Supplemental Online Content

Bagg MK, Wand BM, Cashin AG, et al. Effect of Graded Sensorimotor Retraining on
Pain Intensity in Patients With Chronic Low Back Pain. JAMA. Published online August
2, 2022. doi:10.1001/jama.2022.9930

eMethods. Content of the Interventions (TIDieR checklist)

eFigure 1. Timeline for intervention delivery
eReferences

This supplemental material has been provided by the authors to give readers additional
information about their work.

© 2022 American Medical Association. All rights reserved.

eMethods. Content of the Interventions (TIDieR checklist)

Content of the RESOLVE intervention described using the Template for Intervention
Description and Replication Checklist.

Brief Name (Item #1)

Graded sensorimotor retraining (RESOLVE).

Why (Item #2)

The RESOLVE intervention integrates a contemporary understanding of pain with known
features of best-practice care to address multiple biopsychosocial contributors to the chronic low
back pain experience, including maladaptive conceptualizations of the pain problem,1–3 altered
sensory function,4,5 altered motor function,6–10 and altered self-perception of the back.11

What (Items # 3-4)

The RESOLVE intervention comprises three complementary treatment components:
contemporary pain-science-based education, neuroscience-informed pre-movement treatments,
and precision focused and feedback enriched graded movement and loading.

The contemporary pain-science-based education was based on the book Explain Pain,12
delivered according to a standardized curriculum, and individualized to the participant’s lived
low back pain experience. The contemporary education discussed the biopsychosocial nature of
pain, with learning objectives centered around understanding that movement is safe and helpful
for recovery.13 The material was delivered using graphical media, video, metaphor and
narrative12,14,15 with the end goal being to provide a clear and plausible biopsychosocial rationale
for each individual’s current health status and possible solutions to their situation. Participants
were provided with a link to a bespoke RESOLVE web-platform designed and hosted by
Neuroscience Research Australia. The web-platform hosted an Explain Pain e-book and a series
of educational videos and podcasts. The initial bolus of education was designed to frame the
remainder of the intervention, providing a coherent rationale for the pre-movement treatments
and to facilitate engagement with the physical intervention. Learning beyond the initial sessions
was intended to revisit material for enhanced comprehension, further challenge unhelpful beliefs
and cover the influences of low back pain on work, life and social participation.

The neuroscience-informed pre-movement treatments included sensory precision training and

mental rehearsal of movement. Sensory precision training commenced with tactile localization
and discrimination training (sharp/blunt) over the back. A chop stick – sharpened on one end and
fitted with a pencil eraser (blunt) on the other – was used to provide two contrasting localized
sensory stimuli. The stimulus was applied to numbered points on the back arranged in a grid-like
pattern. The participant viewed a copy of the grid pattern and was asked to nominate which point
had been stimulated (localization) and whether the stimulus was sharp or blunt (discrimination).
As the participant progressed more points were added to the grid (from 9 to 12 to 16 points),
thereby decreasing the distance between points. Participants were given both a chopstick and set
of grid-like images to perform sensory precision training at home. The next progression was
graphaesthesia training where participants where first asked to recognize simple letters drawn on
the back. Following this, participants needed to recognize simple words drawn on the back and

© 2022 American Medical Association. All rights reserved.

finally calculate simple sums drawn on the back. Graphaesthesia training was also progressed by
decreasing the size of the drawn symbols. Mental rehearsal of movement commenced with left-
right recognition training (implicit motor imagery) using the Recognise software (NOIgroup,
Adelaide, Australia). Task difficulty was progressed by using more complex images and
decreasing the time that images were presented. Participants were given access to the Recognise
Back app for their smart phone to practice the task as homework. The next step involved motor
empathy training. Participants received access – via the web-platform – to a series of custom-
designed videos of low back movements and were asked to closely observe the back as the
model performed the movements. Training was progressed by increasing the complexity and
perceived load of the observed tasks. The final progression involved explicit motor imagery.
Participants viewed the same videos but were now asked to imagine themselves performing the
movements as they watched the video. Progression was again from simple back movements, to
more complex, loaded and personally relevant tasks.

