Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor

1 Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor
2 Imagery in an Individual with Frozen Shoulder

3 Eric E. Sawyer1, Amy W. McDevitt2, Adriaan Louw3, Emilio J. Puentedura4, Paul E.
4 Mintken5
5 1Eric
E. Sawyer, PT, DPT, Senior Instructor, University of Colorado School of Medicine,
6 Department of PT, Aurora, CO.
7 2Amy W. McDevitt, PT, DPT, Assistant Professor, University of Colorado School of
8 Medicine, Department of PT, Aurora, CO; Physical Therapist, University of Colorado
9 Health, Sports PT and Rehabilitation at the University of Colorado Hospital, Denver,
Downloaded from www.jospt.org at Univ Canberra on December 24, 2017. For personal use only. No other uses without permission.
10 CO.
11 3Adriaan Louw, PT, PhD, Senior Instructor, International Spine and Pain Institute, Story
12 City, IA.
13 4Emilio J. Puentedura, PT, DPT, PhD, Associate Professor, Department of PT, School
14 of Allied Health Sciences, University of Nevada, Las Vegas, Las Vegas, NV.
15 5PaulE. Mintken, PT, DPT, Professor, University of Colorado School of Medicine,
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
16 Department of PT, Aurora, CO; Lead Clinician at Wardenburg Health Center at the
17 University of Colorado Boulder, Boulder, CO.
18 The subject in this case gave consent to use her medical information and images as
19 part of this publication.
20 Address correspondence to Dr. Paul Mintken, University of Colorado School of
21 Medicine, 13121 E 17th C-244, Avenue, Aurora, Colorado 80045. E-mail:
Journal of Orthopaedic & Sports Physical Therapy®
22 paul.mintken@ucdenver.edu
23
24
1
25 ABSTRACT
26 Study Design: Case report
27 Background: Aggressive PT in the freezing stage of frozen shoulder (FS) may prolong
28 the course of recovery. Central sensitization (CS) may play a role in the early stages of
29 FS. Pain neuroscience education (PNE), tactile discrimination (TD) and graded motor
30 imagery (GMI) have been used in a number of conditions with CS. The purpose of this
31 case report is to describe the examination and treatment of a patient in the freezing
32 stage of FS using PNE, TD and GMI.
33 Case Description: A 54-year-old female with a diagnosis of FS was referred by an
34 orthopedic surgeon following a failed bout of 4 weeks of intensive daily physical therapy
35 (PT). Pain at rest was 7/10 and her Shoulder Pain and Disability Index (SPADI) score
36 was 62%. She had painful and limited active range of motion (AROM) and elevated fear
37 avoidance beliefs. TD and limb laterality were impaired with signs of CS. A "top-down"
38 approach using PNE, TD, and GMI was used for the first 6 weeks followed by a
39 “bottom-up” impairment based approach.
40 Outcomes: The patient was seen for 20 sessions over 12 weeks. At discharge, her
41 SPADI was 22%, resting pain was 0/10, and fear avoidance beliefs improved.
42 Improvements in AROM, laterality and TD were also noted.
43 Discussion: Intensive PT in the freezing stage of FS may be detrimental to long term
44 outcomes. This case report suggests a "top-down approach" may allow a quicker
45 transition through the freezing stage of FS.
46 Level of Evidence: Therapy, level 5
47 Key Words: frozen shoulder, central sensitization, shoulder pain, neuroscience

48 education
49
50
2
51 BACKGROUND
52 The reported prevalence of frozen shoulder (FS) is 2 to 5 percent,47 with diagnosis
53 being made after ruling out other pathologies and noting equal limitations in passive and
54 active range of motion (ROM), most notably with external rotation.21 FS has been
55 reported as generally having four primary stages that reflect a continuum in its course.21
56 Stage 1 is characterized by sharp pain at the end of ROM, achy pain at rest, and sleep
57 disturbance. This stage lasts up to 3 months. Stage 2 is described as the “painful” or
58 “freezing” stage, presents as a gradual loss of ROM in all directions due to pain, and
59 can last up to 9 months. Stage 3, known as the “frozen stage,” lasts 9 to 15 months and
60 includes both pain and stiffness. The final stage , known as the “thawing” stage, is
61 characterized by less pain and prevailing stiffness that becomes a more limiting factor.
62 This last stage can last 15 to 24 months after onset of symptoms.17, 21
63 Nonsurgical treatment of FS has varied over time and had mixed outcomes. A
64 systematic review by Wong et al reported finding no evidence of complete resolution

