RCT of Motor Imagery of Extension for LBP vs. Exercise
Condition: Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      Low back pain (LBP) is the most common musculoskeletal condition treated in physical therapy,
      accounting for an estimated 25-40% of outpatient physical therapy visits. One strategy
      commonly used for treating LBP is directional preference. Directional preference is the
      process of examining a patient with LBP's response to a movement direction, i.e., extension,
      and if it coincides with improvement, the test becomes part of the treatment. Various studies
      have shown evidence for, and use of directional preference by physical therapists.
      Specifically for LBP, directional preference usually involves either an extension-bias or
      flexion-bias, with various studies indication an extension protocol being the most common
      (estimated > 80% of patients). With extension exercises, a favorable therapeutic effect
      result in centralization of symptoms (leg pain migrates proximal), improved range of motion
      (ROM), decreased pain and decreased fear of movement.

      In recent years there has been an increased interest in various pain neuroscience strategies
      to help people in pain, including LBP. 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. 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).
      These neuronal representations of body parts are dynamically maintained. It has been shown
      that patients with pain display different S1 representations than people with no pain. 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. Furthermore, these changes in shape and size of body maps seem to correlate to
      increased pain and disability. Various studies have shown that physical movement is
      associated with restoring the cortical maps, which in turn may be associated with a decreased
      pain experience.

      In patients with high levels of pain, sensitization of the nervous system and fear of
      movement, physical movement itself may increase a pain experience. An added therapeutic
      ability to help restore these cortical maps is motor imagery (visualization). Various studies
      have shown that motor imagery activate the same areas of the brain as when actually
      physically moving, thus restoring the altered maps "without moving."
    

Detailed description: 
      -  Patient arrive to physical therapy with low back pain (physician referral or
           self-referral)

        -  Patient complete standard clinic medical and insurance intake forms

        -  Based on the intake forms, patients are screened by the physical therapists against the
           inclusion criteria and if met, asked to participate in the study

        -  Upon agreement, a written consent is signed

        -  Patients complete research intake forms:

             -  Demographic information

        -  Age

        -  Gender

        -  Duration of LBP

        -  Location of LBP (body chart with grid allocation)

             -  Pain rating (NPRS): Numeric Pain Rating Scale

             -  Fear-Avoidance (Physical and Work Subscales) (FABQ)

             -  Pain Catastrophization Scale (PCS)

        -  Patients undergo a standard physical therapy interview

        -  Patients undergo a standard physical therapy examination

        -  Patients undergo a directional preference test to determine if they are potentially
           responsive to extension exercises

        -  Once patients are shown to be responsive to extension, they are alternately allocated to
           receive motor imagery of extension exercises (experimental group; [EG]) or physical
           extension exercises (control group, [CG]).

        -  Prior to the treatment lumbar extension ROM will be measured via a standardized
           procedure

        -  Upon completion of the tests, patients will receive one of two allocated treatments

      Following the treatment, patients will undergo repeat measures of:

        -  Spinal extension ROM

        -  Pain rating

        -  Fear of movement

        -  Pain catastrophization Patients will be asked to return to physical therapy in 2 to 3
           days (standard care)

      Upon return, measurements will be repeated of:

        -  Pain rating

        -  Fear of movement

        -  Pain catastrophization

        -  Spinal extension ROM This marks the end of data collection (and study) of the individual
           patient - Following the tests the patient is treated per the discretion of the therapist
           as the data collection has been completed
    

Intervention name(s): Motor Imagery. Imaging doing Extension exercises without actually doing them.; Control: Physically performing extension based exercises.
Intervention type(s): Other; Other
Intervention description(s): This study will compare imagining doing specific extension based exercises for LBP vs. actually performing the exercises. This intervention will be just imaging doing the exercises.; This study will compare imagining doing specific extension based exercises for LBP vs. actually doing them. This intervention will be actually, physically performing the exercises.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This is an Randomized Control Trial. Subjects with LBP will be allocated to one of 2 study groups.
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Motor Imagery; McKenzie; Low Back Pain; Directional preference