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60 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
CASE SERIES
Immediate effects of sensory discrimination for chronic low back
pain: a case series
Adriaan Louw PT, PhD, CSMT
Senior Instructor, International Spine and Pain Institute and St. Ambrose University, Physical Therapy Education, Residency Program
Kevin Farrell PT, PhD, FAAOMPT
Orthopedic Residency Chair, St. Ambrose University, Physical Therapy Education, Residency Program
Lauren Wettach PT, DPT
Resident, St. Ambrose University, Physical Therapy Education, Residency Program
Justine Uhl PT, DPT
Resident, St. Ambrose University, Physical Therapy Education, Residency Program
Katherine Majkowski PT, DPT
Resident, St. Ambrose University, Physical Therapy Education, Residency Program
Marcus Welding PT, DPT
Resident, St. Ambrose University, Physical Therapy Education, Residency Program
ABSTRACT
Can a brief tactile intervention associated with brain remapping improve pain and spinal movement in patients with chronic low back
pain? A convenience sample of patients with chronic low back pain completed various pre-intervention measurements including low
back pain (Numeric Pain Rating Scale), fear-avoidance (Fear Avoidance Beliefs Questionnaire), disability (Oswestry Disability Index)
and spinal flexion (fingertip-to-floor). A 5-minute localisation of tactile stimuli treatment was administered to the low back, followed
by immediate post-intervention measurement of pain and spinal flexion. Sixteen patients (female = 12; mean age 48.2 years) with
chronic low back pain (median duration 10 years) presented with a mean low back pain of 5.56 out of 10, moderate disability
(mean Oswestry Disability Index 34.38%) and high fear-avoidance associated with physical activity (average 17.25). Immediately
following treatment, the group’s mean pain rating for low back pain decreased by 1.91, while forward flexion improved by 4.82 cm.
The results from the case series indicate that following a brief tactile discrimination intervention, patients with chronic low back pain
exceeded minimal detectible change for forward flexion. Being able to improve movement, without using physical movement, may
provide an added benefit for patients with chronic low back pain afraid to move.
Louw A, Farrell K, Wettach L, Uhl J, Majkowski K, Welding M (2015) Immediate effects of sensory discrimination for chronic low
back pain: a case series. New Zealand Journal of Physiotherapy 43(2): XX-XX. DOI: XXXXXXXXX
Key Words: Chronic lumbar pain, Sensory, Brain, Tactile, Pre-habilitation
INTRODUCTION
Various epidemiological studies have shown an increase in
the prevalence of chronic low back pain (CLBP) (Goldberg
and McGee 2011, Johannes et al 2010, Parthan et al 2006,
van Hecke et al 2013). Current best-evidence suggests a
combination of education, movement and pharmacological
agents is effective in decreasing pain and disability in chronic
musculoskeletal conditions, including CLBP (Busch et al 2007,
Ferreira et al 2007, Goldenberg 2009, Mistiaen et al 2012, Nijs
et al 2010). Therapeutically, in recent years increased activity in
the field of education has culminated in the increased utilisation
of, and evidence for, pain neuroscience education (Louw et al
2011, Louw et al 2014, Moseley et al 2004, Moseley 2002). In
line with current best-evidence treatments utilising movement,
such as aerobic exercise, are being proposed to treat patients
with CLBP (Ferreira et al 2007, Mistiaen et al 2012, Nijs et al
2012). It is proposed that these treatments help patients with
pain by enhancing various endogenous mechanisms (Bialosky et
al 2009a, Bialosky et al 2009b, Nijs et al 2012).
The correlation between pain, range-of-motion (ROM) and
function is not well understood (Moseley 2004a). It has been
shown that limited spinal movement is correlated to decreased
function, with the American Medical Association (AMA) viewing
loss of spinal ROM as an impairment and used for disability
ratings (Archer et al 2014, Nijs et al 2013, Vlaeyen et al 1995).