65 without treatment, and low-quality evidence suggests patients do not regain full ROM as
66 far as 4 years after onset.78 Most improvement occurs in the early stages, suggesting
67 appropriate treatment strategies in the freezing/painful stage of FS may result in better
68 outcomes.88 While a systematic review by Jain et al19 reported that exercise and joint
69 mobilization were strongly recommended for reducing pain and improving function and
70 ROM in patients with stages 2 and 3 of FS, Dierks and Stevens13 demonstrated that
71 intensive physical therapy interventions produced worse outcomes at 2 years compared
72 to supervised neglect.
73 Central sensitization (CS), defined as an “amplification of neural signaling within
74 the central nervous system (CNS) that elicits pain hypersensitivity,”79 may play a role in
3
75 FS.3, 10, 55, 61 It has been proposed that CS may be present in the early stages because
76 cytokines, which signal inflammation, may provide prolonged stimulation of neurons in
77 the dorsal horn as well as the glial cells of the spinal cord.65 CS may hinder descending
78 pathways for pain inhibition, altering the processing of sensory information and
79 increasing nociceptive signaling mechanisms.79 This can lead to non-noxious stimuli
80 being interpreted as threatening and painful.61 CS has been reported to produce

81 hypersensitivity to cold and heat as well as decreases in pressure pain threshold.10 In
82 the absence of a diagnostic gold standard to diagnose CS, Smart et al62 suggested that
83 the best alternative ‘reference standard’ may be expert clinical judgment. Classification
84 criteria for CS are based on determining which signs and symptoms match the
85 impression of an experienced clinician. Smart et al63 described a symptom and sign
86 cluster for CS with a reported sensitivity of 91.8% and specificity 97.7% in individuals
87 with LBP. The cluster included: 'Disproportionate, non-mechanical, unpredictable
88 pattern of pain provocation in response to multiple/non-specific aggravating/easing

89 factors,' 'Pain disproportionate to the nature and extent of injury or pathology,' 'Strong
90 association with maladaptive psychosocial factors,’ and 'Diffuse/non-anatomic areas of
91 pain/tenderness on palpation.'63
92 Pain neuroscience education (PNE) and graded motor imagery (GMI) have been
93 used successfully in a number of conditions with suspected CS.26, 30, 38, 39, 42 PNE is
94 used to educate individuals on how pain is processed by the nervous system..26 The
95 goal of PNE is to increase movement and function while decreasing pain, fear-
96 avoidance, and disability.30 GMI is a 3-stage process that aims to facilitate sensory
97 cortex reorganization.16, 38, 39 GMI has been used in conjunction with tactile
4
98 discrimination (TD) training to produce clinically meaningful changes in pain.15, 42 The
99 primary sensory cortex receptive fields can reportedly be modified by tactile
100 discrimination training.14 According to Flor et al,15 2 weeks of sensory discrimination
101 training resulted in normalization of cortical organization and a clinically important
102 reduction of pain in amputees. The first stage of GMI includes laterality reconstruction
103 (LR), where patients view various images of body parts to determine if the image
104 portrays the right or left side.72 The second stage targets activation of the primary motor
105 cortex, requiring the patient to imagine moving the involved body part. This has been
106 shown to activate the same areas of the cortex associated with movement of the body
107 part.12 The final stage involves having the patient watch the unaffected body part
108 moving in a mirror to “trick” the brain into thinking the affected body part is actually
109 moving in a pain-free way.31 GMI has been reported to decrease pain intensity and
110 result in marked changes on functional magnetic resonance imaging (fMRI) in areas of
111 discriminative pain processing.75 The sequence of GMI training may be important in
112 systematically activating cortical systems and assisting in reorganization.40 Moseley38
113 described GMI as a treatment approach to “train the brain,” reorganizing the cortex to
114 decrease pain in the presence of CS.
115 The purpose of this report is to describe the examination and treatment of a
116 patient with FS using PNE, TD, and GMI, which has been reported in treating other
117 conditions, but not in FS.
118
119 CASE DESCRIPTION

