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Immediate effects of sensory discrimination for chronic low back pain: a case series

  • International Spine and Pain Institute
  • Blue Power Energy

Abstract and Figures

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 localization 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.
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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
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
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
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.
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.
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).
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.
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.
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).
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
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.
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
Figure 3: Lumbar flexion before and after treatment. (*)
indicates patients who obtained a MDC
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.
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
No financial support was obtained for this study.
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:
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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... For example, it has been shown that when fingers are webbed together for 30 minutes, cortical maps associated with the fingers change from distinct separate regions into one [24]. This finding has significant clinical importance as it underscores the importance of strategies such as movement, tactile and visual stimulation of the skin, central nervous system, and brain as a means to help maintain S1 representation [25,26]. Based on these neuroplastic changes, treatment approaches may target strategies to help normalize these altered cortical representations of body maps. ...
... GMI is a collective term describing various 'brain exercises' and includes normalizing laterality (LRJ of body parts), motor imagery (visualization), mirror therapy, sensory discrimination, sensory integration, graphesthesia and mirror therapy [26][27][28][29]. Various studies have shown that these GMI strategies are able to positively influence pain and movement, including CLBP [25][26][27]. ...
... Recent studies for CLBP started exploring if traditional tactile treatments such as manual therapy would yield any positive effects when applied with an emphasis on cortical remapping [25,26,30]. In a case series of patients with CLBP with a median pain duration of 10 years, a 5-minute tactile localization simulating manual therapy intervention yielded an immediate improvement in pain and lumbar flexion, exceeding the minimal detectable and minimal clinical important difference [25]. ...
Background Chronic low back pain (CLBP) has been associated with altered cortical mapping in the primary somatosensory cortex. Various sensory discrimination treatments have been explored to positively influence CLBP by targeting cortical maps. Objectives To determine if dry needling (DN) applied to patients with CLBP would yield changes in two-point discrimination (TPD) and left-right judgment (LRJ) tasks for the low back. Secondary measurements of pain and limited range of motion (ROM) was also assessed. Methods A sample of 15 patients with CLBP were treated with DN to their low back. Prior to and immediately after DN, TPD, LRJ tasks, low back pain, spinal ROM, and straight leg raise (SLR) were measured. Results Following DN, there was a significant (p < 0.005) improvement in LRJ for low back images in all measures, except accuracy for the right side. TPD significantly improved at the L3 segment with a moderate effect size. A significant improvement was found for pain and trunk ROM after DN with a large effect in changing pain of 3.33 points and improving SLR by 9.0 degrees on average, which exceeds the minimal detectable change of 5.7 degrees. Conclusions This is the first study to explore if DN alters TPD and LRJ tasks in patients with CLBP. Results show an immediate significant positive change in TPD and LRJ tasks, as well as pain ratings and movement.
... While the causal mechanisms that underpin improvement or recovery from CLBP are not well established [13], the Maladaptive Perceptions Model [58] proposes several intermediary variables through which effects might occur. These are cognitions about the back, pain, and movement [69]; back-specific body representations [43]; fidelity and weighting of sensory information from the back [70,71]; and spinal control, movement coordination, and functional tolerance for meaningful activities [33,72]. Components of the RESOLVE treatment were designed to target these factors alongside pain and function. ...
... We have chosen the proposed mediators, pain self-efficacy, back beliefs, pain catastrophizing, kinesiophobia, back perception, tactile acuity, and movement coordination, based on theoretical predictions from the Maladaptive Perceptions Model [58] and the results of pilot studies [33,[69][70][71]73,74]. ...