The graded, precision focused and feedback enriched movement and loading program comprised
three progressive stages. The focus of the first stage was mastering smooth, fluid and
independent (i.e. precise) movement of the lumbar spine, thoracic spine and hips. Training
exercises were undertaken with extensive visual and proprioceptive feedback both in the clinic
and at home. Attentional focus was directed to non-noxious components of task performance, to
discourage the use of symptoms as the primary guide to performance. Early movement was
performed without resistance. The second stage involved completing part practice of components
of functional tasks that the participant had previously identified as being problematic, with
integration of skills from the initial precision training (stage one). Part practice was still precision
focused with various forms of feedback used to direct the participant to towards non-nociceptive
aspects of task performance. The final progression (stage three) was to perform functional
movements relevant to the participants values and goals. The participants integrated learnt skills
into whole task practice of bothersome functional activities in a feedback enriched environment.
Again, emphasis was placed on making movement relaxed and fluid with attentional focus
encouraged towards non-noxious components of task performance. Once participants could
successfully perform previously difficult movements and functional tasks symptom free, any
further progression was based on exercise intensity to match levels that are likely to influence
general aerobic fitness and strength.

Who Provided (Item #5)

The RESOLVE intervention was provided by specifically trained (≥14 hours) physiotherapists
(n=5 in the team) or an exercise physiologist (n=1 in the team). Treating clinicians had varying
experience providing clinical treatments to people with chronic low back pain (range 1 to 15
years).

How (Item #6)

The RESOLVE intervention was provided face-to-face by the treating clinician.

Where (Item #7)

The RESOLVE intervention was delivered at Neuroscience Research Australia, an independent,
not-for-profit research institute based in Sydney, Australia. Clinical facilities at Neuroscience
Research Australia are similar to primary-care.

© 2022 American Medical Association. All rights reserved.

When and How Much (Item #8)
Participants allocated to the RESOLVE intervention group were provided with 12 individual
treatment sessions lasting up to one hour over 12 to 18 weeks (sessions were scheduled
approximately weekly). Participants were also provided with a home treatment component to
complete for 30 minutes five times per week during the treatment period and record their
participation in an intervention dairy.

The participants progressed through the RESOLVE program following a standard protocol
(Figure 1), with mandatory advancement at certain time points. Participants were free to progress
early provided they met criteria for each component of the intervention.

Tailoring (Item #9)

The RESOLVE intervention was standardized to ensure all participants received the same overall
intervention. That is, the three intervention components. The delivery of the intervention was
tailored to the individual’s chronic low back pain experience, goals and barriers identified in the
initial assessment. For example, the contemporary pain-science based education may have
targeted learning concepts that were more relevant to an individual participant’s experience or
identified as key barriers to their recovery. The graded movement and loading training program
also prioritized movements and functional activities that reflected participants’ goals and primary
functional limitations.

Modifications (Item #10)

The Recognise (NOIgroup, Adelaide, Australia) web-platform was discontinued by the
developer during the study (March 2017). We replaced the web-platform with the Recognise
smart-device application (iOS or Android).

How Well (Items #11-12)

Clinician competency was assessed through joint sessions with an experienced colleague, or
independently-led sessions shadowed by an experienced colleague. Every treating clinician had
at minimum five treatment sessions audited by an expert supervising clinician to ensure
treatment fidelity. There were no concerns for treatment infidelity.

Treatment adherence was assessed by recording the attendance of participants at each treatment
session. Median (IQR) number of sessions attended was 12 (0) of 12 sessions for the RESOLVE
intervention group. One-hundred nineteen participants (86·2%) attended at least nine RESOLVE
intervention sessions.

© 2022 American Medical Association. All rights reserved.

Content of the placebo intervention described using the Template for Intervention Description
and Replication Checklist.

Brief Name (Item #1)

Placebo.

Why (Item #2)

The placebo intervention was designed to control for time with an expert clinician, the graded
progression of treatment components found in the active arm, and expectations associated with
receipt of a novel central nervous system directed treatment.