120 History
5
121 The patient was a 54 year-old right-hand dominant female with a 2-month history
122 of gradual onset of right shoulder pain. She reported difficulty sleeping on her involved
123 side and denied any history of trauma. This pain worsened over 4 weeks, so she
124 consulted an orthopedic surgeon. Radiographs were normal, and she was diagnosed
125 with frozen shoulder. She received a corticosteroid injection and was referred for
126 intensive physical therapy. After 4 weeks, with her pain and disability worsening, she
127 stopped attending. She returned to the orthopedist requesting alternative treatment
128 options. The patient was subsequently referred to the senior author for a second
129 opinion. During the patient interview, she reported her pain had started insidiously
130 without a specific mechanism of injury. She stated she was comfortable with her arm by
131 her side, but elevating it would lead to sudden, excruciating pain. It continued to worsen
132 and began to disrupt her sleep, and this motivated her to seek a medical evaluation.
133 The previous episode of physical therapy, which she described as “aggressive,”
134 included ROM exercises and manual techniques to her pain tolerance. She reported
135 this made her symptoms worse, and stated that now everything hurt and she was afraid
136 to move. She complained of hypersensitivity to touch and temperature in both upper
137 extremities. Her functional limitations included sleeping, reaching overhead, reaching
138 behind the back, and washing her hair. She stated, “It now hurts for me for me to even
139 watch someone else move their shoulder. ” She also requested that the therapist not
140 touch her shoulder.”
141 Examination
142 A review of systems was used to screen for serious pathology. She was healthy,
143 didn’t take medications, or have any significant health problems. The examination
6
144 included several subjective assessments. Pain ratings were collected using the
145 Numeric Pain Rating Scale (NPRS), an 11- point scale from 0 to 10 (0=no pain and
146 10=worst imaginable pain).32 It has demonstrated good test-retest reliability in patients
147 with shoulder pain (intraclass correlation coefficient (ICC)=0.74) with a minimal clinically
148 important difference (MCID) of 1.1-2.17.32, 35 Her resting pain was 7/10 and her worst
149 pain was 10/10. A pain diagram was also completed (FIGURE 1) to assess for body
150 mapping issues.25 Body maps may expand or contract with cortical restructuring, in
151 essence increasing or decreasing the body map representation in the brain. 29 Evidence
152 suggests a correlation between the changes in shape and size of body maps with
153 increased pain and disability.14, 24

154 The Shoulder Pain and Disability Index (SPADI) was utilized to capture a
155 baseline measure for her perceived level of disability. It contains 13 items that assess
156 two domains; a 5-item subscale that measures pain and an 8-item subscale that
157 measures disability. A mean is taken of the two subscales to give a total score out of
158 100, with higher scores indicating greater disability.56, 58 The SPADI has demonstrated
159 good test-retest reliability with an ICC of 0.89 in patients with frozen shoulder and is
160 more responsive to change in this population than shoulder ROM measures.70 Her
161 SPADI score was 62%, indicating a high level of disability.58
162 A modified Fear Avoidance Beliefs Questionnaire (FABQ) was administered to
163 assess her beliefs related to her shoulder pain (the term “back” was replaced with
164 “shoulder”). The FABQ has 16 questions comprised of 2 subscales, one related to
165 physical activity (FABQ-PA) and the other to work (FABQ-W).73 Each item is scored
166 from 0-6 on a Likert scale with 0 meaning “completely disagree” to 6 meaning
7
167 “completely agree;” with 24 possible points on the PA subscale and 42 on the work
168 subscale. Lower scores indicate lower fear avoidance behaviors. The modified FABQ
169 has demonstrated excellent reliability in patients with shoulder pain (ICC = 0.88).34 It
170 has also demonstrated concurrent validity with the SPADI for pain and disability in
171 patients with shoulder pain.34 Wertli et al76, 77 proposed cutoff values for elevated fear
172 avoidance beliefs to be FABQ-PA of > 16 points and FABQ-W of > 25 points for
173 individuals with low back pain. The patient’s scores were 22 for the FABQ-PA and 34
174 for the FABQ-W, suggesting elevated levels of fear avoidance beliefs.
175 The physical examination for the shoulder was limited due to the patient’s fear of
176 movement and of being touched. Active and passive ROM of bilateral shoulders was
177 measured (TABLE 1) to assess for a capsular pattern, which, along with normal
178 radiographs, has been suggested for clinical diagnosis of FS.80 Glenohumeral (GH)
179 glides/accessory motions were assessed because limitations in multiple directions are a
180 common impairment found in FS.21

