Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

The effect of visual feedback on people suffering

from chronic back and neck pain – a systematic
review

Martin Heinrich BSc PT, Simon Steiner BSc PT & Christoph Michael Bauer
PhD

To cite this article: Martin Heinrich BSc PT, Simon Steiner BSc PT & Christoph Michael Bauer
PhD (2019): The effect of visual feedback on people suffering from chronic back and neck pain – a
systematic review, Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2019.1571140

To link to this article: https://doi.org/10.1080/09593985.2019.1571140

Published online: 13 Feb 2019.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2019.1571140

The effect of visual feedback on people suffering from chronic back and neck
pain – a systematic review
Martin Heinrich BSc PT, Simon Steiner BSc PT, and Christoph Michael Bauer PhD
Institute of Physiotherapy, School of Health Sciences, Zurich University of Applied Sciences, Winterthur, Switzerland

ABSTRACT ARTICLE HISTORY

Objectives: Visual feedback as an intervention for people suffering from chronic back or chronic Received 5 January 2018
neck pain is a novel approach based on the person’s perception of the painful body part. Visual Revised 8 October 2018
feedback is an innovative therapeutic approach whose effects have not yet been systematically Accepted 17 November 2018
reviewed specifically for people with chronic back or chronic neck pain. Therefore, a systematic KEYWORDS
review was performed on the literature to evaluate the effects of visual feedback on pain intensity Neck pain; back pain;
in people with chronic back or neck pain. chronic pain; sensory
Methods: This systematic review investigated the magnitude and clinical relevance of the feedback; visual feedback;
reported effects, as well as the reporting quality of the included studies. Pain intensity was physical therapy modalities;
defined as the outcome of interest to judge the clinical relevance of the findings. The quality of rehabilitation;
reporting and the risk of bias were assessed. musculoskeletal pain
Results: The original search revealed 359 studies of which five were included following screening
of the title and abstract, application of the inclusion/exclusion criteria and reading the full texts.
All five studies had investigated chronic back pain. Most studies showed either a momentary
decrease of pain intensity during the application of a visual feedback method or a habitual
decrease after treatment for 2 weeks.
Discussion: While visual feedback does appear to alter pain intensity in people with chronic back
pain, there is limited evidence from these studies to support visual feedback as an adjunct to
therapy. These issues point out that future studies may be indicated.

Introduction back and neck pain, but high-quality evidence on

their effect is often lacking (de Campos et al, 2018;
Back pain is a major international health problem, with
Ebadi et al, 2014; Franke, Fryer, Ostelo, and Kamper,
a lifetime prevalence of 80–85%, and it poses substan-
2015; Furlan et al, 2015a; Gross et al, 2015a, 2015b;
tial challenges for clinical management (Costa-Black,
Kälin, Rausch-Osthoff, and Bauer, 2016; Luomajoki,
Loisel, Anema, and Pransky, 2010). Best estimates sug-
Bonet Beltran, Careddu, and Bauer, 2018; Macedo
gest that the prevalence of chronic low back pain
et al, 2016; Poquet et al, 2016; Rubinstein et al, 2013;
(CLBP) is about 23%, disabling 11–12% of the popula-
Saragiotto et al, 2016; Wegner et al, 2013; Yamato et al,
tion (Balagué, Mannion, Pellisé, and Cedraschi, 2012;
2016), indicating that a search for innovative treatment
Hoy, Brooks, Blyth, and Buchbinder, 2010). Neck pain
approaches, such as visual feedback training might be
has a 12-month prevalence between 10% and 20%
warranted (Moseley, 2017).
(Hoy, Protani, De, and Buchbinder, 2010). People in
Visual feedback comprises visualization of a resting
high-income countries, particularly women, and office
or moving painful body part and/or contralateral limb.
computer workers are most affected by neck pain (Hoy,
Visual feedback may utilize mirrors, still images, virtual
Protani, De, and Buchbinder, 2010). Most people with
reality or real-time video capture of a painful, stimu-
new episodes of back or neck pain recover quickly;
lated or moving body part. At a minimum, this requires
however, recurrence is common and in a small propor-
low-tech equipment, such as mirrors or webcams, or
tion of people, pain becomes chronic and disabling
more sophisticated virtual reality equipment.
(Costa-Black, Loisel, Anema, and Pransky, 2010;
A normal-sized visual feedback of one’s own limb or
Hartvigsen et al, 2018; Hoy, Protani, De, and
back is generally used, although studies have experi-
Buchbinder, 2010). A large body of research describes
mented with using minified or magnified images of
multiple interventions for the treatment of chronic
a limb or the back, images of other objects and with

CONTACT Christoph Michael Bauer PhD christoph.bauer@zhaw.ch Institute of Physiotherapy, School of Health Sciences, Zurich University of
Applied Sciences, Technikumstrasse 71, Winterthur 8400, Switzerland
© 2019 Taylor & Francis Group, LLC
2 M. HEINRICH ET AL.