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Background Chronic low back pain (CLBP) is a global health problem associated with an increasing burden on individuals, health care systems, and society. Common treatments for people with CLBP produce, on average, small short-term improvements in pain and function compared with minimal care. The RESOLVE trial randomly allocated 276 people with CLBP to a new complex treatment strategy, pain education integrated with graded sensorimotor precision training (RESOLVE), or a sham control. The RESOLVE treatment was developed within a theoretical framework to target possible treatment mechanisms associated with CLBP development and persistence. Objective This protocol describes the planned evaluation of these proposed treatment mechanisms. Improved understanding of the mechanisms underpinning the RESOLVE treatment may guide its refinement and implementation. Methods We will use causal mediation analysis to evaluate the proposed treatment mechanisms, including pain self-efficacy, back beliefs, pain catastrophizing, kinesiophobia, back perception, tactile acuity, and movement coordination. The primary outcomes are pain intensity and function at 18 weeks following allocation. Data were collected blind to allocation and hypotheses at baseline (mediators, outcomes, confounders), end of treatment (mediators), and at 18 weeks following allocation (outcomes). We will test the robustness of our findings by conducting planned sensitivity analyses. Results Ethical approval was granted by the University of New South Wales Human Research Ethics Committee (HC15357). A total of 276 participants have been recruited from primary care practices and the community in Sydney, Australia. Conclusions The RESOLVE treatment constitutes a new paradigm for CLBP management with potentially wide-reaching implications. This mechanistic evaluation will provide evidence for the hypothesized treatment mechanisms and help explain why the treatment strategy did or did not have an effect on patient-reported outcomes. These results will help guide the treatment refinement and implementation. Trial Registration Australian and New Zealand Clinical Trials Registry ACTRN12615000610538; International Registered Report Identifier (IRRID) DERR1-10.2196/26053
... The goals of sensory and motor retraining for sciatica are to reverse the central nervous system changes related to chronic pain and to improve movement. 326,327 This approach involves sensory acuity training, visual feedback, movement, and other types of feedback or cues in various combinations. Evidence is growing that hands-on manual therapies performed in conjunction with feedback also influence the central nervous system. ...
... 327 Both studies found that graphesthesia training on the lower back reduced LBP. 326,327 Needling therapies may be adapted for sensory training. One study found that acupuncture was more effective in reducing LBP when paired with sensory discrimination training. ...
• The treatment of sciatica differs according to its cause • Most cases warrant a trial of conservative treatment • Integrated programs including manual therapies and exercise may be superior to any single therapy • Surgery is indicated in the presence of red flags and/or a lack of response to conservative treatment
... Because this reorganization occurs rapidly, various studies highlight the importance of using strategies, such as movement and tactile and visual stimulation of the central nervous system, to help maintain it. [50][51][52] For a correct interpretation of the results, the main biases described by the Cochrane Collaboration 53 have been considered in the analysis of the articles included in this review. ...
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Low back pain has a prevalence that reaches up to 70% of the population between 35-55 years of age and is the principal cause of occupational disability. The scientific evidence on the effect of manual therapy on low back pain is conflicting and there are no specific reviews on the Maitland concept of manual therapy. Therefore, the objective of this systematic review is to analyze the effect of the techniques of the Maitland concept of manual therapy in patients with low back pain and/or determine the level of scientific evidence.For this, a search was carried out in the Cinahl, Medline, Web of Science, PubMed and Scopus databases during the months of January and February 2021 and it was updated in August 2021. In the search, 894 records were obtained, of which 15 randomized clinical trials that obtained a minimum of 3 points out of 5 on the Jadad scale were included.The main results in the current scientific literature suggest that there is solid evidence that the manipulations and mobilizations described in the Maitland Concept, applied alone or in combination with other interventions, reduce pain and disability in subjects with low back pain.The effects on musculature are contradictory. Exercise and patient education increase the effect of manual therapy. Future research requires analyzing whether the effects are preserved in the long term and more homogeneous treatment protocols are needed to determine a prescriptive guideline for manual therapy. Level of evidence I; Systematic review. Keywords: Low Back Pain; Systematic Review; Musculoskeletal Manipulations; Exercise Therapy
... management techniques presented in Chapter three demonstrated that there is clinical potential for feedback guided sensory training interventions to improve pain(Flor, Denke, Schaefer, & Grusser, 2001;Koller & Baumgartner, 2017aKoller & Luomajoki, 2013a, 2013bLouw et al., 2015;Schneider et al., 2015;Wakolbinger et al., 2018) and sensorimotor function outcomes for people living with PLP(Wakolbinger et al., 2018). This would likely lead to benefits in other outcome domains such as quality of life. ...