181 Centrally-mediated pain was suspected due to the presence of the cluster
182 predictive of CS reported by Smart et al.63 She complained of hypersensitivity to cold,
183 heat and pressure both locally and distant from the site of symptoms.50 These were
184 each investigated by the treating therapist by applying a hot pack, ice cup and digital
185 pressure 3 times to both shoulders and volar forearms.10, 50 The patient stated that each
186 stimulus elicited a painful response at all points tested, suggesting allodynia and
187 possible centrally-mediated pain.55
188 To further investigate suspected deficiencies in sensory processing, two-point
189 discrimination (TPD) testing of the shoulders and laterality testing (LT) of the shoulders
8
190 and hands was completed.38, 42 Norms for TPD in the shoulders of healthy adults are
191 reported to range between 40 and 45mm,4, 51 and TPD has good intra-rater reliability.7
192 Norms for LT of the shoulder and hands have been established for both accuracy (94-
193 95%4, 6 and 94%,41 respectively) and response time (1.3 seconds4, 6 and 2.3 seconds,41
194 respectively). Impairments were noted in both TPD and LT in this patient (Table 2),
195 and, interestingly, a reduction in resting pain of 3 points was reported after laterality
196 testing.
197 Evaluation
198 The diagnosis of FS was originally made by the orthopedic physician, and the PT
199 examination corroborated this. According to the Clinical Practice Guideline (CPG) for
200 Shoulder Pain and Mobility Deficits: Frozen shoulder the diagnosis is determined from
201 the history and physical examination.21 She met the CPG criteria for FS: age 40-65
202 years of age; gradual onset and progressive worsening of pain and stiffness; and painful
203 and limited GH active and passive ROM in multiple directions, with external rotation the
204 most limited (Figure 2). Her GH rotation decreased as the humerus was abducted, and
205 her accessory motions were restricted in all directions.21 The examination findings,
206 severity of pain and functional limitations suggested that she was in stage 2, the
207 freezing stage. The possibility of centrally-mediated pain was reinforced by her reports
208 of hypersensitivity away from the right shoulder, fear of movement, diminished TPD,
209 and impaired laterality in both the shoulders and hands (TABLE 2). These findings
210 suggested that she could potentially benefit from GMI, including sensory discrimination
211 training.25
212 Interventions
9
213 Due to her fear of movement and being touched, a “top-down,” cognitive-
214 based treatment approach was implemented to address the probable centralized pain.
215 She was first educated on lifestyle management issues to expedite her recovery and
216 manage her symptoms, including the importance of a positive outlook about her
217 recovery. A systematic review by Mondloch et al36 reported that positive expectations
218 were associated with better health outcomes. Dean and Soderland11 suggest
219 addressing lifestyle behavior change in individuals with pain might improve outcomes,
220 and should be included in first-line management of musculoskeletal pain conditions.
221 Therefore, she was educated on the importance of hydration, proper nutrition, and
222 adequate sleep. Additionally, a smartphone application (Calm™) was used for stress
223 reduction/relaxation techniques to manage stress and allow her to concentrate on her
224 recovery. Breathing exercises and stress reduction techniques have been shown to
225 reduce pain and improve function.8 A fitness program was encouraged, aiming for
226 moderate-intensity aerobic exercise (brisk walking) 150 minutes per week. 1 Moderate
227 intensity aerobic exercise can improve chronic pain symptoms.22, 46, 71
228 Pain neuroscience education (PNE) was also initiated in the first week. Key
229 concepts included: a) Pain is an output produced by our brain in response to what it
230 perceives as danger; b) pain is not necessarily associated with tissue damage; c) a
231 variable relationship exists between nociception and pain; d) environment can influence
232 perceived pain intensity; e) persistent pain creates an upregulation in nociception; f) and
233 the nervous system is plastic and adaptable.28 The second phase of treatment began in
234 the second week of therapy, consisting of 4 stages, each one week in duration. They
235 included TD training15, 42 and the three steps of GMI: laterality training, imagined
10
236 movements, and mirror therapy.38, 39 Typically, TD training precedes GMI, but LT was
237 implemented first in this case because the patient did not want her shoulder touched
238 and LT had resulted in an immediate reduction in resting pain. TD training occurred in
239 week 3, followed by imagined movements in week 4 and mirror therapy in week 5.
240 Below is a brief description of each stage:
241 Step 1 : Laterality Training (LT)