understated or overstated movement (Diers, Löffler, Methods

Zieglgänsberger, and Trojan, 2016; Harvie et al, 2015;
This systematic review followed the Centre for Reviews
Wittkopf, Lloyd, and Johnson, 2018). In patients with
and Dissemination’s guidance for undertaking reviews
chronic pain, neurological conditions, or kinesophobia,
in health care and the Cochrane Handbook for
this treatment approach aims to restore mismatches
Systematic Reviews of Interventions (Centre for
between afferent input from the sensory and motor
Reviews and Dissemination, 2009; Higgins and Green,
systems, improve perception of a painful or neglected
2011). The study protocol registration number is
body part, and distract from pain during training
CRD42017076733 by PROSPERO.
(McCabe, 2011; Shinoura et al, 2008). The underlying
mechanisms are not fully understood, but watching
one’s own hand increases intracortical inhibition on Data sources and searches
the primary sensory cortex, leading to reorganization
of somatotopic maps, which might partly explain the Using the MEDLINE (through PubMed), CINAHL,
analgesic effect of visual feedback (Cardini, Longo, and EMBASE, and Cochrane Libraries, study identifica-
Haggard, 2011; Haggard, Iannetti, and Longo, 2013). tion commenced with an online database search to
Illusions of body parts produced by mirror visual identify relevant articles in English or German pub-
feedback reduce pain when used as a prolonged treat- lished up to May 2017. Search terms used were low
ment (Boesch, Bellan, Moseley, and Stanton, 2016). back pain, back pain, chronic, unspecific, visual
Movement representation techniques such as mirror feedback, visual feedback training, visual feedback
visual feedback reduce limb pain and should be con- therapy, physiotherapy, rehabilitation, virtual rea-
sidered for the treatment of patients with chronic regio- lity, mirror feedback, mirror therapy, neck pain,
nal pain syndrome (CRPS) (Thieme et al, 2016). whiplash, WAD, and whiplash-associated disorder.
Moreover, visual feedback enhances the effect of other A combination of these terms was used to extract
treatments; real-time video visual feedback of a comprehensive list of articles from which the
a patient’s own back during massage therapy is helpful titles and abstracts were screened for eligibility.
in alleviating chronic back pain (CBP) (Löffler, Trojan, A search of additional sources was conducted for
Zieglgänsberger, and Diers, 2017). However, visual grey literature on issue-specific databases, based on
feedback may cause unwanted or negative symptoms, citation tracking and key author searches and the
such as increased pain levels, motor extinction, tremor, references of identified studies (i.e. Networked
or dystonia in patients following hand surgery, stroke, Digital Library of Theses and Dissertations: DART
or in those suffering from CRPS (McCabe, 2011). Europe E-Thesis Portal (http://www.dart-europe.eu/
Furthermore, while there is a growing body of research basic-search.php), Open Grey Literature Europe
on the effect of various types of visual feedback deliv- (http://www.opengrey.eu/), and Swiss National
ered to people suffering from chronic pain, the hetero- Library). An example search is provided in
geneity between these studies, their high risk of bias, Appendix A.
and the wide range of investigated pathologies, prevents The inclusion/exclusion criteria to determine study
any firm conclusions being drawn (Wittkopf, Lloyd, eligibility are illustrated in Table 1. Two reviewers
and Johnson, 2018). independently evaluated records for eligibility.
In this light, a recent systematic review centered on the Disagreement was resolved by discussion and consen-
effect of visual feedback of body parts on pain perception sus. Reported arbitration would have been applied by
(Wittkopf, Lloyd, and Johnson, 2018). It analyzed the effect a third person, if required. To avoid duplication in
of visual feedback of body parts on experimentally induced pooling, data were included only once if they were
and clinical pain from a wide range of pathologies, such as reported in a previously published work.
CRPS, phantom limb pain, fibromyalgia, or back pain
(Wittkopf, Lloyd, and Johnson, 2018). They found tentative
Quality assessment
evidence of pain reduction in favor of visual feedback and
emphasized the aforementioned study limitations. Thus, The included studies were type classified following the
there is currently no systematic evidence with a chronic tool developed by Seo et al. (2016). Two reviewers inde-
back and chronic neck pain focus on the effect of visual pendently analyzed the reporting quality of the included
feedback, or on the superiority of any one visual feedback studies using the STROBE (Strengthening the Reporting
tool. Therefore, this systematic review, based on a literature Of Observational Studies in Epidemiology) criteria (www.
search for evidence, aimed to determine the effect of visual strobe-statement.org, 2007) or the Cochrane Back and
feedback on chronic back and chronic neck pain intensity. Neck group’s Risk of Bias criteria (Furlan, Pennick,
 PHYSIOTHERAPY THEORY AND PRACTICE 3

Table 1. Inclusion/exclusion criteria.

Inclusion Exclusion
Participants are 18 years or older Participants are younger than 18 years
Participants suffered from chronic non-specific back or neck pain for three months or more Participants suffered from pain for less than
three months
Participants suffered from specific back or
neck pain
Visual feedback applied through either mirrors, videos or other tools employing visual feedback. No visual feedback applied
The main content of the feedback program (i.e. more than 50%) is based on visual feedback, consisting of Visual feedback comprises less than 50% of
the visual perception of a stimulated or moving body part. the feedback program
There was either a control group or a control condition such as exercise, placebo, sham feedback, no There was neither a control group nor
feedback, passive treatment (such as ultrasound or electrotherapy), visual feedback combined with a control condition
other therapies, or other types of feedback.
VFT alone was used in minimum of one group
Validated instruments for the outcome measurement of pain intensity (e.g. visual analogue scale VAS)