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Introduction: Phantom limb pain (PLP) is intractable to treatment. Sensory discrimination training (SDT) is a non-pharmacological treatment, which shows potential promise for PLP, but robust clinical trials are lacking. This thesis aimed to develop a robust RCT protocol to investigate the efficacy of an automated, self-management SDT device (SP1X) for the treatment of PLP. Methods: Three studies contributed to the development of an RCT protocol to investigate the efficacy of SP1X. Firstly, a qualitative study explored participants perceptions of PLP self-management. Secondly, a systematic review investigated the efficacy and safety of SDT for chronic musculoskeletal pain conditions. Thirdly, a measurement study investigated the psychometric properties of key outcome measures for use with the PLP population. Results: Participants experiences of self-management of PLP were positive highlighting self-management as an acceptable and feasible approach. The systematic review found SDT does not appear to be associated with any adverse effects and shows potential regarding its clinical efficacy. However, high-quality evidence upon which to make firm clinical recommendations was lacking. The measurement study found three outcome measures for pain intensity, and one for quality of life, possessed acceptable psychometric properties for use in future research trials. Two sensorimotor outcome measures required further development and subsequent psychometric testing prior to use in future research trials. Conclusions and implications: Self-management strategies are an acceptable and feasible approach that could be incorporated into the lives of people with PLP. SDT has the potential to be safe and effective for PLP. Existing outcome measures for pain are sufficiently reliable for use in PLP research but should be interpreted cautiously on an individual patient level. This thesis developed a robust protocol to investigate the efficacy of SP1X. The protocol now needs to be undertaken to investigate the efficacy of SP1X before any recommendations on its use can be made.
... Indeed, some preliminary studies support this possibility in both neuropathic [11] and non-neuropathic 12 13 pain conditions, although not all studies report positive effects [14]. Currently, success in reducing pain cannot be directly linked to improved tactile acuity, because tactile acuity is rarely used as an outcome variable [11][12][13][14]. Additionally, differences in training paradigms among studies may affect tactile acuity improvements and explain differences in efficacy [14]. ...
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Background: Neck pain can be associated with a reduction in tactile acuity that is thought to reflect disrupted sensory processing. Tactile acuity training may normalise sensory processing and improve symptoms. This proof-of-concept trial will assess the feasibility of a novel tactile acuity training method and whether this intervention improves tactile acuity in people with persistent neck pain. Methods: and analysis: In this two-arm randomised clinical proof-of-concept trial we will recruit participants with neck pain receiving usual care physiotherapy in a secondary outpatient healthcare setting. Thirty-six participants will be randomised 2:1 to receive four weeks of either tactile acuity training using the Imprint Tactile Acuity Device (iTAD) or a placebo intervention, in addition to usual care. The placebo intervention will consist of a de-activated TENS machine (iTENS) said to deliver a sub-threshold inhibitory therapy. Outcomes will be assessed at baseline, mid-treatment, and at 5-weeks and 2-months follow-up. The primary outcome tactile acuity will be evaluated using the two-point discrimination test and locognosia tests. Feasibility will be informed by recruitment and attrition rates, adherence, credibility of the interventions, treatment satisfaction and blinding. Pain intensity and anatomical spread will be analysed as secondary outcomes. The effect of iTAD training on tactile acuity will be assessed using a 2 (Group: iTAD vs. iTENS) x 4 (Time: baseline, mid-treatment, 5-week and 2-month outcome assessment) mixed ANOVA. Secondary outcomes including pain and pain spread, will be analysed with a focus on informing sample size calculations in future trials. Ethics and dissemination: Risks associated with this study are minor. Usual care is not withheld, and participants consent to random allocation of either iTAD or iTENS. Potential benefits to participants include any benefit associated with the interventions and contributing to research that may assist people with chronic pain in the future. Trial results will be disseminated via academic journals and conference presentations. The study is approved by the Human Research Ethics Committee of Griffith University (2017/128).