242 LT is the first step in the GMI program to improve the accuracy of the patient’s
243 cortical representation of his/her body.39 The patient trains by looking at left and right
244 images of body parts in different positions. Flash cards (Figure 3) or a smartphone
245 application created by the Neuro Orthopaedic Institute (NOI) can be used (brand name:
246 Recognise™ (http://www.recognise.noigroup.com/recognise/; noigroup.com, Adelaide,
247 Australia). The patient downloaded the Recognise™ Hand and Shoulder applications
248 onto her iPhone®. The application records both accuracy and response times, and
249 allows the user to set the difficulty of the images by modifying context and background.
250 She was encouraged to train 1-2 hours/day in short sessions using 20 images and to
251 look at people throughout the day and say “that’s left, that’s right.”39 Additionally, she
252 was urged to look through magazines with pictures of people and circle right shoulders.
253 LT was progressed by increasing the number and difficulty of the images (Table 3).
254 Step 2: Tactile discrimination Training42
255 TD training was then performed on the patient’s involved shoulder. A digital
256 photograph was taken of her shoulder, and 5 points were marked in different areas of
257 the photograph (Figure 4). All were located in her painful area, and the distance
11
258 between points was approximately the same as her TPD results (~6cm). She was
259 positioned in a seated position with a dressing mirror positioned between her legs,
260 enabling her to look at her unaffected shoulder while her right shoulder was behind the
261 dressing mirror (Figure 5). Moseley and Wiech42 reported that allowing subjects to see
262 the mirror image of the affected body part resulted in greater improvements in pain and
263 tactile acuity compared to not seeing the reflected image. The photograph with the 5
264 points was taped on the mirror for reference. Her husband used the eraser of a pencil
265 to lightly touch the painful shoulder in one of the 5 points depicted, and the patient was
266 asked to identify which area was touched. The patient was instructed to perform 6
267 minute blocks of 24 stimuli (inter-stimulus interval 15 seconds), 3 times per day, for a
268 total of 18 minutes per day.42 This was initially painful for her, but after 2 days she no
269 longer had pain with light touch. At this point, TPD was initiated with the distance
270 between points set to the normal distance for the shoulder (~40mm). The patient was
271 instructed to localize what area was touched and determine whether she was touched
272 by 1 or 2 points. She continued this training for the rest of the week, and her accuracy
273 and tactile acuity improved (Table 4).
274 Step 3: Imagined Movements
275 During the 4th week, the treatment progressed by having the patient imagine
276 moving her painful shoulder. Moseley39 describes this stage of GMI as preparing the
277 patient to move. A picture with 8 different shoulder postures was used for this training
278 (Figure 6). The exact cues given were: “Imagine your involved shoulder in the pictured
279 postures without actually moving. Imagine each posture twice, and repeat the entire
280 process 3 times per day.” Imagined body movements are reported to activate the
12
281 cortex similar to executed movements.23 This intervention was utilized due to her report
282 of pain with watching other people move. The patient continued to make improvements
283 in pain and ROM with this intervention (Table 3).
284 Step 4: Mirror Therapy
285 In week 5, we introduced the final step of GMI, mirror therapy. Mirror therapy
286 involves using a mirror to observe movement of the unaffected body part. 5, 39 This
287 creates the illusion that the painful body part is moving in a pain-free fashion. She was
288 instructed to look at the mirror image of the unaffected shoulder and move that shoulder
289 into the 8 positions used for imagined movements training (Figure 7). She did this twice
290 per session, 3 times per day. She was instructed that once she was able to view the
291 mirrored movement without pain, she could begin to simultaneously perform the
292 movements with the affected shoulder. Mirror therapy provides strong positive sensory
293 cortical feedback that movement does not have to be painful, and may disprove
294 cognitions of the mind allowing the patient to believe pain free movement is possible.
295 After one week of mirror therapy, she was able to actively move her involved shoulder
296 through all of the movements with < 3/10 pain.
297 By the sixth week of treatment, the treating therapist postulated that the patient’s
298 pain and fear of movement had decreased to where she would tolerate manual therapy
299 and exercise in the plan of care. The patient was amenable to trying hands-on
300 treatments. Treatment commenced with a regional interdependence74 manual therapy
301 approach directed to areas with impaired mobility adjacent to her shoulder, specifically
302 thoracic manipulation and cervical mobilizations.33, 57, 66 These were applied for one
303 week with continued improvements in pain and ROM (Table 3). At this time the patient
13
304 gave consent to use manual therapy directed at the shoulder along with the
305 cervicothoracic manual techniques.9 The final addition to the treatment regimen was to
306 add stretching and progressive resistive exercises in the 8th week of treatment. The
307 final 4 weeks focused on stretching exercises and neuromuscular re-education per the
308 CPG:21 Stretches were progressed into tissue resistance as long as it did not produce
309 post-treatment pain, and neuromuscular re-education focused on integrating gains in