What (Items # 3-4)

The placebo intervention comprised verbal ventilation, sham cranial electrical stimulation, sham
low-intensity laser therapy, sham transcranial direct current stimulation and sham (detuned) short
wave diathermy.

The ventilation involved a reflective, empathic, non-directive discussion with the clinician bereft
of any advice or counselling. Participants were given the opportunity to discuss their chronic low
back pain, current and past treatments and experiences, and any other problems that they may
have.16

Sham low-intensity laser therapy (Model 300, Diolase, Mountain View, USA) was delivered to
the most painful part of the lumbar spine for 20 minutes per session from session three onwards.
The sham laser unit functions identically to the standard unit except that it does not emit energy.
Participants were told that they will not feel anything whilst the device is active and laser therapy
produces no detectable sensations when used in its veridical mode.

Sham transcranial direct current stimulation (DC Stimulator, NeuroConn, Ilmenau, Germany)
was delivered to the motor and prefrontal cortices on the contralateral side of worst pain and
delivered for 10 minutes per session from session three onwards. The sham transcranial direct
current stimulation unit functions identically to the standard unit except that it does not emit any
current. Participants were told that they would not feel anything whilst the device is active and
transcranial direct current stimulation produces no detectable sensations when used in its
veridical mode beyond an initial short lived tingling sensation.

Detuned short wave diathermy was delivered for 20 minutes per session from session six
onwards. The detuned short wave diathermy unit functions identically to the standard unit except
that it does not emit energy. Participants were told that they would not feel anything whilst the
device is active and short wave diathermy produces no detectable sensations when used in its
veridical mode.

Sham (detuned) cranial electrical stimulation was self-administered at home for 30mins per day,
five days per week. Participants were given the device to use at home from session three
onwards and were told that they will not feel anything whilst the device is active and cranial
electrical stimulation produces no detectable sensations when used in its veridical mode.

© 2022 American Medical Association. All rights reserved.

Who Provided (Item #5)
The placebo intervention was provided by specifically trained physiotherapists (n=4 in the team).

How (Item #6)

The placebo intervention was provided face-to-face by the treating clinician.

Where (Item #7)

The placebo intervention was delivered at Neuroscience Research Australia. Neuroscience
Research Australia is an independent, not-for-profit research institute based in Sydney, Australia.
Clinical facilities at Neuroscience Research Australia are similar to primary-care.

When and How Much (Item #8)

Participants allocated to the placebo intervention group were provided with 12 individual
treatment sessions lasting up to one hour over 12 to 18 weeks (sessions were scheduled weekly).
Participants were also provided with a home treatment component to complete for 30 minutes
five times per week during the treatment period and recorded their participation in an
intervention diary.

The participants progressed through the placebo program following a standard progression
protocol (Figure 1), with mandatory advancement at certain time points.

Tailoring (Item #9)

The placebo intervention was standardized to ensure all participants received the same
intervention. There was no tailoring to the individual within the placebo intervention.

Modifications (Item #10)

From participant 073 onwards, sham transcranial direct current stimulation was removed from
the placebo intervention treatment package because the device was broken. Participants instead
received sham low-intensity laser therapy for an additional 10 minutes.

How Well (Items #11-12)

Clinician competency was assessed through joint sessions with an experienced colleague, or
independently-led sessions shadowed by an experienced colleague. Every treating clinician had
at minimum five treatment sessions audited by an expert supervising clinician to ensure
treatment fidelity. There were no concerns of treatment infidelity.

Treatment adherence was assessed by recording the attendance of participants at each treatment
session. Median (IQR) number of sessions attended was 12 (0) of 12 sessions for the placebo
intervention group. One-hundred twenty-one (87·7%) attended at least nine placebo intervention
sessions.

© 2022 American Medical Association. All rights reserved.

A.

B.

eFigure 1. Timeline for intervention delivery. A = RESOLVE, B = Placebo. Lighter squares

denote possible continuation of component of intervention if necessary.

© 2022 American Medical Association. All rights reserved.

eReferences
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© 2022 American Medical Association. All rights reserved.

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© 2022 American Medical Association. All rights reserved.