Using Graded Motor Imagery for Chronic Low Back Pain with Online Tools

Background and Purpose

I was introduced to many chronic pain patient cases during my first clinical rotation at an outpatient orthopedic clinic where many of the patients faced various psychosocial factors and had experienced chronic pain for years before coming to physical therapy. Of those cases, the majority of those patients experienced low back pain specifically and many of the patients coming in for other conditions had low back pain as a co-morbidity. At the time, chronic pain interventions were new to me, and I did not feel that I had the knowledge base to implement the interventions properly. Our curriculum touches on chronic pain in multiple courses, but does not have a unit dedicated to it. In addition, many chronic pain interventions involve patient education where the patient passively receives the information given to them, but I wanted to create a patient resource where they could actively participate in the treatment. As a result, I chose graded motor imagery as my intervention and developed online tools patients could use on their phones to complete the exercises involved with the graded motor imagery process. Graded motor imagery integrates neuroplasticity and motor learning concepts into a 3 stage process that patients can progress through at a pace suitable for their condition. While chronic pain cases are often associated with outpatient orthopedics, clinicians in every area will have patients who experience chronic pain on their caseload and can use these tools with them.

Statement of Need

Chronic pain affects 20% of adults and estimated costs of chronic pain is 560 to 635 billion dollars per year in the US, which includes patient care costs, days and hours of missed work, and decreased wages due to disability.^1,2 About 65 million adults have experienced a recent episode of back pain and about 16 million adults in the US report having chronic low back pain.² Chronic pain can lead to cortical restructuring and changes in gray matter density, so interventions targeting neuroplasticity, such as graded motor imagery, can be beneficial for these patients.³ Many chronic pain patients often also have high levels of fear avoidance regarding movement due to their experiences with pain, so graded motor imagery can be used as a starting point for their recovery process to ease them into active movement and therapeutic exercises. Graded motor imagery is also an intervention that does not require expensive equipment and can be done as part of a home exercise program, so it is more accessible to patients of various backgrounds.

References

1. Chronic Pain and High impact Chronic Pain Among US Adults – Number 390 – November 2020. Accessed January 18, 2022. https://www.cdc.gov/nchs/products/databriefs/db390.htm
2. Druss BG, Marcus SC, Olfson M, Pincus HA. The most expensive medical conditions in America. Health Aff (Millwood). 2002;21(4):105-111. doi:10.1377/hlthaff.21.4.105
3. Apkarian AV, Baliki MN, Geha PY. Towards a theory of chronic pain. Prog Neurobiol. 2009;87(2):81-97. doi:10.1016/j.pneurobio.2008.09.018

Products

For this project, I created a presentation discussing chronic pain, graded motor imagery, and a walk through on how to use the online assessment tools with patients. I created two online tools for patients to use on their phones to help guide them through the graded motor imagery process. The assessment tool is meant to be used during evaluation of a patient with chronic low back pain to assess which movements they fear the most. The results of the assessment tool can be used to guide explicit motor imagery (visualizing themselves performing various movements) and their fear hierarchy during the graded exposure stage where patients begin to incorporate active movements of the exercises and positions they fear. Then after discussing the results with their PT, they will use the intervention tool as part of their HEP to facilitate the explicit motor imagery stage.

Video Presentation

Assessment Tool:

Intervention Tool:

Supplementary Materials

Literature Review and Evidence Table

Chronic Pain CAT Analysis

Evaluation

For evaluation, I created an evaluation form for physical therapists to assess the effectiveness of the presentation and online tools. I also created an evaluation form for patients to fill out about the online tools. The physical therapists who filled out the evaluation form largely reported that the presentation improved their knowledge of how to implement graded motor imagery with patients and their role in facilitating the graded motor imagery process.

Since I was not currently working in clinic with low back pain patients, I enlisted 5 individuals with chronic low back pain and served as the “PT” to educate them on the results of the assessment tool and taught them how to use the intervention tool. They filled out the eval form after  using both tools. All the patients rated the online tools as easy to access and use and 4/5 participants felt that having the app as a resource would improve their accountability with their HEP.

PT Evaluation Form

Patient Evaluation Form

Self-reflection

My individual learning objectives for this project were to become knowledgeable on graded motor imagery and be able to create a presentation that would help other physical therapy students and physical therapists implement this process with their patients. When I first started this project, I knew I wanted to do my project on specific chronic pain interventions, but learned early on that there was a breadth of options, all with varying levels of evidence to support it. With the guidance of my advisor, Debby Givens, I was able to narrow my focus onto graded motor imagery. She also encouraged me to think more outside the box about the mediums I could use for my patient education materials. In the past, I have created patient pamphlets and informational handouts, but this time I wanted to create something more interactive that patients could easily access on their phones. I do not have very much experience with creating online applications, so sometimes even adding in simple functions required extra time spent on the Qualtrics forums. One struggle I often face in clinic is increasing patient compliance to their HEP, so I wanted to create something that they could easily set as an application on their phone and complete the exercises anywhere. Through this project, I have deepened my understanding of how chronic pain can lead to cortical changes in the brain and how graded motor imagery can lead to neuroplasticity changes and healing in patients with chronic pain.

Acknowledgements

To Dr. Deborah Givens, PT, DPT, PHD, FAPTA: Thank you for your guidance and advice on ways to narrow my focus and encouraging me to be more creative with my patient education materials. The research resources you gave me helped me build a solid foundation for my presentation and this project would not be what it is without you.

To Dr. Sarah van der Horst, PT, DPT, OCS: Thank you for your continual support and encouragement. Your clinical experience and feedback helped me refine my online tools and integrate my chosen intervention into the bigger clinical picture.

To Dr. Joshua Torrey, PT, DPT, OCS: Thank you for your feedback on my materials and giving me feedback on how to make my presentation more comprehensive.

Project References

See presentation for reference list