Tactile Acuity Training for Those With Chronic Low Back Pain
Tactile Acuity Training for Those With Chronic Low Back Pain
Twenty four individuals volunteered to participate for this study. Nine participants, three from the intervention group and six from the placebo group did not complete the study. Thus, 15 (9 intervention: 6 Placebo) participants completed the quantitative component of the study (Figure 1). Non-completers had a significantly shorter pain duration history than completers (10 vs. 3 years, p < 0.001) but there were no statistical differences for age, gender, height, weight, BMI or tactile acuity. There was no difference in participant demographics between the intervention group and the placebo group (Table 1). Eight participants (5 intervention; 3 Placebo) and their informal carers attended the focus groups.
(Enlarge Image)
Figure 1.
Participant flow chart. This figure shows the pathway of recruitment and retention of participants.
Pain decreased and function levels increased in both groups from pre to post treatment (Figures 2, 3, and 4). The magnitude of the change was greater for the placebo group, however, there was no significant difference (mean difference (95% CI), p-value) between groups for change in pain (25.6 (-0.7 to 51.9), p = 0.056) or function (2.2 (-1.6 to 6.0), p = 0.237) when controlling for baseline measures.
(Enlarge Image)
Figure 2.
Function levels pre and post treatment. This figure shows the function levels, as measured by the Roland Morris Disability Questionnaire (RMDQ) pre and post treatment for both groups. * indicates a statistically significant (p < 0.05) change in function from pre to post treatment in the placebo group. Data are presented as mean (1SD).
(Enlarge Image)
Figure 3.
Pain levels pre and post treatment. This figure shows the pain levels, as measured by a 0–100 mm Visual Analogue Scale (VAS) pre and post treatment for both groups. * indicates a statistically significant (p < 0.05) change in pain from pre to post treatment in the placebo group. Data are presented as mean (1SD).
(Enlarge Image)
Figure 4.
Change in pain and function pre to post treatment. This figure shows the change in pain and function levels from pre to post treatment, as measured by the 0–100 mm pain Visual Analogue Scale (VAS) and Roland Morris Disability Questionnaire (RMDQ) respectively. Data are presented as mean (1SD).
When the data were analysed by comparing the number of individuals achieving a minimally clinically significant improvement there was no difference between groups for function (4/9 vs. 4/6, p = 0.529). The placebo group, however, had significantly better outcomes for pain with all participants in the placebo group achieving 30% improvement or more compared to only a third of the intervention group (6/6 vs. 3/9, p = 0.036) (Table 2).
The methodology checking measures are compared between groups in Table 3. There was no statistically significant difference between groups for any of these measures with both groups reporting a similar number of hospital based training sessions, usual care treatments, levels of treatment credibility and credibility of the home training component.
Five themes were identified within the focus groups: 1. intervention barriers (with subthemes: practical, psychosocial and condition specific barriers): 2. scepticism and lack of understanding; 3. intervention effects; 4. concentration vs. relaxation; and 5. hospital better than home.
Intervention Barriers. Participants identified multiple barriers to implementing the intervention. These barriers can be broken down into three subthemes: i. practical, ii. psychosocial and iii. condition specific barriers.
Practical Barriers: Patients reported a number of practical barriers to carrying out the home training. These barriers included lack of time, difficulty co-ordinating their time with the informal carers time, the body markers washing away in the shower, difficulty lying flat for any period of time, and poor ergonomic set-up for the informal carers in the home environment. Additionally, participants felt the CD instructions and manual needed to be clearer. This was also consistently noted by the informal carers.
"If one was in the other was out or vice versa so it was just trying to get two people, me and somebody else in the same room to do it" R7 (patient)
"I don't like the time that it took; it was a long time" R5 (patient)
"It was annoying having to write the numbers on every time you've had a shower remembering where the numbers stuck" R5 (patient)
"I can't lie flat long enough for it to be done" R5 (patient)
"It wasn't very good from my husband's perspective to do it on the bed because he's twisting his body in order to get to the areas so it wasn't so good for him to do it on the bed because the bed's not a very good height to bend over for that length of time and sitting on the bed he was twisting his body to do the treatment so that wasn't good" R2 (patient)
"Well the CD we couldn't even hear what he said" R3 (patient)
"The DVD wasn't very good at all" R1 (informal carer)
There was also a barrier specific to the graphaesthesia training in that one of the participants reported her informal carer was dyslexic.