Bombardier, and van Tulder, 2009; Furlan et al. 2015a; feedback compared to control feedback or control
Furlan et al, 2015b) for randomized controlled trials interventions were quantified with Cohens d, or, in
(RCT)s. Discrepancies were resolved by consensus. Pain the case of a repeated measures design, with Cohens
intensity was defined as the outcome of interest to judge d for repeated measures. According to Cohen,
the clinical relevance of the findings. Twenty units out of d was classified as a small (0.2–0.5), middle
100 for pain were considered the minimal clinically (0.5–0.8), or large (> 0.8) effect (Cohen, 1988).
important difference (MCID) for determining clinical
relevance (Ostelo et al, 2008; Salaffi et al, 2004).
Different outcome measures to rate pain were rescaled Results
from 0 to 100 units for each outcome measure (Hayden, The literature search identified 356 papers. Three addi-
van Tulder, Malmivaara, and Koes, 2005). tional papers were retrieved from the grey literature search.
Following screening of the titles and abstracts, application
of the inclusion and exclusion criteria and reading of the
Data analysis complete publication, five studies were deemed eligible and
Two reviewers independently extracted relevant included in the qualitative analysis. A summary of the
information from each study, including the study search results is presented in Figure 1. Appendix
setting, characteristics of patients, inclusion and B summarizes the applied methods, participants’ charac-
exclusion criteria, the use of visual feedback instru- teristics, interventions, and outcome measures used in the
mentation, intervention and control intervention, included studies. The studies were classified as: before-after
study protocol, and outcome of pain intensity. The studies (Diers, Löffler, Zieglgänsberger, and Trojan, 2016;
primary analyses, defined a priori, were: (1) visual Löffler, Trojan, Zieglgänsberger, and Diers, 2017); case-
feedback compared to no feedback/therapy or to control study (Diers et al, 2013); or randomized controlled
sham feedback/therapy; (2) visual feedback com- trials (Trapp et al, 2015; Wand et al, 2012). Data on the
pared to an alternative feedback/therapy; and (3) reporting quality, methodological quality, and assessment
visual feedback including a feedback/therapy com- for risk of bias are shown in Tables 2 and 3. The quality of
pared to the feedback/therapy without visual feed- reporting (STROBE) varied considerably in the before-
back. Due to the expected methodological diversity after and cross-sectional studies. Some studies did not
of the studies, it was decided a priori to analyze the present information on risk of bias or their attempts to
findings using a qualitative narrative synthesis reduce bias (Table 2) (Diers, Löffler, Zieglgänsberger, and
approach instead of a quantitative synthesis Trojan, 2016; Diers et al, 2013; Löffler, Trojan,
approach, according to the recommendations of Zieglgänsberger, and Diers, 2017). The randomized con-
the Cochrane group (Centre for Reviews and trolled studies were considered to have a high risk of bias
Dissemination, 2009; Higgins and Green, 2011). (Table 3) (Furlan et al, 2015b; Furlan, Pennick,
The qualitative narrative synthesis of this systematic Bombardier, and van Tulder, 2009; Trapp et al, 2015;
review was structured according to the Centre for Wand et al, 2012).
Reviews and Dissemination’s guidance for under-
taking reviews in health care (Centre for Reviews
Subjects
and Dissemination, 2009) and the Cochrane
Handbook for Systematic Reviews of Interventions A total of 111 patients with back pain participated in
(Higgins and Green, 2011). The effect sizes of visual the five included studies. The back pain patients were
4 M. HEINRICH ET AL.

Studies retrieved Studies retrieved

through online through additonal
database search sources
N=356 N=3

Studies after removal of duplicates and screening of titles

Exclusion of studies
and abstracts
N=10
N=19

Studies after application of inclusion and exclusion

Further exclusion
criteria
N=4
N=9

Studies after reading the complete publication

N=5

Figure 1. Study flow chart.

classified either as CBP patients (n = 37) with a mini-

mum painful episode duration of 6–12 months Table 2. Strobe score.
(Diers, Löffler, Zieglgänsberger, and Trojan, 2016; Case-
control
Diers et al, 2013), CLBP patients (n = 49) with study Before-after studies
a minimum painful episode of 6 months (Löffler, Diers Diers, Löffler, Löffler, Trojan,
Trojan, Zieglgänsberger, and Diers, 2017; Trapp et al. Zieglgänsberger, Zieglgänsberger,
Item (2013) and Trojan (2016) and Diers (2017)
et al, 2015), or chronic non-specific LBP patients Title and abstract yes yes yes
(n = 25) suffering from pain for longer than 6 months Background yes yes yes
Objectives yes yes yes
(Wand et al, 2012). Study design yes yes yes
Setting no yes yes
Participants yes yes yes
Effect on pain intensity Variables yes yes yes
Data sources/ yes yes yes
The magnitude of the effects and effect sizes are measurements
Bias no no no
illustrated in Table 4. The implementation of online Study size no yes yes
video feedback of the back during the application of Quantitative variables yes yes yes
Statistical methods yes yes yes
painful pressure or electrical stimulation reduced Participants (Results) yes yes yes
perceived pain intensity compared to online video Descriptive data yes yes yes
Outcome data yes yes yes
feedback of another body part, both in CBP patients Main results yes yes yes
and controls (Diers et al, 2013). This effect was Other analyses yes yes yes
Key results yes yes yes
independent of the scale of representation of the Limitations yes yes yes
back (i.e. whether the back’s image was size- Interpretation yes yes yes
Generalizability yes yes yes
controlled, downscaled, or enlarged) (Diers et al, Funding yes yes yes
2013). Without stimulation, watching a real-time,
1 min of video images of their own back resulted
in decreased pain intensity in CBP patients com- watching a neutral object, watching another person
pared to control conditions, such as watching being massaged, a picture of their own back or
a neutral object (Diers, Löffler, Zieglgänsberger, closing their eyes (Löffler, Trojan, Zieglgänsberger,
and Trojan, 2016). Receiving real-time video feed- and Diers, 2017). Visual feedback training based on
back of their own back during massage treatment mirrors also decreased pain intensity: the average
reduced pain intensity significantly more than pain intensity reported by patients performing
 PHYSIOTHERAPY THEORY AND PRACTICE 5

Table 3. Risk of bias assessment.