310 mobility into normal movement during functional activities.
311 OUTCOMES
312 The patient was seen for 20 visits over 12 weeks. She demonstrated consistent
313 improvements in her pain ratings and AROM measurements throughout the episode of
314 care (TABLE 3). At discharge, her pain ratings had dropped from 7/10 at rest to 0/10
315 and from 10/10 at worst to 3/10 (Table 4). Michener et al32 reported the minimally
316 clinically important difference (MCID) for the NPRS was 2.17 in patients with shoulder
317 pain. The patient’s AROM in the painful shoulder also demonstrated clinically
318 meaningful improvements during the episode of care (Table 4). Muir et al45 reported
319 the minimal detectable change (MDC) for flexion, abduction and ER ranged from 11°-
320 16°. Tveita et al68 reported the ICC for test-retest differences ranged from 0.61 to 0.93
321 for all measurements.
322 The SPADI and the modified FABQ were re-administered at week 6 and
323 discharge to determine changes in function and fear of movement (Figure 8). The
324 patient also completed the SPADI and FABQ by email 13 months after discharge. Her
325 SPADI score dropped from 64% to 22% at discharge, which surpassed the MDC of 17
326 for individuals with FS and the MCID of 8-13 in individuals with shoulder pain (Table
14
327 4).59, 69 Thirteen months after discharge, her SPADI score was 7%. Her FABQ-PA
328 dropped 14 points (22 to 6) while the FABQ-W decreased by 20 points (34 to14) at
329 discharge, which exceeded the MDC of 8 for the FABQ-PA and 13 for the FABQ-W
330 subscales in people with upper extremity injuries.18 This suggests a potentially
331 meaningful change in her fear related behaviors. At 13 months post discharge, her
332 FABQ-PA was 2 and the FABQ-W was 6 (Table 4, Figure 8).
333 DISCUSSION
334 This case report describes the examination and treatment of a patient with a
335 highly irritable FS and suspected central sensitization using a “top-down” approach for
336 the first 6 weeks. This treatment approach was adopted early on due to the patient’s
337 request that her shoulder not be touched. This case is novel because this approach is
338 commonly used in conditions with CS,5, 38 but to our knowledge, this is the first
339 description of its use in a patient with a FS. Recent reports3, 10, 61, 65 have suggested the
340 presence of CS in some individuals with shoulder pain, and the treating therapist
341 suspected centrally-mediated pain in this case. Therefore, tests and measures were
342 performed to test this hypothesis, specifically tactile discrimination and laterality. As
343 noted earlier, conventional physical therapy approaches have not proven efficacious in
344 the treatment of FS, and this patient had already failed a previous bout of therapy.
345 Since PNE and GMI have been shown to reduce pain and disability in some
346 chronic pain conditions,5, 26, 30 these interventions were implemented to address
347 suspected changes in pain processing. PNE may be an important component of a GMI
348 program because it helps the patient to understand the upregulation of neural
349 processing and to decrease pain by explaining the biological processes involved in
15
350 pain.49, 60 Utilization of PNE has demonstrated effectiveness in decreasing pain, fear,
351 and pain perception as well as increasing patient compliance with the GMI program.26,
352 30, 37, 44 A recent systematic review and meta-analysis by Thieme et al67 concluded that
353 GMI was effective in reducing pain and disability in patients with limb pain and
354 suggested that GMI techniques should be considered in the treatment of acute pain
355 after trauma and surgery.67 Another recent systematic review by Bowering et al5
356 concluded that GMI and mirror therapy alone may be effective for the treatment of
357 chronic pain. Finally, Louw et al27 reported that a brief mirror therapy intervention
358 resulted in statistically significant improvements in pain, pain catastrophization, fear
359 avoidance, and shoulder flexion AROM in patients presenting with shoulder pain. Each
360 element of GMI was utilized in this case with dosage as described by Moseley39 over
361 the first 6 weeks of care. In addition, TD training was added because it has been shown
362 to be effective at improving tactile acuity and decreasing pain in individuals with chronic
363 limb pain, phantom limb pain and CRPS.15, 42, 43

364 During the first 6 weeks using this “top-down” approach, positive changes were
365 seen in the patient’s pain, function and ROM (Table 3). She was then open to
366 transitioning to an approach utilizing manual therapy and exercise. This approach is
367 supported by a retrospective cohort study by Jewell et al20 that included 2,370 patients
368 with FS, concluding that these interventions were more effective than passive modalities
369 in improving pain and function. As the patient was apprehensive about hands-on
370 shoulder interventions, a regional interdependence approach74 was initiated targeting
371 impairments in the cervicothoracic spine.2, 33, 52-54, 57, 64 These interventions helped to
372 instill confidence in the patient that manual therapy would not be harmful, and the
16
373 following week she allowed the treating therapist to use manual therapy to address
374 impairments in her shoulder. Pain, ROM, and disability continued to improve until
375 discharge at 12 weeks after the evaluation. At that time, her hand and shoulder
376 laterality accuracy and speed were within normal ranges, and TPD had improved by 10
377 mm (Table 4). She returned to all her desired activities, and in a 13-month follow up
378 email, she characterized herself as “recovered.”