This loss of spinal ROM has thus become the target of various
therapeutic interventions, especially in chronic pain as a means
to decrease disability (Archer et al 2014, Nijs et al 2013, Vlaeyen
et al 1995). One such treatment may be the reduction of pain
(Moseley 2004a). Pain intensity however has shown very little
correlation to fear of movement, thus questioning strategies
to ease pain intensity (Vlaeyen et al 1995). Despite the limited
evidence for a reduction in pain intensity improving ROM,
various authors have tested treatments aimed at reducing pain
issues such as pain intensity, pain-related fear and cognitions of
pain to assess its effect on movements (Daly and Bialocerkowski
2009, Louw et al 2011). For example, pain neuroscience
education has shown an immediate clinically meaningful
improvement in spinal movements including spinal flexion,
straight leg raise and cervical extension in chronic whiplash
associated disorders (Moseley 2004a, Moseley et al 2004, Van
Oosterwijck et al 2011). For low back patients, spinal flexion
is often seen as a particularly fearful movement and often
NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 61
associated with pain (Barrett et al 1999, George et al 2009,
Schnebel et al 1989). This poor understanding of pain and
limited ROM leaves spinal patients and clinicians in a precarious
position since it is well established patients with CLBP display
all three of these elements of limited ROM, high levels of pain
and decreased function (Angst et al 2006, Louw et al 2011,
Moseley 2004b). Adding to the complexity, emerging advances
in neuroscience and brain imaging studies have shown that
decreased movement of the lumbar spine leads to functional
changes in the brain (Flor et al 1997, Wand et al 2011). It is well
established that the physical body of a person is represented
in the brain by a network of neurons, often referred to as a
representation of that particular body part in the brain (Flor
2000, Penfield and Boldrey 1937, Stavrinou et al 2007, Wand
et al 2011). This representation refers to the pattern of activity
that is evoked when a particular body part is stimulated. The
most famous area of the brain associated with representation is
the primary somatosensory cortex (S1) (Flor 2000, Penfield and
Boldrey 1937, Stavrinou et al 2007, Wand et al 2011). From a
physiotherapy perspective it is important to understand that
these neuronal representations of body parts are dynamically
maintained (Flor et al 1997, Flor et al 1998, Lotze and Moseley
2007, Maihofner et al 2003, Moseley 2005a, Moseley 2008).
It has been shown that patients with pain display different S1
representations than people with no pain (Flor et al 1997, Flor
et al 1998, Lotze and Moseley 2007, Maihofner et al 2003,
Moseley 2005a, Moseley 2008). The interesting phenomenon
associated with cortical restructuring is the fact that the body
maps expand or contract, in essence increasing or decreasing
the body map representation in the brain. Various authors have
drawn a correlation between the changes in shape and size of
body maps and increased pain and disability (Flor et al 1997,
Lloyd et al 2008). Although various factors have been linked
to the development of this altered cortical representation of
body maps in S1, it is believed that issues such as neglect and
decreased use of the painful body part (Marinus et al 2011) may
be a significant source of the altering of body maps (Beggs et
al 2010, Flor et al 1997). Various authors have postulated that
a viscious cycle may emerge between decreased movement,
cortical reorganisation and increased pain (Flor 2000, Moseley et
al 2012b).
Based on these neuroplastic changes, physiotherapy has
focused on strategies to help normalise these altered cortical
representations of body maps. One approach is graded motor
imagery (GMI) (Bowering et al 2013, Daly and Bialocerkowski
2009, Moseley 2004b, Moseley 2006). GMI is a collective term
describing various “brain exercises” including normalising
laterality (left/right discrimination of body parts), motor imagery
(visualisation), mirror therapy, sensory discrimination, sensory
integration and graphaesthesia (Daly and Bialocerkowski 2009,
Moseley 2004b, Moseley 2006). Various studies have shown
that these GMI strategies are able to positively influence pain
and movement (Bowering et al 2013, Daly and Bialocerkowski
2009, Moseley 2004b, Moseley 2006), however in line with
CLBP, the correlation remains poorly understood. Most research,
however, has focused on Complex Regional Pain Syndrome
(CRPS) of the extremities with little information on its potential
to help patients with CLBP (Daly and Bialocerkowski 2009,
Moseley 2004b, Moseley 2006).
This case series aimed to further explore the relationship
between pain intensity and movement. The main goal was to
determine if patients with CLBP who received tactile acuity
training to their lower back in the absence of movement,
experience any advantageous therapeutic effect in regards to
pain intensity and/or spinal flexion.