Risk of bias criteria Trapp et al. (2015) Wand et al. (2012)
Author’s judgment Support for judgment Author’s judgment Support for judgment
Random sequence Low risk of bias “… using a random list created before the Low risk of Bias “A random number sequence was computer-
generation inclusion of the first participant (external generated by an individual not involved
(selection bias) randomisation).” with the study.”
Allocation High risk of bias No mention of any attempts to conceal High risk of bias “…the research assistant opened the
concealment allocation envelope that corresponded to the
(selection bias) participant`s research number and
participants were randomised…
Blinding of High risk of bias No mention of any attempts to blind High risk of bias “Participants were not blinded to condition
participants participants and we did not assess to see if any subjects
were familiar with the concept MVF for the
management of pain.”
Blinding of High risk of bias No mention of any attempts to blind care High risk of bias “…, the researcher recording the time to
personnel/care providers ease was not blinded to condition – …”
providers
(performance bias)
Blinding of outcome High risk of bias No mention of any attempts to blind High risk of bias No mention of any attempts to blind
assessors assessors assessors
(detection bias)
Incomplete outcome High risk of bias “1 Subject from the Feedback group had toHigh risk of Bias “Two participants withdrew after the
data (attrition bias) quit because of a newly herniated disc.” completion of the first condition, one from
Reason for missing outcome possibly the visual feedback condition and one from
related to the true outcome. the no vision condition.” No reason for
withdrawal given, it cannot be excluded that
missing outcomes are related to the true
outcome
Selective reporting Low risk of bias All expected outcomes are mentioned Low risk of bias All outcomes are mentioned.
(reporting bias)
Group similarity at Low risk of bias “The groups did not differ in any of the Unclear risk of bias Not clearly mentioned (“… pre movement
baseline (selection measures.” pain scores for the two conditions were
bias) nearly identical,…”
Co-interventions Low risk of bias “Both groups received identical Low risk of bias There were no other interventions.
(performance bias) treatment…,” the feedback group received
additional visual feedback while the control
group received additional physiotherapy
and movement training (walking)
Compliance Unclear risk of bias Not mentioned High risk of bias “While considerable effort was made to
(performance bias) standardise the range, speed and number of
movements that were performed, attending
to the reflection in the mirror may have
induced different movement characteristics
between the two conditions.”
Intention-to-treat Unclear risk of bias Not mentioned Unclear risk of bias Not mentioned
analysis
Timing of outcome Low risk of bias Measurements were taken on day 1 Low risk of Bias All measurements were measured on the
assessments and day 14. same day
(detection bias)
Other bias High risk of bias - “Our findings are based on a small sam- Low risk of bias “The greater novelty of the MVF condition or
ple consisting of 30 patients,…” greater expectation of benefit from this
- …, no objective method like ultrasound condition may have introduced some
imaging was used to survey whether bias, although we attempted to control for
the musculus multifidus (MM) was this by blinding participants to the
specifically activated by the partici- hypotheses of the study.”
pants, Choosing MM activation as low
back movement was somewhat
arbitrary.”

lumbar spine movements while visualizing their table, were asked to watch an image of their own
own back in a mirror was less than when they back recorded in real-time via webcam during
moved without visualization (Wand et al, 2012). a brief 2-point discrimination training (Trapp
Patients that received visual feedback in addition et al, 2015).
to an evidence-based CLBP rehabilitation program
reported lower pain intensity after 2 weeks, com-
Clinical relevance
pared to a control group that only received the
rehabilitation program (Trapp et al, 2015). During Although four studies reported a statistically significant
the visual feedback sessions, the patients, whilst effect of visual feedback on pain intensity (Diers,
lying in the prone position on a massage therapy Löffler, Zieglgänsberger, and Trojan, 2016; Diers et al,
6 M. HEINRICH ET AL.

Table 4. Effect sizes in back pain studies.

Mean Mean (±SD)
Study VF condition Control condition Remarks Patients (±SD) VF Control d
Wand et al. (2012) Watching own back while moving Moving without CLBP 35.5 ± 22.8 44.7 ± 26.0 0.38
visual feedback
Diers et al. (2013) Size-controlled image of own back Image of own hand Pressure on CBP 6.94 ± 0.92 7.28 ± 1.05 0.39*
muscle
Enlarged image of own back Image of own hand Pressure on CBP 7.02 ± 1.26 7.28 ± 1.05 0.24*
muscle
Downscaled image of own back Image of own hand Pressure on CBP 6.85 ± 0.97 7.28 ± 1.05 0.53*
muscle
Size-controlled image of own back Image of own hand Electric CBP 6.27 ± 0.80 6.54 ± 0.81 0.48*
stimulation
Enlarged image of own back Image of own hand Electric CBP 6.2 ± 0.89 6.54 ± 0.81 0.54*
stimulation
Downscaled image of own back Image of own hand Electric CBP 6.22 ± 0.88 6.54 ± 0.81 0.84*
stimulation
Diers, Löffler, Size-controlled video of own back Before receiving CBP 2.74 ± 2.45 3.42 ± 2.19 0.29
Zieglgänsberger, and visual feedback
Trojan (2016)
Image of book Before receiving CBP 3.63 ± 2.14 3.63 ± 2.29 0.01
visual feedback
Size-controlled video of another Before receiving CBP 3.21 ± 1.96 3.26 ± 1.73 0.02
person’s back visual feedback
Picture of own back Before receiving CBP 3.00 ± 1.92 3.00 ± 1.92 0.00
visual feedback
Eyes closed Before receiving CBP 3.11 ± 2.54 3.53 ± 2.48 0.16
visual feedback
Trapp et al. (2015) Evidence-based back pain Evidence-based back Mean and SD CLBP 2.53 ± 1.82 3.09 ± 1.49 0.37
treatment plus visual feedback pain training after treatment
Löffler, Trojan, Video of own back while receiving Before massage CBP 1.16 ± 1.34 3.42 ± 2.19 1.24
Zieglgänsberger, and Diers massage therapy therapy
(2017)
Abbreviations: CBP – chronic back pain, CLBP – chronic low back pain, d – Cohens d, SD – standard deviation, VF – visual feedback * Cohens d for repeated
measures

2013; Trapp et al, 2015; Wand et al, 2012), the effect enable clinicians or other researchers to verify the find-
was below 20/100 units and, thus, below the MCID ings in their own clinics or laboratories (Wand et al,
(Ostelo et al, 2008; Salaffi et al, 2004). One study 2012). Two studies also lacked an adequate explanation
reported a clinically relevant reduction in pain intensity of their sample size (Diers et al, 2013; Wand et al,
from visual feedback of the own back while receiving 2012). Three studies did not describe the author’s
massage therapy (Löffler, Trojan, Zieglgänsberger, and efforts to address potential sources of bias (Diers,
Diers, 2017). The estimated effect sizes ranged from Löffler, Zieglgänsberger, and Trojan, 2016; Diers et al,
a small to large positive effect of visual feedback on 2013; Wand et al, 2012). The randomized studies are
CBP intensity (Diers, Löffler, Zieglgänsberger, and considered to have a high risk of bias (Trapp et al, 2015;
Trojan, 2016; Diers et al, 2013; Löffler, Trojan, Wand et al, 2012) (Table 3), since the blinding of
Zieglgänsberger, and Diers, 2017; Trapp et al, 2015; patients, care providers, or outcome assessors was
Wand et al, 2012). The large effect sizes were reported either not possible or not reported, and the information
from watching a video of their own back during mas- provided about the allocation process was insufficient.
sage therapy and viewing a downscaled image of their
own back while undergoing electrical stimulation
Discussion
(Diers et al, 2013; Löffler, Trojan, Zieglgänsberger,
and Diers, 2017) (Table 4). The aim of this study was to determine the influence of
visual feedback on chronic back or chronic neck pain.
Only studies investigating CBP could be included. The
Quality of reporting and risk of bias
collected data show a mitigating influence of visual
The overall quality of reporting was good, with some feedback on CBP (Diers, Löffler, Zieglgänsberger, and
exceptions (Table 2). Two out of three case-control, Trojan, 2016; Diers et al, 2013; Löffler, Trojan,
respectively before-after studies, did not describe the Zieglgänsberger, and Diers, 2017; Trapp et al, 2015;
setting (including locations and periods of recruitment) Wand et al, 2012). We found that visual feedback
(Diers et al, 2013; Wand et al, 2012). One study did not does appear to alter pain intensity in people with CBP
describe their patient population in sufficient detail to (Diers, Löffler, Zieglgänsberger, and Trojan, 2016;
 PHYSIOTHERAPY THEORY AND PRACTICE 7