379 CONCLUSION
380 Current evidence suggests that pain is a “top down” and a “bottom up”
381 phenomenon.48 The treating therapist suspected centrally-mediated pain, and

382 developed a plan of care that included a hands-off, “top-down” approach. PNE, TD and
383 GMI were used to decrease the patient’s high level of irritability, fear of movement, and
384 suspected centrally mediated pain. The patient made consistent and meaningful
385 improvements throughout the episode of care, particularly at a time when she had signs
386 of high irritability. One cannot infer cause and effect from a single case, and it is
387 possible that the improvements she experienced would have occurred with no treatment
388 at all. Additional research should be considered to investigate the effectiveness of PNE,
389 TD and GMI, both alone and in combination, in the treatment of individuals with FS.
390
17
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590
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596
22
Table 1. Range of Motion (ROM)
Range of Motion (ROM)
Flexion Abduction External Internal

Rotation Rotation
Side L R L R L R L R
Active 165 o 61 o 148 o 32 o 70 o 3o T7 Hip
Passive 170 o 65 o 152 o 40 o 74 o 8o N/T N/T

Table 2. Central Sensitization Testing

Central Sensitization Testing Left Right
2-Point Discrimination 40 mm 58 mm
Hand Laterality Test Accuracy: 70% Accuracy: 50%

Speed: 2.2 sec Speed: 4.2 sec

Shoulder Laterality Test Accuracy: 80% Accuracy: 60%
Speed: 2.5 sec Speed: 4.9 sec
Table 3. Treatment Progression and Outcomes
Treatment Progression and Outcomes
NPRS AROM
(Rest-
Treatment Focus Week Worst) Flexion Abduction ER IR
Arm by
side
7/10 - o o o
Initial Exam 0 10/10 61 32 3 To hip
Neuroscience 5/10 - o o o SI
Education 1 7/10 82 38 12 Joint
4/10 – o o o
Laterality 2 6/10 97 43 17 L5
3/10 – o o o
Motor Imagery 3 6/10 105 55 25 L3
3/10 –
o o o
Mirror therapy 4 6/10 112 62 34 L3
Tactile 3/10 – o o o
Discrimination 5 4/10 120 70 38 L2
CervicoThoracic 2/10 – o o o
(CT) MT 6 3/10 125 79 42 L1
At
o
90 ABD:
CT and Shoulder 1/10 – o o o
MT 7 3/10 142 90 48 T12
0/10 – o o o
MT + Exercise 8 3/10 154 104 52 T10
Table 4. Outcomes Measures
Initial Exam Discharge 13 months post
discharge
Pain (Right Shoulder) 7/10 (best) 0/10 (best)

10/10 (worst) 3/10 (worst)
Degrees of AROM Right 61o, 32 o, 3 o 162 o, 111 o, 65 o
Shoulder (Flexion,
Abduction, ER)
SPADI 64% 22% 7%

FABQ-W 34 14 6
FABQ-PA 22 6 2
2-Point Discrimination 58 mm 48 mm
(Right Shoulder)
Hand Laterality Test Accuracy: 50% Accuracy: 80%

(Right Hand) Speed: 4.2 sec Speed: 2.5 sec
Shoulder Laterality Test Accuracy: 60% Accuracy: 80%
(Right Shoulder) Speed: 4.9 sec Speed: 2.3 sec
AROM: Active Range of Motion, SPADI: Shoulder Pain and Disability Index, FABQ-W:
Fear Avoidance Beliefs Questionnaire Work Subscale, FABQ-PA: Fear Avoidance
Beliefs Questionnaire Physical Activity Subscale

Figure 1. Pain Diagram
internal rotation (D) ROM

Figure 2. Notable losses of shoulder external rotation (A), abduction (B), flexion (C) and
4
5
Figure 4. Tactile discrimination