METHODS
Patients
A convenience sample of patients with CLBP currently attending
physiotherapy for rehabilitation was invited to participate in the
study. Four patients from each of four physiotherapy clinics in
a large metropolitan area were recruited for the study. Internal
review board (IRB)/Ethics approval was obtained. Upon obtaining
informed consent, patient demographic data were collected.
Patient intake forms, including medical history, were reviewed
for any items thought to predict a higher risk of serious
pathology and warrant referral for further diagnostic testing,
making patients ineligible for the study. Patients were excluded
if they could not read or understand the English language,
were under age 18 (minor), had undergone spinal surgery, had
any skin or medical condition preventing them from receiving
tactile stimuli on the lower back or had specific movement-
based precautions, e.g. no active spinal flexion. Patients had
to present with back pain and patients presenting with leg pain
only, or neurological deficit only in the lower extremity were
additionally excluded.
Measurements
Patients were asked to complete various outcome measures
prior to treatment intervention:
Pain: Low back pain at rest was measured using a Numeric Pain
Rating Scale (NPRS), as it is commonly used in various spinal pain
studies (Moseley 2003, Moseley 2005b, Moseley 2002). The
minimal detectable change (MDC) for the NPRS is reported to be
2.1 (Cleland et al 2008a).
Function: Perceived disability was measured using the Oswestry
Disability Index (ODI) which has good evidence for its reliability
and validity as a measure of functional limitations related to LBP
(Deyo et al 1998, Fritz and Irrgang 2001, Hakkinen et al 2007).
A change of 5 points (10%) has been proposed as the MDC
(Ostelo et al 2008).
Fear avoidance (Fear Avoidance Beliefs Questionnaire [FABQ]):
The FABQ is a 16-item questionnaire that was designed to
quantify fear and avoidance beliefs in individuals with LBP. The
FABQ has two subscales: 1) a 7-item scale to measure fear-
avoidance beliefs about work, and 2) a 4-item scale to measure
fear avoidance beliefs about physical activity. Each item is
scored from 0 to 6 with possible scores ranging between 0 and
24 and 0 and 42 for the physical activity and work sub-scales
respectively, with higher scores representing an increase in
fear-avoidance beliefs. The FABQ has demonstrated acceptable
levels of reliability and validity in previous LBP studies (Cleland
et al 2008b, Grotle et al 2006, Poiraudeau et al 2006). Presence
of avoidance behavior is associated with increased risk of
prolonged disability and work loss. It is proposed that FABQ-W
scores >34 and FABQ-PA >14 are associated with a higher
likelihood of not returning to work (Burton et al 1999, Fritz and
George 2002).
62 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
Lumbar flexion: Active trunk forward flexion, measured from
the longest finger on the dominant hand to the floor (Moseley
2004a, Moseley et al 2004, Zimney et al 2014). This method
was chosen as it is commonly used in pain science studies
(Louw et al 2012, Moseley 2004a, Moseley et al 2004, Zimney
et al 2014). MDC for active trunk forward flexion utilising this
method has been reported as 4.5 cm (Ekedahl et al 2012).
Immediately following the treatment intervention, low back
pain (NRS) and lumbar flexion were re-measured to determine
the immediate therapeutic effect of the proposed intervention.
Pre- and post-treatment measurements were performed by the
therapists who provided the GMI interventions (LW, JU, KM and
MW). Upon completion of the trial (pre-tests, tactile stimulation
and post-test), the attending therapists continued with their
usual therapy treatments based on their current plan of care.
Intervention
Various strategies have been proposed to help patients develop
an increased acuity of faulty body maps, including two-point
discrimination, graphaesthesia and sensory discrimination (Daly
and Bialocerkowski 2009, Moseley 2004b, Moseley 2006,
Moseley et al 2008b). For this study, based on previous CLBP
research (Luomajoki and Moseley 2011, Wand et al 2011) it was
decided to use localisation of tactile stimuli. Prior to localisation,
patients were provided with an explanation of the proposed
treatment and aim of the study. They were shown a picture of
the brain map (homunculus) and taught how, when people are
in pain, the map becomes “less sharp” since it’s not being moved
and it is believed that when the map is sharpened, it may help
reduce their pain. By touching the back in various areas and
sharpening their attention to where they were being touched
with a pen, the therapy would aim to “sharpen” the map.