Diers et al, 2013) and that there is limited evidence to and Diers, 2017; Trapp et al, 2015; Wand et al, 2012).
use visual feedback as an enhancement to evidence- Thus, the effect of visual feedback might depend on the
based back pain therapy, movement, and massage ther- underlying painful condition.
apy (Löffler, Trojan, Zieglgänsberger, and Diers, 2017; One study investigated whether the size of the visua-
Trapp et al, 2015; Wand et al, 2012). lized body part (i.e. enlarged, normal, and minified) has
While the documented effects of visual feedback on an effect on CBP. In CBP patients, a reduction in pain
chronic back intensity are typically statistically significant, intensity regardless of the size of the visualized back
most of the estimated effect sizes are small and generally was reported (Diers et al, 2013). Minifying an affected
below the MICD. However, these effects indicate the hand significantly decreased movement-induced
potential of visual feedback to be developed into an effec- chronic hand pain while magnifying the affected hand
tive enhancement of another intervention (Moseley, significantly increased movement-induced pain
2017). This was evidenced by Löffler, Trojan, (Moseley, Parsons, and Spence, 2008). There is insuffi-
Zieglgänsberger, and Diers (2017) when they integrated cient evidence to determine whether the size of the
visual feedback into a massage therapy intervention. Two visualized body part has an effect on pain intensity in
of the included studies were designed as intervention other pain conditions (De Kooning et al, 2017;
studies (Trapp et al, 2015; Wand et al, 2012), while three Moseley, Parsons, and Spence, 2008; Preston and
studies were classified as before-after (Diers, Löffler, Newport, 2011; Wittkopf, Lloyd, and Johnson, 2018).
Zieglgänsberger, and Trojan, 2016; Löffler, Trojan, Diers, Löffler, Zieglgänsberger, and Trojan (2016)
Zieglgänsberger, and Diers, 2017), respectively case- reported a larger effect for normal-sized visual feedback
control studies (Diers et al, 2013). Such study types are of a patient’s own back in CBP patients compared to
useful in assessing the effect of innovative techniques but other types of visual feedback. This is in contrast to
prone to potential sources of bias, including the subject other studies that report that visual feedback of the
expectation bias (i.e. subjects themselves expect to get stimulated body part is not superior to other types of
better because of the study intervention), lack of blinding visual feedback (e.g. view of another body part) for
of participants and assessors, and give no differentiation reducing experimentally induced pain in pain free par-
between an immediate effect and trends over time. ticipants (De Kooning et al, 2017; Johnson and Gohil,
Furthermore, the statistical analyses in the before-after 2016; Longo, Betti, Aglioti, and Haggard, 2009; Longo
and case-control studies did not take possible confound- et al, 2012; Martini, Perez-Marcos, and Sanchez-Vives,
ing factors, expectations or anxiety, into account. The 2014; Nierula et al, 2017; Osumi et al, 2014; Torta,
small sample sizes might have precluded multivariate Legrain, and Mouraux, 2015; Wittkopf, Lloyd, and
analyses of the data. Longitudinal study designs, with Johnson, 2018). The mechanisms associated with
blinded participants and larger sample sizes might be hyperalgesia in experimental studies might differ from
indicated. The intervention studies did not follow an patients with CBP, as most likely pain-free participants
intention-to-treat approach, which should be followed do not have a disrupted mental representation of their
in future larger-scaled trials to obtain a better estimation back (Wittkopf, Lloyd, and Johnson, 2018). However,
of the actual effect of visual feedback. Therefore, the effect there is a lack of imaging studies investigating cortical
sizes give only a very early indication of what could be reorganization when using visual feedback techniques
expected from visual feedback in future practice. (Diers et al, 2010; Flor, Denke, Schaefer, and Grüsser,
A recent systematic review centered on the effect of 2001; Foell, Bekrater-Bodmann, Diers, and Flor, 2014).
visual feedback of body parts on pain perception, covering Translating the findings of the included studies into
a wide range of pain conditions (Wittkopf, Lloyd, and a clinical setting might be relatively simple compared to
Johnson, 2018). They reported that mirror-based visual other innovative interventions that rely on more sophis-
feedback of a normal-sized painful body part resulted in ticated and expensive technology (Matheve, Brumagne,
a significant reduction of pain intensity in CRPS patients, and Timmermans, 2017; Moseley, 2017). The equipment
but not in phantom limb pain patients (Brodie, Whyte, used in these studies was relatively low-tech and low-cost,
and Niven, 2007; Cacchio et al, 2009; Chan et al, 2007; e.g. mirrors and webcams (Diers, Löffler, Zieglgänsberger,
McCabe et al, 2003; Tilak et al, 2016; Vural et al, 2016; and Trojan, 2016; Diers et al, 2013; Löffler, Trojan,
Wittkopf, Lloyd, and Johnson, 2018). The five studies Zieglgänsberger, and Diers, 2017; Trapp et al, 2015;
included in this review show either a momentary decrease Wand et al, 2012). Although such equipment, especially
of CBP intensity during the application of normal-sized mirrors, are frequently used in daily physiotherapy prac-
visual feedback or a habitual decrease after treatment for tice, these could limit the type of exercises or other treat-
2 weeks (Diers, Löffler, Zieglgänsberger, and Trojan, ments a physiotherapist can utilize because, for example,
2016; Diers et al, 2013; Löffler, Trojan, Zieglgänsberger, vision might be impaired in specific exercise positions.
8 M. HEINRICH ET AL.