... e eighth and the final lecture focused on how a traditional biomedically oriented intervention like manual therapy can be incorporated in the treatment of patients in chronic pain. 106,107 Research was reviewed on the multifaceted mechanisms of manual therapy, [108][109][110] how sensory discrimination can improve with manual work, 111 and how patient expectations influence the success of manual therapy interventions, 112,113 specifically discussing why manual therapy performed under anesthesia is not as effective as normal manual therapy. [114][115][116] Students also learned how pain education can improve the effectiveness of manual therapy 106 and how manual therapy at one joint can improve pressure pain threshold values throughout the body, 109 pointing to the importance of not just local but also central mechanisms for the effectiveness of manual therapy. ...
Pain education within physical therapist educational programs needs to continually evolve to meet current best practice guidelines. This model presentation describes the successful implementation of a pain curriculum using various active learning approaches including VoiceThread assignments in an entry-level physical therapist educational program. An 8-week curriculum was developed to assist students in meeting the synthesis and evaluation learning objectives of the International Association for the Study of Pain (IASP) curricular guidelines. Active learning homework assignments allowed students to practice communicating difficult pain principles while receiving constructive feedback. Course outcomes were measured through changes in a modified version of the Pain Attitude and Beliefs Scale (PABS), the Pain Care Confidence Scale (PCCS), qualitative student feedback, and performance on both practical and written examinations. All students passed the practical examination where they successfully demonstrated pain principle communication skills. The students showed less biomedical beliefs in 5 of the 7 PABS biomedical subscale questions and greater biopsychosocial beliefs in 2 of the 7 biopsychosocial subsections (P < .05). Student scores on the PCCS also improved significantly (P < .05) from 5.0 to 8.1 on the combined confidence level for treating patients in pain. Implementation of the IASP curriculum within an entry-level physical therapist education program resulting in positive results in student learning and changing beliefs using a combined lecture and active learning approach.
... Evening/nightly attacks of 10/ 10 (VAS) no longer occurred during the intervention phase. Louw et al., 2015 Case series CLBP n = 16 12 females 48 9-block grid shown on a body chart. TPD = back of a pen. ...
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Background Sensory discrimination training (SDT) is a form of feedback guided sensory training used in the treatment of chronic musculoskeletal pain (CMP). Objective This systematic review aimed to investigate the efficacy and safety of SDT for CMP. Methods MEDLINE, CINAHL, EMBASE, AMED, CENTRAL, PsycINFO, Scopus, OT Seeker, PEDro, ETHOS, Web of Science, and Open Grey were searched for appropriate randomized controlled trials (RCTs). Included papers were assessed for risk of bias, and evidence was graded using the GRADE approach. The protocol was published on PROSPERO (anonymized). Results Ten RCTs met the inclusion/exclusion criteria. There was conflicting evidence from seven RCTs for the efficacy of SDT for chronic low back pain (CLBP). There was very low-quality evidence from two studies supporting the efficacy of SDT for phantom limb pain (PLP). There was very low-quality evidence from one RCT for the efficacy of SDT for Fibromyalgia. No adverse effects of SDT were identified. Conclusions SDT has been delivered in multiple forms in the literature. SDT does not appear to be associated with any adverse effects and shows potential regarding its clinical efficacy. However, there is a lack of high-quality evidence upon which to make any firm clinical recommendations.
