Is there any benefit of adding a central nervous system-focused intervention to a manual therapy and home stretching program for people with frozen shoulder? A randomized controlled trial.

BACKGROUND: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion. The aim of this study was to evaluate the effect of adding a central nervous system (CNS)-focused approach to a manual therapy and home stretching program in people with FS. METHODS: A total of 34 patients with a diagnosis of primary FS were randomly allocated to receive a 12-week manual therapy and home stretching program or manual therapy and home stretching program plus a CNS-focused approach including graded motor imagery and sensory discrimination training. The Shoulder Pain and Disability Index score, self-perceived shoulder pain (visual analog scale score), shoulder range of motion, and the Patient-Specific Functional Scale score were measured at baseline, after a 2-week washout period just before starting treatment, after treatment, and at 3 months' follow-up. RESULTS: No significant between-group differences in any outcome were found either after treatment or at 3 months' follow-up. CONCLUSION: A CNS-focused approach provided no additional benefit to a manual therapy and home stretching program in terms of shoulder pain and function in people with FS.

The clinical impact of pain neuroscience continuing education on physical therapy outcomes for patients with low back and neck pain.

OBJECTIVES: Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program was associated with any observed changes to patient outcomes and also clinical practice. METHODS: Participants were 25 different physical therapists who treated 3,705 patients with low back pain (LBP) or neck pain before and after they had completed an online PNE CE course. Change in outcomes measures of pain and disability at discharge were compared for the patients treated before and after the therapist training. Clinical practice patterns of the therapists, including total treatment visits, duration of care, total units billed, average units billed per visit, percentage of 'active' billing units and percentage of 'active and manual' billing units, were also compared for the patient care episodes before and after the therapist training. RESULTS: There was no significant difference for change in pain scores at discharge for patients treated after therapist CE training compared to those treated before regardless of the condition (LBP or neck pain). However, patients with LBP who were treated after therapist CE training did report greater improvement in their disability scores. Also after CE training, for each episode of care, therapists tended to use less total visits, billed fewer units per visit, and billed a greater percentage of more 'active' and 'active and manual' billing units. DISCUSSION: Attending an online 3-hour CE course on PNE resulted in improved disability scores for patients with LBP, but not for those with neck pain. Changes in clinical behavior by the therapists included using less visits, billing fewer total units, and shifting to more active and manual therapy interventions. Further prospective studies with control groups should investigate the effect of therapist CE on patient outcomes and clinical practice.

A Case-Series of Dry Needling as an Immediate Sensory Integration Intervention.

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.

The clinical application of pain neuroscience, graded motor imagery, and graded activity with complex regional pain syndrome-A case report.

BACKGROUND: Chronic Regional Pain Syndrome (CRPS) is a condition that physical therapists may encounter in an outpatient orthopedic setting. In physical therapy (PT) treatment of CRPS addresses pain and the changes observed in the brain through the use of graded motor imagery (GMI). CASE DESCRIPTION: A 57-year-old female presented to an outpatient PT clinic with CRPS type 1. Complicating psychosocial factors such as kinesiophobia and catastrophization were present. The patient engaged in a treatment plan including GMI: pain neuroscience education (PNE), laterality training, motor imagery, and mirror training. As symptoms improved, graded functional exposure and functional restoration occurred. OUTCOMES: The patient was seen for a total of 26 visits over a 9-month period. FAAM measures exceeded reported clinically important change that was sustained at two-year follow-up. Long term outcomes showed no functional deficits related to her foot or ankle and minimal to no catastrophizing and fear avoidance behaviors. DISCUSSION: This case report showcases the use of GMI with a patient with CRPS type 1 in an outpatient orthopedic clinic. Clinicians may consider the use of GMI to progress a patient toward maximal functional gains.

Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual With Frozen Shoulder.