Consequently, it might be promising to integrate visual References

feedback based on webcams or virtual reality into
Balagué F, Mannion AF, Pellisé F, Cedraschi C 2012 Non-
a technology supported therapy system, exploiting some specific low back pain. Lancet 379: 482–491.
of the benefits technology supported therapy offers Boesch E, Bellan V, Moseley GL, Stanton TR 2016 The effect
(Matheve, Brumagne, and Timmermans, 2017). Harvie of bodily illusions on clinical pain: A systematic review and
et al.’s (2015) findings from their study of neck pain meta-analysis. Pain 157: 516–529.
complement these results, by showing that visual feedback Brodie EE, Whyte A, Niven CA 2007 Analgesia through the
affects the onset of pain when perception overstates or looking-glass? A randomized controlled trial investigating
the effect of viewing a ‘virtual’ limb upon phantom limb
understates an active rotation of the cervical spine.
pain, sensation and movement. European Journal of Pain
The results from this review and from Wittkopf, Lloyd, 11: 428–436.
and Johnson (2018) point out that many factors should be Cacchio A, De Blasis E, Necozione S, di Orio F, Santilli V
addressed before visual feedback can be developed as an 2009 Mirror therapy for chronic complex regional pain
intervention for chronic back or chronic neck pain. While syndrome type 1 and stroke. New England Journal of
the included studies investigated the effects of visual feed- Medicine 361: 634–636.
Cardini F, Longo MR, Haggard P 2011 Vision of the body
back on pain intensity (Diers, Löffler, Zieglgänsberger, and modulates somatosensory intracortical inhibition. Cerebral
Trojan, 2016; Diers et al, 2013; Löffler, Trojan, Cortex 21: 2014–2022.
Zieglgänsberger, and Diers, 2017; Trapp et al, 2015; Centre for Reviews and Dissemination 2009 Centre for
Wand et al, 2012), they did not examine its effect on the reviews and disseminations guidance for undertaking
central nervous system, such as the cortical representation reviews in health care. York: University of York.
Chan BL, Witt R, Charrow AP, Magee A, Howard R,
of the lower back. This is a limitation since it prevents any
Pasquina PF, Heilman KM, Tsao JW 2007 Mirror therapy
conclusions concerning the neurophysiological mechan- for phantom limb pain. New England Journal of Medicine
isms underlying any treatment effect. Other issues are the 357: 2206–2207.
identification of the patient group most likely to benefit Cohen J 1988 Statistical power analysis for the behavioral
from visual feedback, the best type of visual feedback, and sciences. Hilsdale. NJ: Lawrence Earlbaum Associates.
the best duration, intensity and frequency of a visual feed- Costa-Black KM, Loisel P, Anema JR, Pransky G 2010 Back
pain and work. Best Practice and Research Clinical
back intervention. Future trials should also address other Rheumatology 24: 227–240.
dimensions of pain besides pain intensity, for example, de Campos TF, Maher CG, Steffens D, Fuller JT, Hancock MJ
disability or fear avoidance beliefs. 2018 Exercise programs may be effective in preventing
a new episode of neck pain: A systematic review and
Conclusions meta-analysis. Journal of Physiotherapy 64: 159–165.
De Kooning M, Daenen L, Verhelpen S, Don S, Voogt L,
While visual feedback appears to alter pain intensity in Roussel N, Ickmans K, Van Loo M, Cras P, Nijs J 2017
people with CBP, there is limited evidence from studies Abnormal pain response to visual feedback during cervical
movements in chronic whiplash: An experimental study.
to support visual feedback as an adjunct to conven- Pain Practice 17: 156–165.
tional therapy (Diers, Löffler, Zieglgänsberger, and Diers M, Christmann C, Koeppe C, Ruf M, Flor H 2010
Trojan, 2016; Diers et al, 2013; Löffler, Trojan, Mirrored, imagined and executed movements differentially
Zieglgänsberger, and Diers, 2017; Trapp et al, 2015; activate sensorimotor cortex in amputees with and without
Wand et al, 2012). The open questions regarding this phantom limb pain. Pain 149: 296–304.
Diers M, Löffler A, Zieglgänsberger W, Trojan J 2016
innovative treatment method (Moseley, 2017), such as
Watching your pain site reduces pain intensity in chronic
its unknown effect over time, point out that future back pain patients. European Journal of Pain 20: 581–585.
studies may be indicated. Such studies should pay Diers M, Zieglgänsberger W, Trojan J, Drevensek AM,
close attention to the risk of bias and to the applicabil- Erhardt-Raum G, Flor H 2013 Site-specific visual feedback
ity to clinical practice. reduces pain perception. Pain 154: 890–896.
Ebadi S, Henschke N, Nakhostin Ansari N, Fallah E, van
Tulder MW 2014 Therapeutic ultrasound for chronic
Acknowledgments low-back pain. Cochrane Database of Systematic Reviews
3: CD009169.
The authors thank Karen Linwood for her advice on English Flor H, Denke C, Schaefer M, Grüsser S 2001 Effect of
language and terminology. sensory discrimination training on cortical reorganisation
and phantom limb pain. Lancet 357: 1763–1764.
Foell J, Bekrater-Bodmann R, Diers M, Flor H 2014 Mirror
Disclosure statement therapy for phantom limb pain: Brain changes and the role of
The authors declare that they have no competing interests. body representation. European Journal of Pain 18: 729–739.
 PHYSIOTHERAPY THEORY AND PRACTICE 9