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This meta-analysis investigated whether more negative psychological factors are associated with less spinal amplitude of movement and higher trunk muscle activity in individuals with low back pain (LBP). Furthermore, it examined whether pain intensity was a confounding factor in this relationship. We included studies that provided at least one correlation coefficient between psychological (pain-related fear, catastrophizing, depression, anxiety and self-efficacy) and spinal motor behaviour (spinal amplitude and trunk muscle activity) measures. In total, 52 studies (3949 participants) were included. The pooled correlations coefficients (95% CI; number of participants) were -0.13 (-0.18 to -0.09; 2832) for pain-related fear, -0.16 (-0.23 to -0.09; 756) for catastrophizing, -0.08 (-0.13 to -0.03; 1570) for depression, -0.08 (-0.30 to 0.14; 336) for anxiety and -0.06 (-0.46 to 0.36; 66) for self-efficacy. The results indicated that higher levels of pain-related fear, catastrophizing and depression are significantly associated with reduced amplitudes of movement and larger muscle activity, and were consistent across subgroup and moderation analyses. Pain intensity did not significantly affect the association between these psychological factors and spinal motor behaviour, and had a very small independent association with spinal motor behaviour. In conclusion, the very small effect sizes found in the meta-analyses question the role of psychological factors as major causes of spinal movement avoidance in LBP. Experimental studies with more specific and individualized measures of psychological factors, pain intensity and spinal motor behaviour are recommended.
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Abstract Objective: To investigate a proposed model in which manipulative therapy produces a treatment-specific initial hypoalgesic and sympathoexcitatory effect by activating a descending pain inhibitory system. The a priori hypothesis tested was that manipulative therapy produces mechanical hypoalgesia and sympathoexcitation beyond that produced by placebo or control. Furthermore, these effects would be correlated, thus supporting the proposed model. Design: A randomized, double-blind, placebo-controlled, repeated-measures study of the initial effect of treatment. Setting: Clinical neurophysiology laboratory. Subjects: Twenty-four subjects (13 women and 11 men; mean age, 49 yr) with chronic lateral epicondylalgia (average duration, 6.2 months). Intervention: Cervical spine lateral glide oscillatory manipulation, placebo and control. Outcome Measures: Pressure pain threshold, thermal pain threshold, pain-free grip strength test, upper limb tension test 2b, skin conductance, pileous and glabrous skin temperature and blood flux. Results: Treatment produced hypoalgesic and sympathoexcitatory changes significantly greater than those of placebo and control (p < .03). Confirmatory factor-analysis modeling, which was performed on the pain- related measures and the indicators of sympathetic nervous system function, demonstrated a significant correlation (r = .82) between the latencies of manipulation-induced hypoalgesia and sympathoexcitation. The Lagrange Multiplier test and Wald test indicated that the two latent factors parsimoniously and appropriately represented their observed variables. Conclusion: Manual therapy produces a treatment-specific initial hypoalgesic and sympathoexcitatory effect beyond that of placebo or control. The strong correlation between hypoalgesic and sympathoexcitatory effects suggests that a central control mechanism might be activated by manipulative therapy. Author keywords Chiropractic Manipulation; Confirmatory Factor Analysis; Elbow; Pain; Physical Therapy; Sympathetic Nervous System
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Study Design. Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy.Objective. To determine if the addition of NE to usual preoperative education would result in superior outcomes in regards to pain, function, surgical experience and healthcare utilization post-surgery.Summary of Background Data. One in four patients following lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is non-responsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in chronic low back pain (LBP) populations.Methods. Eligible patients scheduled for LS for radiculopathy were randomized to receive either usual preoperative care (UC) or a combination of UC plus one session of NE delivered by a physical therapist (verbal one-on-one) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and one, three, six and 12 months after LS: LBP (Numeric Rating Scale (NRS)), leg pain (NRS), function (Oswestry Disability Index), various beliefs and experiences related to LS (10 item survey with Likert responses), and post-operative utilization of healthcare (Utilization of Healthcare Questionnaire).Results. At one-year follow up, there were no statistical difference between the experimental and control groups in regards to primary outcome measure of LBP (p = 0.183), leg pain (p = 0.075) and function (p = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (p = 0.001); preoperative session preparing them for LS (p < 0.001) and LS meeting their expectations (p = 0.021). Healthcare utilization post-LS also favored the NE group (p = 0.007) resulting in 45% less healthcare expenditure compared to the control group in the 1-year follow-up period.Conclusion. NE resulted in significant behavior change. Despite a similar pain and functional trajectory over the one year trial, LS patients who received NE viewed their surgical experience more favorably and utilized less healthcare in the form of medical tests and treatments.