Patients were treated in a private treatment room; their backs
were exposed and they were seated in a comfortable position,
allowing access to the lower back. A 9-block grid was designed
and shown on a body chart to the patient. Corresponding with
the patient viewing the body chart and 9-block grid, the patient
was taught via tactile stimulus with the back of a pen where
each block was in relation to their lower back, thus familiarizing
them with the 9-block grid (Figure 1) (Luomajoki and Moseley
2011, Wand et al 2011). Subsequently, the therapist randomly
stimulated the 9-blocks asking for continuous verbal feedback
as to the location of the stimulus; this was done for 5 minutes
in total. With a correct identification of the area, the therapist
proceeded to the next block for identification. In the event of an
incorrect answer, the area was re-stimulated and the therapists
would teach the patient which grid was touched, in essence
helping the patient develop a greater ability to identify the
stimulated grid. The stimulation of the grids was at random and
decided upon per discretion of the clinicians. Forward flexion and
low back pain were assessed immediately after the intervention.
RESULTS
Patients
This case series comprises data from 16 patients (12 female; mean
age 48.2 years) attending outpatient physiotherapy for CLBP
(median duration 10 years; range 6 months – 30 years), mean
LBP 5.56 out of 10 on a NPRS, moderate disability (mean ODI
34.38%) and high fear-avoidance associated with physical activity
(mean 17.25). Patient demographics can be found in Table 1.
Post-treatment Measurements
The immediate changes in NRS for LBP and forward flexion
for each patient can be found in Figures 2 and 3. Immediately
following treatment, the mean pain rating for LBP decreased by
1.91 (range 0-6), while forward flexion improved by a mean of
4.82cm (range -1 to 21).
IDISCUSSION
The results from this case series show that a treatment devoid of
physical movement and associated with cortical reorganisation
immediately increased lumbar flexion for patients with CLBP.
Movement is key in the recovery of patients with CLBP (Bray
and Moseley 2011, Moseley et al 2012b). Apart from limited
Figure 1: Localisation treatment grid
Table 1: Case series patient demographics
Variables Results
Age (years) 48.19 (range 20.7 – 71.7)
Females (n = 12) 75%
Height (meters) 1.73
Weight (kilograms) 88.85
Body Mass Index (BMI) 30.63
Duration of symptoms (years) Mean 11.9 (range 6 months –
30 years)
Median 10.0
FABQ – Physical Activity 17.25
FABQ – Work 18.38
ODI 34.38%
NPRS low back 5.56
Flexion (cm) 25.73
NEW ZEALAND JOURNAL OF PHYSIOTHERAPY | 63
spinal movement being correlated to decreased function (Archer
et al 2014, Nijs et al 2013, Vlaeyen et al 1995), therapeutic
treatments associated with a hypoalgesic effect (aerobic
exercise; manual therapy) require movement (George et al 2006,
Nijs et al 2012, Vicenzino et al 1998). In some patients with
CLBP, however, movement based strategies such as exercise
and manual therapy in themselves may pose a threat (Louw et
al 2012). If patients correlate movement to pain and vice versa,
clinicians are faced with a clinical dilemma (Moseley 2007,
Moseley et al 2008a). Various authors, however, have proposed
a series of techniques prior to physical rehabilitation (pre-
habilitation) to prepare the affected body part for rehabilitation,
including visualisation, left/right discrimination and
graphaesthesia (Daly and Bialocerkowski 2009, Moseley 2004b,
Moseley 2006, Moseley et al 2008b). It is believed that these
strategies access the premotor cortex and in essence, facilitate
preparation for and execution of motor cortex activation
(movement) (Daly and Bialocerkowski 2009, Moseley 2004b,
Moseley 2006, Moseley et al 2008b, Tsao et al 2008, Tsao
and Hodges 2007). The treatment provided in this case series,
albeit a brief intervention, resulted in a MDC in forward flexion,
similar to pain science education studies aimed at altering pain
cognitions (Moseley 2004a, Moseley et al 2004, Stavrinou et al
2007). Furthermore, the findings of this case series concur with
CRPS studies utilising various tactile interventions (localisation
and two-point discrimination) aimed at cortical reorganisation of
affected body maps to help ease pain and disability and improve
movement (Daly and Bialocerkowski 2009, Moseley 2004b,
Moseley 2006, Moseley et al 2008b).