Franke H, Fryer G, Ostelo RW, Kamper SJ 2015 Muscle energy Longo MR, Betti V, Aglioti SM, Haggard P 2009 Visually
technique for non-specific low-back pain. Cochrane Database induced analgesia: Seeing the body reduces pain. Journal of
of Systematic Reviews 2: CD009852. Neuroscience 29: 12125–12130.
Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M Longo MR, Iannetti GD, Mancini F, Driver J, Haggard P
2015a Massage for low-back pain. Cochrane Database of 2012 Linking pain and the body: Neural correlates of
Systematic Reviews 9: CD001929. visually induced analgesia. Journal of Neuroscience 32:
Furlan AD, Malmivaara A, Chou R, Maher CG, Deyo RA, 2601–2607.
Schoene M, Bronfort G, van Tulder MW, Editorial Board Luomajoki HA, Bonet Beltran MB, Careddu S, Bauer CM 2018
of the Cochrane Back and Neck Group 2015b 2015 Effectiveness of movement control exercise on patients with
Updated method guideline for systematic reviews in the non-specific low back pain and movement control
Cochrane back and neck group. Spine 40: 1660–1673. impairment: A systematic review and meta-analysis.
Furlan AD, Pennick V, Bombardier C, van Tulder M 2009 Musculoskeletal Science and Practice 36: 1–11.
2009 updated method guidelines for systematic reviews in Macedo LG, Saragiotto BT, Yamato TP, Costa LO, Menezes
the Cochrane back review group. Spine 34: 1929–1941. Costa LC, Ostelo RW, Maher CG 2016 Motor control
Gross A, Kay T, Paquin J, Blanchette S, Lalonde P, Christie T, exercise for acute non-specific low back pain. Cochrane
Dupont G, Graham N, Burnie S, Gelley G, et al. 2015a Database of Systematic Reviews 2: CD012085.
Exercises for mechanical neck disorders. Cochrane Martini M, Perez-Marcos D, Sanchez-Vives MV 2014
Database of Systematic Reviews 1: CD004250. Modulation of pain threshold by virtual body ownership.
Gross A, Langevin P, Burnie S, Bédard-Brochu M, Empey B, European Journal of Pain 18: 1040–1048.
Dugas E, Faber-Dobrescu M, Andres C, Graham N, Matheve T, Brumagne S, Timmermans AA 2017 The effec-
Goldsmith C, et al. 2015b Manipulation and mobilisation tiveness of technology-supported exercise therapy for low
for neck pain contrasted against an inactive control or back pain: A systematic review. American Journal of
another active treatment. Cochrane Database of Physical Medicine and Rehabilitation 96: 347–356.
Systematic Reviews 9: CD004249. McCabe C 2011 Mirror visual feedback therapy. A Practical
Haggard P, Iannetti GD, Longo MR 2013 Spatial sensory Approach. Journal of Hand Therapy 24: 170–179.
organization and body representation in pain perception. McCabe C, Haigh R, Ring E, Halligan P, Wall P, Blake D
Current Biology 23: R164–R176. 2003 A controlled pilot study of the utility of mirror visual
Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, feedback in the treatment of complex regional pain syn-
Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, drome (type 1). Rheumatology 42: 97–101.
Sieper J, et al. 2018 What low back pain is and why we Moseley GL 2017 Innovative treatments for back pain. Pain
need to pay attention. Lancet 391: 2356–2367. 158: S2–S10.
Harvie DS, Broecker M, Smith RT, Meulders A, Madden VJ, Moseley GL, Parsons TJ, Spence C 2008 Visual distortion of
Moseley GL 2015 Bogus visual feedback alters onset of a limb modulates the pain and swelling evoked by
movement-evoked pain in people with neck pain. movement. Current Biology 18: R1047–R1048.
Psychological Science 26: 385–392. Nierula B, Martini M, Matamala-Gomez M, Slater M,
Hayden JA, van Tulder MW, Malmivaara A, Koes BW 2005 Sanchez-Vives MV 2017 Seeing an embodied virtual
Exercise therapy for treatment of non-specific low back hand is analgesic contingent on colocation. Journal of
pain. Cochrane Database of Systematic Reviews 3: Pain 18: 645–655.
CD000335. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von
Higgins JPT, Green S (eds.) 2011 . Cochrane handbook for Korff M, Bouter LM, de Vet HC 2008 Interpreting change
systematic reviews of interventions Version 5.1.0 [updated scores for pain and functional status in low back pain:
March 2011]. The cochrane collaboration. Available from Towards international consensus regarding minimal
www.handbook.cochrane.org. important change. Spine 33: 90–94.
Hoy D, Brooks P, Blyth F, Buchbinder R 2010 The epide- Osumi M, Imai R, Ueta K, Nakano H, Nobusako S,
miology of low back pain. Practice and Research Clinical Morioka S 2014 Factors associated with the modulation
Rheumatology 24: 769–781. of pain by visual distortion of body size. Frontiers in
Hoy DG, Protani M, De R, Buchbinder R 2010 The epide- Human Neuroscience 8: 137.
miology of neck pain. Best Practice and Research Clinical Poquet N, Lin CW, Heymans MW, van Tulder MW,
Rheumatology 24: 783–792. Esmail R, Koes BW, Maher CG 2016 Back schools for
Johnson MI, Gohil M 2016 An investigation into enlarging and acute and subacute non-specific low-back pain. Cochrane
reducing the size of mirror reflections of the hand on Database of Systematic Reviews 4: CD008325.
experimentally-induced cold-pressor pain in healthy human Preston C, Newport R 2011 Analgesic effects of multisensory
participants. Scandinavian Journal of Pain 10: 19–25. illusions in osteoarthritis. Rheumatology 50: 2314–2315.
Kälin S, Rausch-Osthoff AK, Bauer CM 2016 What is the Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van
effect of sensory discrimination training on chronic low Tulder MW 2013 Spinal manipulative therapy for acute
back pain? A systematic review. BMC Musculoskeletal low back pain: An update of the Cochrane review. Spine
Disorders 17: 143. 38: E158–177.
Löffler A, Trojan J, Zieglgänsberger W, Diers M 2017 Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W 2004
Visually induced analgesia during massage treatment in Minimal clinically important changes in chronic muscu-
chronic back pain patients. European Journal of Pain 21: loskeletal pain intensity measured on a numerical rating
1623–1631. scale. European Journal of Pain 8: 283–291.
10 M. HEINRICH ET AL.