Study Design Case report. Background Aggressive physical therapy in the freezing stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Pain neuroscience education, tactile discrimination, and graded motor imagery have been used in a number of conditions with central sensitization. The purpose of this case report was to describe the examination and treatment of a patient in the freezing stage of frozen shoulder using pain neuroscience education, tactile discrimination, and graded motor imagery. Case Description A 54-year-old woman with a diagnosis of frozen shoulder was referred by an orthopaedic surgeon following lack of progress after 4 weeks of intensive daily physical therapy. Pain at rest was 7/10, and her Shoulder Pain and Disability Index score was 64%. She had painful and limited active range of motion and elevated fear-avoidance beliefs. Tactile discrimination and limb laterality were impaired, with signs of central sensitization. A "top-down" approach using pain neuroscience education, tactile discrimination, and graded motor imagery was used for the first 6 weeks, followed by a "bottom-up" impairment-based approach. Outcomes The patient was seen for 20 sessions over 12 weeks. At discharge, her Shoulder Pain and Disability Index score was 22%, resting pain was 0/10, and fear-avoidance beliefs improved. Improvements in active range of motion, laterality, and tactile discrimination were also noted. Discussion Intensive physical therapy in the freezing stage of frozen shoulder may be detrimental to long-term outcomes. This case report suggests that a top-down approach may allow a quicker transition through the freezing stage of frozen shoulder. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2018;48(3):174-184. Epub 19 Dec 2017. doi:10.2519/jospt.2018.7716.

Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion.

OBJECTIVE: To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain. DESIGN: Single-blind case series. SETTING: Three outpatient physical therapy clinics. PARTICIPANTS: Patients with shoulder pain and limited AROM (N=69). INTERVENTION: Patients moved their unaffected shoulder through comfortable AROM in front of a mirror so that it appeared that they were moving their affected shoulder. MAIN OUTCOME MEASURES: We measured pain, pain catastrophization, fear avoidance, and AROM in 69 consecutive patients with shoulder pain and limited AROM before and immediately after mirror therapy. RESULTS: There were significant differences in self-reported pain (P=.014), pain catastrophization (P<.001), and the Tampa Scale of Kinesiophobia (P=.012) immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase (mean, 14.5°) in affected shoulder flexion AROM immediately postmirror therapy (P<.001), which exceeded the MDC of 8°. CONCLUSIONS: A brief mirror therapy intervention can result in statistically significant improvements in pain, pain catastrophization, fear avoidance, and shoulder flexion AROM in patients presenting with shoulder pain with limited AROM. The immediate changes may allow a quicker transition to multimodal treatment, including manual therapy and exercise in these patients. Further studies, including randomized controlled trials, are needed to investigate these findings and determine longer-term effects.

Moving without moving: immediate management following lumbar spine surgery using a graded motor imagery approach: a case report.

Representational body maps are dynamically maintained in the brain and negatively influenced by neglect, decreased movement and pain. Graded motor imagery (GMI) utilizing various tactile and cognitive processes has shown efficacy in decreasing pain, disability and movement restrictions in musculoskeletal pain. Limited information is known about the cortical changes patients undergo during lumbar surgery (LS), let alone the therapeutic effect of GMI for LS. A 56-year-old patient underwent LS for low back pain, leg pain and progressive neurological deficit. Twenty-four hours prior to and 48 h after LS various psychometric, physical movement and tactile acuity measurements were recorded. Apart from predictable postoperative increases in pain, fear-avoidance, disability and movement-restrictions, pressure pain thresholds (PPT), two-point discrimination (TPD) and tactile acuity was greatly reduced. The patient underwent six physiotherapy (PT) treatments receiving a GMI program aimed at restoring the PPT, TPD and tactile acuity. The results revealed that GMI techniques applied to a patient immediately after LS caused marked improvements in movement (flexion average improvement/session 3.3 cm; straight leg raise average 8.3°/session) and an immediate hypoalgesic effect. GMI may provide PT with a non-threatening therapeutic treatment for the acute LS patient and establish a new role for PT in acute LS patients.