To the best of our knowledge, to date, this is the first study
utilising this approach in a CLBP population. The ability to
improve movement, without physical movement, especially in the
early phase of rehabilitation, is important. This pre-habilitation
reorganisation of an affected body map may be especially
important for the more severely afflicted patients with CLBP.
Pain, limited movement and function are often closely associated
with high levels of fear-avoidance, which has been shown to be
a significant predictor of disability and especially of an inability
to return to work (Burton et al 1999, Fritz and George 2002),
Louw et al 2011, Moseley 2004b). In this case series, the patients
presented with a median CLBP duration of 10 years and a mean
FABQ-PA score of 17.25, well over the threshold associated with
a higher likelihood of not returning to work (Burton et al 1999,
Fritz and George 2002). By not engaging in painful and/or fearful
therapeutic movements and utilising treatments that provide an
immediate positive effect on pain and movement, it may indeed
facilitate a faster recovery. Future studies will need to explore if
this immediate change in pain and spinal movement leads to an
expedited return to function.
The case series failed to provide an overall MDC of pain ratings
in patients with CLBP (1.91 versus 2.1). Care should be taken in
regards to the interpretation of pain ratings in a case series with
eight patients failing to produce a MDC for pain. In line with the
search for the association of pain, limited ROM and function,
four patients, however, did obtain such positive changes. Apart
from collectively being close to MDC, it is worthy to highlight
the fact that the intervention was brief (5 minutes) and only
utilized one of the proposed GMI techniques (“localization”).
In a clinical setting it has been proposed and taught that
patients with chronic pain, including CLBP, should receive a
more comprehensive GMI approach, in addition to pain science
education (Moseley et al 2012a). Pain science education alone has
shown immediate improvements to physical movements such as
spinal flexion (Moseley 2004a, Moseley et al 2004, Stavrinou et
al 2007). The pain reduction in this case series warrants further
investigation into the clinical application of a GMI programme
with/without pain science education in patients with CLBP.
This case series has limitations. First, by its nature, a case
series does not offer a control group for comparison and the
design did not allow patients to serve as their own controls.
Second, the intervention was chosen arbitrarily based on
previous studies, and no attempt was made to determine if
such impairments were in place and in need of intervention.
Additionally, no attempt was made to examine if accuracy
of localisation did occur, and if it correlated to improved
movement and/or reduced low back pain. The fact that the pre-
tests, post-tests and treatments were performed by the same
treating clinicians infer bias which cannot be ignored in the
interpretation of the findings.
CONCLUSION
A brief intervention helping patients with CLBP identify the location
of tactile stimuli in their lower back led to immediate changes
in forward flexion. This case series provides preliminary evidence
Figure 2: NPRS of LBP before and after treatment. (*)
indicates patients who obtained a MDC
Participants
Figure 3: Lumbar flexion before and after treatment. (*)
indicates patients who obtained a MDC
Participants
64 | NEW ZEALAND JOURNAL OF PHYSIOTHERAPY
warranting larger controlled trials of GMI for patients with CLBP
or LBP in general, and whether specific sub-groupings need to be
considered. Finally, the results provide a potential for clinicians to
impact movement for patients with CLBP prior to a movement-
based approach such as exercise and/or manual therapy.
KEY POINTS
• Treatments involving movement may increase fear and pain-
related fear in patients with chronic low back pain.
• Decreased localisation of tactile stimuli is associated with
chronic pain and may impact movement itself.
• Strategies aimed at improving tactile stimulus localisation
may help decrease pain and improve movement.
• Cortical reorganisation strategies may provide a pre-
habilitation strategy to enhance movement without
movement.
ACKNOWLEDGEMENTS
No financial support was obtained for this study.
ADDRESS FOR CORRESPONDENCE
Adriaan Louw, Senior Instructor: International Spine and Pain
Institute, Adjunct Faculty: St. Ambrose University, PO Box 232,
Story City, IA 50248. Fax: 1-515-733-2744. Phone: 1-515-722-
2699. E-mail: Adriaan@ispinstitute.com
PERMISSIONS
Ethics
This study was approved by the Internal Review Board (IRB)/
Ethics at Southwest Baptist University. Patients provided written
and verbal consent to participate in the study.
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