation Panel, resulted in a complete and content valid list of topics. Furthermore, a complete response was obtained in the first three rounds, and only one was missing in Round 4 resulting in a consistent share of each Delphi Panel member’s judgment in all rounds.

Importantly, since the outcome of the Delphi study relies heavily on the quality of the judgment of the panelists, multiple methodological steps were taken for bias reduction. First, the multitude of topics could lead to rating topics less known to the rater as less important (i.e., recognition heuristic) (Erdfelder, Küpper-Tetzel, and Mattern, 2011). To address this, an option of “unknown topic” was added. Second, a social-desirability responder bias was mitigated by the anonymity of responses: raters were able to hide unfamiliarity with a topic (Edwards, 1953). Based upon the frequent usage of the “unknown topic” option in all panels, we postulate that this form of bias is not dominantly present. Additionally, in every subsequent round, an explanation of unknown topics based upon the ratings and comments or misunderstood topics based upon comments was given to increase the familiarity with the topic and thus the validity of each panel member's rating. Third, to avoid contrast effects, where two topics are judged compared to one another and therefore rated increasingly higher, topics were sorted based upon the importance obtained in the former round to reduce the actual contrast between topics (Sumer and Knight, 1996). Additionally, all topics were clustered into categories and presented as one cluster per page to avoid comparison with more extremely rated topics of other categories. Fourth, our results show many topics rated as important by most raters. An overestimation of importance could be addressed to the acquiescence bias (Lavrakas, 2008). To counter this, the positive importance of ratings was divided into three scales, which was also used to prevent ceiling effects. Fifth, national bias, which could limit the generalizability to a national level, was reduced by including the ratings of the Validation Panel consisting of EFIC and IASP representatives. Sixth, using different clusters of experts of non-equal level of expertise may enhance the validity and comprehensiveness of the consensus (Sorooshian, 2018). Seventh, group bias and a possible bandwagon effect were minimized using Validation Panels. The panels were either potentially more or less biased toward the higher importance of pain topics; the postgraduate educators versus the non-pain lecturers in the field of higher education in physical therapy. Finally, different levels of experience and applicability were taken into account by including advanced students, recent graduates, and physical therapists. The results of all panels showed usage of the unknown option, reduced ceiling effects, and panel differences (e.g., EFIC and IASP representatives rated more topics as highly important). In summary, by applying these strategies the risk of (serious) bias in this study is reduced and thereby contributing to the robustness of the results.

Limitations

Although many methodological steps have been taken to strengthen this study, there are still limitations to address. Even though all raters were asked to rate the importance of the pain topic free of competence level, some comments revealed that an ambiguous response was possible while using the same reasoning. Topics were rated as important, but only on a “recognition” level (i.e., Competence Level 1), while the panel used the same reasoning to rate the topic as non-important. Additionally, comments revealed that topics rated as non-important in this study can still be (highly) important on a higher level of competence (e.g., postgraduate courses). In contrast, different reasoning methods were shown to support an equal rating of importance: reasons based on complexity, clinical relevance, practical implications, applicability, and the evidence base of a strategy. To address these limitations within reasoning, a degree of consensus was added when analyzing the topics. A larger dispersion resulted in a rerating in the next round, and panelists were asked to comment on a specific topic. Finally, the global generalizability of the study results is enhanced by using an international Validation Panel. Still, direct use of these results could be limited by differences in educational systems per country and hence varying levels of educational standards (i.e., preregistration undergraduate, graduate, and postgraduate levels). Consequently, implementation of results needs to be done carefully.

Conclusion

In conclusion, the list of 63 topics could serve as a starting point for (further) development of a comprehensive preregistration undergraduate physical therapy pain curricula and should be taught as part of the development toward the graduate level as IASP and EFIC curriculum outlines. As national biases were reduced, the results could be generalized to other countries while considering the local curricula structure.

Educators can use this study as a benchmark for their own curriculum. If deficits exist, new content can be supplemented to their curriculum. Additional investigation of areas of disagreement will enable educators to consider the scope and depth of content on ideas that should be covered. Further, the level of competence should be taken into account in curriculum development. In developing these curricula, the following questions should be considered: (1) Dosage: What amount of time should the pain curriculum take; (2) Timing: Where in the curriculum should pain-related content be incorporated; (3) Delivery: What educational formats should be used; (4) Assessment: How should instructors assess the efficacy of the curriculum; and (5) Teacher competency: How can educators achieve competence in teaching in a pain curriculum?

Acknowledgments

We thank the participants of the Delphi Panel representing the Universities of Applied Sciences in the Netherlands: Hogeschool van Amsterdam; Hogeschool Arnhem Nijmegen; Hanze Hogeschool Groningen; Hogeschool Zuyd Heerlen; Hogeschool Leiden; Hogeschool Rotterdam; Hogeschool Saxion Enschede; Hogeschool Utrecht; Thim Hogeschool of Physical Therapy; Fontys Hogeschool Eindhoven; Avans Hogeschool Breda; and SOMT University of Physical Therapy Amersfoort. We thank all the participants of the Validation Panels: early career physical therapists; physical therapists; non-pain lecturers; postgraduate pain educators; EFIC; and IASP representatives. Finally, we thank A. Engers, S. Mooren-van der Meer, E. de Raaij, and H. Wittink for their help during the inception of the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/09593985.2022.2144562

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.