"my son is dyslexic and if he's doing the b's doing it the wrong way round" R4 (patient)
Another considerable difficulty noted by the participants was getting the informal carer to the hospital to observe the therapist undertaking the training/observation. For most this was to do with time but for one participant, who could not drive and required ambulance transportation, she was not allowed to be accompanied by an informal carer in the ambulance.
"I had to have the ambulance service bring me because I don't drive and they don't they wouldn't let him [informal carer] come" R5 (patient)
Psychosocial Barriers: Patients reported emotional/psychological barriers to the home training component, including feelings of embarrassment at being touched on the back by the informal carer and guilt at taking the informal carer's time, despite patients not getting a sense that the carer shared these issues.
"He [informal carer/son] didn't find it embarrassing but I did …… I was a bit embarrassed as well because it was my son who was doing it for me" R5
"It's a big deal to me because it was quite time consuming for him as well and saying 'do you mind if we do it now?' I used to be quite apologetic you know having to say to him 'do you mind just giving me fifteen minutes……..He didn't mind doing it and never made a fuss about it, I just felt slightly guilty occasionally asking him" R4
In contrast to this some patients reported a great eagerness to help on behalf of the informal carer.
"I think the opposite [to guilt] really, I think Linda was so keen on this hoping that it could make a difference to me" R8
There was a sense that some of the guilt stemmed from a feeling that the treatment would not work and so asking the carer to help was a waste of their time.
"I just feel I wasn't able to convince him that it would work, I really wanted to say right we can do this it will work and then I would have felt better about asking, not that he ever minded but I would have felt better" R4
In contrast none of the informal carers reported any emotional barriers associated with the home training.
Condition Specific Barriers: The participants noted some challenges to the intervention that were specific to their chronic back pain condition. One individual reported some paraesthesia/numbness in the area which made the testing difficult and frustrating. The same individual reported their pain increased during training because one area being stimulated was on a tender surgical scar, and it wasn't until after a number of home training sessions that she asked her physiotherapist about this and he altered the positioning of the training away from the scar.
"The bits where I totally feel numb didn't get them, I always them wrong all the time and I found it frustrating because he was going 'oh no' and I found it frustrating because the more I got it wrong" R5 (patient)
"at the really sensitive part I found that very painful, very painful and I hated the pin bit…" R5 (patient)
Scepticism and Lack of Understanding. Some participants did make indirect suggestions that they were not optimistic about the intervention having an effect and it seemed to be linked with a lack of understanding of the mechanisms of action of how the intervention might work.
"if it worked, we couldn't see that it would but if it did" R8 (patient)
"I just feel I wasn't able to convince him that it would work, I really wanted to say right we can do this it will work and then I would have felt better about asking, not that he ever minded but I would have felt better" R4 (patient)
Intervention Effects. Some participants reported improved symptoms while others did not, with a participant from the placebo group reporting the greatest improvements. Two patients, both in the intervention group, did report improved or enhanced awareness of their lower back and some noted that this was maintained after the treatment had ceased.
"I found the area did improve, the sensitivity improved" R4 (Patient - intervention)
"Can feel it [my back] more…and actually having stopped .. the training the testing that area is still more sensitive than it ever has been for a long time.. knowing and feeling it" R2 (Patient-intervention)
Relaxation vs. Concentration. During the training itself one of the participants reported that they felt relaxed and felt this might be due to the human touch component of the training and another reported being so relaxed during the treatment when doing it at night time that they were tending to drift off to sleep. In contrast to this one participant who stated that it could be relaxing also said that it required concentration and could be draining.
"It could be quite relaxing just being touched in that gentle kind of way" R4 (patient)
"I found that if I did it at night I feel asleep" R8 (patient)
"I found it really you had to concentrate…and I found it hard work, I was absolutely drained at the end of it every night" R4 (patient)
Hospital Better Than Home. A number of the participants, when asked if the home delivery was better/worse than the hospital delivery, appeared to be in favour of the hospital setting. They stated that this was because the hospital setting was more serious facilitating better concentration on the training task, and they could get feedback/reassurance on whether the training was being carried out correctly and could ask questions.