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Abstract Acute low back pain (LBP) from injuries is prevalent in the work place. It has been shown that patients with psychosocial factors often progress with persistent pain and lead to significant workers compensation costs. Therapeutic Neuroscience Education (TNE) has been shown to be beneficial in changing a patient's cognition regarding their pain state, which may result in decrease fear, anxiety and catastrophization. A 19-year-old female who developed LBP from a work injury was the patient for this case report. A physical examination, Numeric Pain Rating Scale (NRPS), Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire (FABQ), Keele STarT Back Screening Tool (Keele SBST) and Acute Low Back Pain Screening (ALBPS) Questionnaires were assessed during initial physical therapy visit and discharge. Treatment consisted of use of TNE, manual therapy and exercises. She attended five total visits over a 2-week period prior to full discharge. During the initial visit the patient reported NRPS = 3/10, ODI = 36%, FABQ-PA = 23, FABQ-W = 30, Keele SBST = 4/9, ALBPS = 101. At discharge the patient reported a 0 on all outcome questionnaires with ability to return to full work and no pain complaints.
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Severe exacerbation of symptoms following physical activity is characteristic for chronic-fatigue syndrome (CFS) and fibromyalgia (FM). These exacerbations make it understandable for people with CFS and FM to develop fear of performing body movement or physical activity and consequently avoidance behaviour toward physical activity. The aims of this article were to review what measures are available for measuring fear of movement and avoidance behaviour, the prevalence fear of movement and avoidance behaviour toward physical activity and the therapeutic options with fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM. The review revealed that fear of movement and avoidance behaviour toward physical activity is highly prevalent in both the CFS and FM population, and it is related to various clinical characteristics of CFS and FM, including symptom severity and self-reported quality of life and disability. It appears to be crucial for treatment (success) to identify CFS and FM patients displaying fear of movement and avoidance behaviour toward physical activity. Individually tailored cognitive behavioural therapy plus exercise training, depending on the patient's classification as avoiding or persisting, appears to be the most promising strategy for treating fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.
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This paper argues that the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points: (i) that pain does not provide a measure of the state of the tissues; (ii) that pain is modulated by many factors from across somatic, psychological and social domains; (iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and (iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger. These issues raise conceptual and clinical implications, which are discussed with particular relevance to persistent pain. Finally, this conceptualisation is used as a framework for one approach to understanding complex regional pain syndrome.
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Unlabelled: Graded motor imagery (GMI) is becoming increasingly used in the treatment of chronic pain conditions. The objective of this systematic review was to synthesize all evidence concerning the effects of GMI and its constituent components on chronic pain. Systematic searches were conducted in 10 electronic databases. All randomized controlled trials (RCTs) of GMI, left/right judgment training, motor imagery, and mirror therapy used as a treatment for chronic pain were included. Methodological quality was assessed using the Cochrane risk of bias tool. Six RCTs met our inclusion criteria, and the methodological quality was generally low. No effect was seen for left/right judgment training, and conflicting results were found for motor imagery used as stand-alone techniques, but positive effects were observed for both mirror therapy and GMI. A meta-analysis of GMI versus usual physiotherapy care favored GMI in reducing pain (2 studies, n = 63; effect size, 1.06 [95% confidence interval, .41, 1.71]; heterogeneity, I(2) = 15%). Our results suggest that GMI and mirror therapy alone may be effective, although this conclusion is based on limited evidence. Further rigorous studies are needed to investigate the effects of GMI and its components on a wider chronic pain population. Perspective: This systematic review synthesizes the evidence for GMI and its constituent components on chronic pain. This review may assist clinicians in making evidence-based decisions on managing patients with chronic pain conditions.