1
Figure 3. RecogniseTM flashcards
2
Figure 5. Use of Mirror for Tactile Discrimination (Shoot picture)

Figure 6. Shoulder Movements for GMI motor imagery and mirror therapy. (A) Shrug,
(B) Protraction, (C) Retraction, (D) Internal Rotation, (E) External Rotation, (F)
Abduction, (G) Flexion, (H) Extension
Figure 7. Mirror therapy

70
60
50
40
SPADI
30 FABQW
FABQPA
20
10
0
Initial 6 weeks Discharge 13 months post
discharge
Figure 8. Outcomes Measures. SPADI: Shoulder Pain and Disability Index, FABQ-W:
Fear Avoidance Beliefs Questionnaire Work Subscale, FABQ-PA: Fear Avoidance
Beliefs Questionnaire Physical Activity Subscale

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1 Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor

2 Imagery in an Individual with Frozen Shoulder

47 Key Words: frozen shoulder, central sensitization, shoulder pain, neuroscience

52 The reported prevalence of frozen shoulder (FS) is 2 to 5 percent,47 with diagnosis

57 disturbance. This stage lasts up to 3 months. Stage 2 is described as the “painful” or

62 This last stage can last 15 to 24 months after onset of symptoms.17, 21

64 systematic review by Wong et al reported finding no evidence of complete resolution

67 appropriate treatment strategies in the freezing/painful stage of FS may result in better

71 intensive physical therapy interventions produced worse outcomes at 2 years compared

73 Central sensitization (CS), defined as an “amplification of neural signaling within

76 cytokines, which signal inflammation, may provide prolonged stimulation of neurons in

79 increasing nociceptive signaling mechanisms.79 This can lead to non-noxious stimuli

80 being interpreted as threatening and painful.61 CS has been reported to produce

81 hypersensitivity to cold and heat as well as decreases in pressure pain threshold.10 In

85 impression of an experienced clinician. Smart et al63 described a symptom and sign

87 with LBP. The cluster included: 'Disproportionate, non-mechanical, unpredictable

88 pattern of pain provocation in response to multiple/non-specific aggravating/easing

90 association with maladaptive psychosocial factors,’ and 'Diffuse/non-anatomic areas of

99 primary sensory cortex receptive fields can reportedly be modified by tactile

100 discrimination training.14 According to Flor et al,15 2 weeks of sensory discrimination

101 training resulted in normalization of cortical organization and a clinically important

112 systematically activating cortical systems and assisting in reorganization.40 Moseley38

114 decrease pain in the presence of CS.

117 conditions, but not in FS.

119 CASE DESCRIPTION

140 touch her shoulder.”

153 increased pain and disability.14, 24

161 SPADI score was 62%, indicating a high level of disability.58

162 A modified Fear Avoidance Beliefs Questionnaire (FABQ) was administered to

180 common impairment found in FS.21

182 predictive of CS reported by Smart et al.63 She complained of hypersensitivity to cold,

187 possible centrally-mediated pain.55

188 To further investigate suspected deficiencies in sensory processing, two-point

220 and should be included in first-line management of musculoskeletal pain conditions.

240 Below is a brief description of each stage:

241 Step 1 : Laterality Training (LT)

246 Recognise™ (http://www.recognise.noigroup.com/recognise/; noigroup.com, Adelaide,

254 Step 2: Tactile discrimination Training42

273 and tactile acuity improved (Table 4).

274 Step 3: Imagined Movements

283 in pain and ROM with this intervention (Table 3).

284 Step 4: Mirror Therapy

296 through all of the movements with < 3/10 pain.

300 treatments. Treatment commenced with a regional interdependence74 manual therapy

309 post-treatment pain, and neuromuscular re-education focused on integrating gains in

310 mobility into normal movement during functional activities.

321 for all measurements.

358 resulted in statistically significant improvements in pain, pain catastrophization, fear

363 limb pain, phantom limb pain and CRPS.15, 42, 43

370 shoulder interventions, a regional interdependence approach74 was initiated targeting

378 email, she characterized herself as “recovered.”

381 phenomenon.48 The treating therapist suspected centrally-mediated pain, and

419 reference to chronic pain? BMC Musculoskelet Disord. 2015;16:87.

Flexion Abduction External Internal

Passive 170 o 65 o 152 o 40 o 74 o 8o N/T N/T

Table 2. Central Sensitization Testing

Hand Laterality Test Accuracy: 70% Accuracy: 50%

Speed: 2.2 sec Speed: 4.2 sec

Treatment Progression and Outcomes