"I think we take it more serious when we come to physio because when he's doing it for you and when you're at home it's not as serious as; there's a bit of messing about or you know….I think it was better coming doing it a physio because you're concentrating more" R6 (patient)
"You could find out if there was anything you were doing wrong [with the hospital based sessions] R1 (patient)
Results
Participants
Twenty four individuals volunteered to participate for this study. Nine participants, three from the intervention group and six from the placebo group did not complete the study. Thus, 15 (9 intervention: 6 Placebo) participants completed the quantitative component of the study (Figure 1). Non-completers had a significantly shorter pain duration history than completers (10 vs. 3 years, p < 0.001) but there were no statistical differences for age, gender, height, weight, BMI or tactile acuity. There was no difference in participant demographics between the intervention group and the placebo group (Table 1). Eight participants (5 intervention; 3 Placebo) and their informal carers attended the focus groups.
(Enlarge Image)
Figure 1.
Participant flow chart. This figure shows the pathway of recruitment and retention of participants.
Primary Outcome Measures
Pain decreased and function levels increased in both groups from pre to post treatment (Figures 2, 3, and 4). The magnitude of the change was greater for the placebo group, however, there was no significant difference (mean difference (95% CI), p-value) between groups for change in pain (25.6 (-0.7 to 51.9), p = 0.056) or function (2.2 (-1.6 to 6.0), p = 0.237) when controlling for baseline measures.
(Enlarge Image)
Figure 2.
Function levels pre and post treatment. This figure shows the function levels, as measured by the Roland Morris Disability Questionnaire (RMDQ) pre and post treatment for both groups. * indicates a statistically significant (p < 0.05) change in function from pre to post treatment in the placebo group. Data are presented as mean (1SD).
(Enlarge Image)
Figure 3.
Pain levels pre and post treatment. This figure shows the pain levels, as measured by a 0–100 mm Visual Analogue Scale (VAS) pre and post treatment for both groups. * indicates a statistically significant (p < 0.05) change in pain from pre to post treatment in the placebo group. Data are presented as mean (1SD).
(Enlarge Image)
Figure 4.
Change in pain and function pre to post treatment. This figure shows the change in pain and function levels from pre to post treatment, as measured by the 0–100 mm pain Visual Analogue Scale (VAS) and Roland Morris Disability Questionnaire (RMDQ) respectively. Data are presented as mean (1SD).
When the data were analysed by comparing the number of individuals achieving a minimally clinically significant improvement there was no difference between groups for function (4/9 vs. 4/6, p = 0.529). The placebo group, however, had significantly better outcomes for pain with all participants in the placebo group achieving 30% improvement or more compared to only a third of the intervention group (6/6 vs. 3/9, p = 0.036) (Table 2).
Methodology Checking Measures
The methodology checking measures are compared between groups in Table 3. There was no statistically significant difference between groups for any of these measures with both groups reporting a similar number of hospital based training sessions, usual care treatments, levels of treatment credibility and credibility of the home training component.
Focus Group Findings
Five themes were identified within the focus groups: 1. intervention barriers (with subthemes: practical, psychosocial and condition specific barriers): 2. scepticism and lack of understanding; 3. intervention effects; 4. concentration vs. relaxation; and 5. hospital better than home.
Intervention Barriers. Participants identified multiple barriers to implementing the intervention. These barriers can be broken down into three subthemes: i. practical, ii. psychosocial and iii. condition specific barriers.
Practical Barriers: Patients reported a number of practical barriers to carrying out the home training. These barriers included lack of time, difficulty co-ordinating their time with the informal carers time, the body markers washing away in the shower, difficulty lying flat for any period of time, and poor ergonomic set-up for the informal carers in the home environment. Additionally, participants felt the CD instructions and manual needed to be clearer. This was also consistently noted by the informal carers.
"If one was in the other was out or vice versa so it was just trying to get two people, me and somebody else in the same room to do it" R7 (patient)
"I don't like the time that it took; it was a long time" R5 (patient)
"It was annoying having to write the numbers on every time you've had a shower remembering where the numbers stuck" R5 (patient)
"I can't lie flat long enough for it to be done" R5 (patient)
"It wasn't very good from my husband's perspective to do it on the bed because he's twisting his body in order to get to the areas so it wasn't so good for him to do it on the bed because the bed's not a very good height to bend over for that length of time and sitting on the bed he was twisting his body to do the treatment so that wasn't good" R2 (patient)
"Well the CD we couldn't even hear what he said" R3 (patient)
"The DVD wasn't very good at all" R1 (informal carer)
There was also a barrier specific to the graphaesthesia training in that one of the participants reported her informal carer was dyslexic.