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Exercise is an effective treatment for various chronic pain disorders, including fibromyalgia, chronic neck pain, osteoarthritis, rheumatoid arthritis, and chronic low back pain. Although the clinical benefits of exercise therapy in these populations are well established (i.e. evidence based), it is currently unclear whether exercise has positive effects on the processes involved in chronic pain (e.g. central pain modulation). Reviewing the available evidence addressing the effects of exercise on central pain modulation in patients with chronic pain. Narrative review. Exercise activates endogenous analgesia in healthy individuals. The increased pain threshold following exercise is due to the release of endogenous opioids and activation of (supra)spinal nociceptive inhibitory mechanisms orchestrated by the brain. Exercise triggers the release of beta-endorphins from the pituitary (peripherally) and the hypothalamus (centrally), which in turn enables analgesic effects by activating μ-opioid receptors peripherally and centrally, respectively. The hypothalamus, through its projections on the periaqueductal grey, has the capacity to activate descending nociceptive inhibitory mechanisms. However, several groups have shown dysfunctioning of endogenous analgesia in response to exercise in patients with chronic pain. Muscle contractions activate generalized endogenous analgesia in healthy, pain-free humans and patients with either osteoarthritis or rheumatoid arthritis, but result in increased generalised pain sensitivity in fibromyalgia patients. In patients having local muscular pain (e.g. shoulder myalgia), exercising non-painful muscles activates generalized endogenous analgesia. However, exercising painful muscles does not change pain sensitivity either in the exercising muscle or at distant locations. The reviewed studies examined acute effects of exercise rather than long-term effects of exercise therapy. A dysfunctional response of patients with chronic pain and aberrations in central pain modulation to exercise has been shown, indicating that exercise therapy should be individually tailored with emphasis on prevention of symptom flares. The paper discusses the translation of these findings to rehabilitation practice together with future research avenues.
The fear-avoidance model offers a promising framework for understanding the development of chronic postoperative pain and disability. However, limited research has examined this model in patients undergoing spinal surgery. To determine whether preoperative and early postoperative fear of movement predicts pain, disability, and physical health at 6 months following spinal surgery for degenerative conditions, after controlling for depressive symptoms and other potential confounding variables. A prospective cohort study conducted at an academic outpatient clinic. One hundred forty-one patients undergoing surgery for lumbar or cervical degenerative conditions. Self-reported pain and disability were measured with the Brief Pain Inventory and the Oswestry Disability Index/Neck Disability Index, respectively. The physical composite scale of the 12-Item Short-Form Health Survey (SF-12) measured physical health. Data collection occurred preoperatively and at 6 weeks and 6 months following surgery. Fear of movement was measured with the Tampa Scale for Kinesiophobia and depression with the Prime-MD PHQ-9. One hundred and twenty patients (85% follow-up) completed the 6-month postoperative assessment. Multivariable mixed-method linear regression analyses found that early postoperative fear of movement (6 weeks) predicted pain intensity, pain interference, disability, and physical health at 6-month follow-up (p<.05). Preoperative and early postoperative depression predicted pain interference, disability, and physical health. Results provide support for the fear-avoidance model in a postsurgical spine population. Early postoperative screening for fear of movement and depressive symptoms that do not acutely improve following surgical intervention appears warranted. Cognitive and behavioral strategies may be beneficial for postsurgical patients with high fear of movement and/or depressive symptoms.
Tactile dysfunction in chronic pain is explained as disruption in somatotopically based processing of stimuli. We hypothesized that people with chronic back pain also demonstrate a spatially defined disruption of tactile processing. In 3 cross-sectional experiments, 26 patients with unilateral low back pain and 12 healthy controls made temporal order judgments of pairs of tactile stimuli. We analyzed the stimulus onset asynchrony at which participants perceived them to be simultaneous (PSS). Stimuli were delivered to either side of the back or to both index fingers. For hand stimuli, the position of the hands were 1) one either side of the back or 2) in front of the body, 3) one behind the back and one in front on the affected side or 4) on the unaffected side. In patients, mean ± SD PSS for stimuli to either side of the lower back occurred when the affected side received the stimulus 25 ± 25 msec before the unaffected side. PSS for stimuli to the hands with one hand held near the affected area was similar when the other hand was behind the back on the opposite side of the midline (17 ± 17 msec) or in front of the body on the affected side (31 ± 21 msec). These PSS values were greater than that for all other conditions and in healthy controls (p < 0.01), which approached zero. Spatial representation of vibrotactile stimuli is disrupted in chronic unilateral back pain.