Proposed framework for an undergraduate pre-clinical curriculum to provide medical students in Europe with fundamentals on pain

Notes :

• This framework was developed in light of the IASP "Outline curriculum on pain for medical schools" (Pilowsky committee report 1987), the IASP "Core curriculum for professional education in pain" (Fields, HL ed., IASP Press, 1995, and draft update 2002), feedback from EFIC Council, and discussions among EFIC and IASP principals.
• It is intended to provide the beginning student with background for later instruction in mechanism-based diagnosis and therapy.
• The curriculum is built horizontally, cutting across specific pain diagnoses.
• Users may wish to modify the order in which the main topic categories (Roman numerals) are presented. However, the suggested order has internal logic (e.g. pain definitions considered only after the student has had contact with central issues).
• Users may with to distribute the main topic categories as modules in more general courses (e.g. neuroscience, psychology). However, it is intended that each student be exposed to all of the main topic categories.
• Like any course of studies, it is possible to adjust the number of teaching hours by expanding or contracting the level of detail entered into for each topic. A value in: 1) percent (%) of course time, and 2) course time in hours assuming 20h net total, is provided as a guide. This breakdown is not intended to reflect the relative importance of the various main topics, but rather the relative time typically required to master the key concepts involved.
• The curriculum should be accompanied by appropriate reading materials. In addition, source references should be provided to permit the student to investigate individual topics in greater depth. In the future EFIC might consider production of such a course in the form of a set of annotated Powerpoint (.ppt) lectures.
• Under ideal conditions the course should be accompanied by independent work assignments, a laboratory practicum, and some exposure to pain patients and physicians.

 

a) Normal biology

1. anatomy, physiology, pharmacology of primary afferent neurons
2. anatomy, physiology, pharmacology of spinal cord and trigeminal brainstem neurons including modality convergence (WDR/ multireceptive neurons) and flexor reflex
3. ascending pathways (including to cerebellum, brainstem, limbic forebrain)
4. descending control pathways and state-induced analgesia (incl. placebo)
5. response properties of supraspinal areas including noninvasive imaging in humans
6. acute and late effects of lesions to identified pathways/ areas
7. opioids, NSAIDS, local anesthetics: pharmacology including receptors and endogenous ligands

b) Pathobiology

1. inflammation and peripheral sensitization including effects on phenotype of primary afferent neurons
2. axotomy effects on phenotype of primary afferent neurons (including ectopic hyperexcitability)
3. consequences of demyelination for axonal conduction and ectopic hyperexcitability.
4. central sensitization
5. other effects of peripheral inflammation and of axotomy on spinal/ trigeminal brainstem processing (including sprouting, map reorganization, altered gene expression)
6. effects of peripheral tissue and nerve pathology on supraspinal processing (including map reorganization)
7. experimental models (human and animal) for the study of pain pathobiology
8. the concept of chronic pain as a disease rather than a symptom

 

a) Quality of life (QOL)

1. consequences of acute pain (trauma, postoperative, obstetric) including stress, immuno-suppression, effects on rate of recovery
2. consequences of chronic pain on the individual (QOL, sleep, disability, psychology, stigmatization), including inter-individual variability (incl. sex, ethnicity)
3. consequences of chronic pain on the patient's relation with carers (including family/friends, healthcare professionals) and the larger society
4. under-prescription and under-administration of analgesics
5. risks of substance abuse associated with pain management
6. transition from acute to chronic pain (biology, psychology, social interactions)
7. pain and illness behavior used by patients as a signal of psychosocial distress
8. risk factors (including genetics, environment, is there a pain-prone personality ?)
9. end-of-life problems, palliative care, the issue of assisted suicide
10. ethical considerations: failure to relieve pain (including medical procedures, children, obstetrics)… what is acceptable ?
11. ethical considerations: experimentation on humans, animals

b) Financial burden

1. prevalence/ epidemiology (including variation with age)
2. types and limits of third-party coverage, compensation
3. effects of pain and disability on employment
4. costs to employers and to society (including comparison with other major diseases)
5. physician liability and other medico-legal issues
6. high tech vs. low tech management approaches (cost-effect analysis)

 

a) Measurement

1. definitions of pain
2. basic pain measurement (VAS, numerical scales, quantitative sensory testing (QST), thermography and other autonomic variables) with discussion of specificity and scaling
3. problems of assessment in special groups (children, elderly, nonverbal)
4. effects of compensation status (financial and psychosocial) on pain/ illness behavior
5. critical evaluation of clinical trials, meta-analysis
6. pain as a 5th vital sign (with pulse, bp, temp, respiration)

b) Diagnosis

1. signs, symptoms, syndromes, and progression (natural history)
2. major systems and diagnostic categories (e.g. IASP taxonomy, International Headache Society diagnostic guidelines, psychiatric diagnostic guide DSM-IV)
3. clinical diagnostic entities vs. mechanism-based diagnosis

 

a) Pain management delivery systems (with historical context)

1. general practice, relevant specialties, sub-specialization in pain medicine, narrow spectrum and multidisciplinary pain clinics, rational expectations and the concept of "pain management"
2. types of management: drug treatments, nerve and spinal blocks, stimulators, surgical, physical, psychological and psychiatric, non-medical

b) Some examples of acute and chronic pain conditions, and their management

1. acute medical conditions
2. trauma and postoperative pain
3. arthritis
4. headache
5. low back pain
6. neuropathic pain
7. cancer pain
8. visceral pain (e.g. chronic pelvic pain)

This is only a DRAFT Your comments and suggestions are encouraged.
Please contact Profs. D. Niv or M. Devor, or EFIC's secretariat (see About EFIC )