"my son is dyslexic and if he's doing the b's doing it the wrong way round" R4 (patient)
Another considerable difficulty noted by the participants was getting the informal carer to the hospital to observe the therapist undertaking the training/observation. For most this was to do with time but for one participant, who could not drive and required ambulance transportation, she was not allowed to be accompanied by an informal carer in the ambulance.
"I had to have the ambulance service bring me because I don't drive and they don't they wouldn't let him [informal carer] come" R5 (patient)
Psychosocial Barriers: Patients reported emotional/psychological barriers to the home training component, including feelings of embarrassment at being touched on the back by the informal carer and guilt at taking the informal carer's time, despite patients not getting a sense that the carer shared these issues.
"He [informal carer/son] didn't find it embarrassing but I did …… I was a bit embarrassed as well because it was my son who was doing it for me" R5
"It's a big deal to me because it was quite time consuming for him as well and saying 'do you mind if we do it now?' I used to be quite apologetic you know having to say to him 'do you mind just giving me fifteen minutes……..He didn't mind doing it and never made a fuss about it, I just felt slightly guilty occasionally asking him" R4
In contrast to this some patients reported a great eagerness to help on behalf of the informal carer.
"I think the opposite [to guilt] really, I think Linda was so keen on this hoping that it could make a difference to me" R8
There was a sense that some of the guilt stemmed from a feeling that the treatment would not work and so asking the carer to help was a waste of their time.
"I just feel I wasn't able to convince him that it would work, I really wanted to say right we can do this it will work and then I would have felt better about asking, not that he ever minded but I would have felt better" R4
In contrast none of the informal carers reported any emotional barriers associated with the home training.
Condition Specific Barriers: The participants noted some challenges to the intervention that were specific to their chronic back pain condition. One individual reported some paraesthesia/numbness in the area which made the testing difficult and frustrating. The same individual reported their pain increased during training because one area being stimulated was on a tender surgical scar, and it wasn't until after a number of home training sessions that she asked her physiotherapist about this and he altered the positioning of the training away from the scar.
"The bits where I totally feel numb didn't get them, I always them wrong all the time and I found it frustrating because he was going 'oh no' and I found it frustrating because the more I got it wrong" R5 (patient)
"at the really sensitive part I found that very painful, very painful and I hated the pin bit…" R5 (patient)
Scepticism and Lack of Understanding. Some participants did make indirect suggestions that they were not optimistic about the intervention having an effect and it seemed to be linked with a lack of understanding of the mechanisms of action of how the intervention might work.
"if it worked, we couldn't see that it would but if it did" R8 (patient)
"I just feel I wasn't able to convince him that it would work, I really wanted to say right we can do this it will work and then I would have felt better about asking, not that he ever minded but I would have felt better" R4 (patient)
Intervention Effects. Some participants reported improved symptoms while others did not, with a participant from the placebo group reporting the greatest improvements. Two patients, both in the intervention group, did report improved or enhanced awareness of their lower back and some noted that this was maintained after the treatment had ceased.
"I found the area did improve, the sensitivity improved" R4 (Patient - intervention)
"Can feel it [my back] more…and actually having stopped .. the training the testing that area is still more sensitive than it ever has been for a long time.. knowing and feeling it" R2 (Patient-intervention)
Relaxation vs. Concentration. During the training itself one of the participants reported that they felt relaxed and felt this might be due to the human touch component of the training and another reported being so relaxed during the treatment when doing it at night time that they were tending to drift off to sleep. In contrast to this one participant who stated that it could be relaxing also said that it required concentration and could be draining.
"It could be quite relaxing just being touched in that gentle kind of way" R4 (patient)
"I found that if I did it at night I feel asleep" R8 (patient)
"I found it really you had to concentrate…and I found it hard work, I was absolutely drained at the end of it every night" R4 (patient)
Hospital Better Than Home. A number of the participants, when asked if the home delivery was better/worse than the hospital delivery, appeared to be in favour of the hospital setting. They stated that this was because the hospital setting was more serious facilitating better concentration on the training task, and they could get feedback/reassurance on whether the training was being carried out correctly and could ask questions.
"I think we take it more serious when we come to physio because when he's doing it for you and when you're at home it's not as serious as; there's a bit of messing about or you know….I think it was better coming doing it a physio because you're concentrating more" R6 (patient)
"You could find out if there was anything you were doing wrong [with the hospital based sessions] R1 (patient)
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