Saragiotto BT, Maher CG, Yamato TP, Costa LO, Menezes of the back during movement. Clinical Journal of Pain 28:
Costa LC, Ostelo RW, Macedo LG 2016 Motor control 602–608.
exercise for chronic non-specific low-back pain. Wegner I, Widyahening IS, van Tulder MW, Blomberg SE, de
Cochrane Database of Systematic Reviews 1: CD012004. Vet HC, Bronfort G, Bouter LM, van der Heijden GJ 2013
Seo HJ, Kim SY, Lee YJ, Jang BH, Park JE, Sheen SS, Traction for low-back pain with or without sciatica.
Hahn SK 2016 A newly developed tool for classifying Cochrane Database of Systematic Reviews 8: CD003010.
study designs in systematic reviews of interventions and Wittkopf PG, Lloyd DM, Johnson MI 2018 The effect of
exposures showed substantial reliability and validity. visual feedback of body parts on pain perception:
Journal of Clinical Epidemiology 70: 200–205. A systematic review of clinical and experimental studies.
Shinoura N, Suzuki Y, Watanabe Y, Yamada R, Tabei Y, Saito K, European Journal of Pain 22: 647–662.
Yagi K 2008 Mirror therapy activates outside of cerebellum and Yamato TP, Maher CG, Saragiotto BT, Hancock MJ,
ipsilateral M1. NeuroRehabilitation 23: 245–252. Ostelo RW, Cabral CM, Costa LC, Costa LO 2016 Pilates
Thieme H, Morkisch N, Rietz C, Dohle C, Borgetto B 2016 for low back pain: Complete republication of a Cochrane
The efficacy of movement representation techniques for review. Spine 41: 1013–1021.
treatment of limb pain - A systematic review and
meta-analysis. Journal of Pain 17: 167–180. Appendix A. Example search strategy
Tilak M, Isaac SA, Fletcher J, Vasanthan LT, Subbaiah RS,
Babu A, Bhide R, Tharion G 2016 Mirror therapy and Pubmed search strategy
transcutaneous electrical nerve stimulation for manage-
ment of phantom limb pain in amputees - A single blinded (1) low back pain (30,544)
randomized controlled trial. Physiotherapy Research (2) back pain (57,878)
International 21: 109–115. (3) chronic (1,128,004)
Torta DM, Legrain V, Mouraux A 2015 Looking at the hand (4) unspecific (9848)
modulates the brain responses to nociceptive and non-noci- (5) visual feedback (13,866)
ceptive somatosensory stimuli but does not necessarily mod- (6) visual feedback training (2229)
ulate their perception. Psychophysiology 52: 1010–1018. (7) visual feedback therapy (3309)
Trapp W, Weinberger M, Erk S, Fuchs B, Mueller M, (8) physiotherapy (146,653)
Gallhofer B, Hajak G, Kübler A, Lautenbacher S 2015 (9) rehabilitation (498,906)
A brief intervention utilising visual feedback reduces (10) virtual reality (6814)
pain and enhances tactile acuity in CLBP patients. (11) mirror feedback (706)
Journal of Back and Musculoskeletal Rehabilitation 28: (12) mirror therapy (8321)
651–660. (13) neck pain (23,505)
Vural SP, Yuzer GFN, Ozcan DS, Ozbudak SD, Ozgirgin N (14) whiplash (3627)
2016 Effects of mirror therapy in stroke patients with (15) WAD (1067)
complex regional pain syndrome type 1: A randomized (16) whiplash-associated disorder (455)
controlled study. Archives of Physical Medicine and (17) (1 OR 2) AND (5 OR 6 OR 7) (85)
Rehabilitation 97: 575–581. (18) (1 OR 2 OR 13) AND (5 OR 6 OR 7 OR 10 OR 11 OR
Wand BM, Tulloch VM, George PJ, Smith AJ, Goucke R, 12) (195)
O’Connell NE, Moseley GL 2012 Seeing it helps: (19) (3 OR 4) AND 2 AND 5 AND (8 OR 9) (23)
Movement-related back pain is reduced by visualization (20) (13 OR 14 OR 15 OR 16) AND (5 OR 6 OR 7) (53)
Appendix B. Study characteristics

Pain intensity
Study Design Participants Intervention instrument
Wand et al. (2012) Randomized crossover Twenty-five patients suffering from CLBP were recruited using the Participants were randomized into two groups: “Movement with VAS (0–100)
cross-sectional study following criteria visual feedback” condition or “movement without visual feedback”
Inclusion criteria: condition.
● 18–60 years old The position of each spinous process of the lumbar spine, the iliac
● Reported back pain as their main symptom (intensity of at least crest and the 12th ribs were marked to augment visual feedback.
moderate) While standing in a marked square on the floor, the subjects were
● Suffering from non-specific low back pain for at least 6 months asked to “move as far as they comfortably could whilst performing
● No cognitive impairment lumbar flexion, extension, lateral flexion to each side, as well as glide
Exclusion criteria: to each side.” The distance reached by the fingertips on the leg was
● Nerve root pain or evidence of specific spinal pathology, e.g. marked for each movement. Two large mirrors were placed at the
malignancy, infection, fracture, inflammatory disease. front and at the back of the subjects so that they received a clear
All participants were screened for eligibility by their referring clin-
view of the reflection of their back in the front mirror.
ician and blinded to the study hypothesis. The mirror was first covered with a sheet and the patients were
asked to assess the intensity of pain in their lower back using the
VAS.
For the visual feedback group, the sheet was then removed. The
other group was instructed to look at the sheet throughout the
experiment. All participants performed 10 repetitions of flexion,
extension, lateral flexion to each side, as well as glide to each side,
the VF group whilst watching the reflection of their back in the
mirror. The subjects were asked to assess their momentary pain
intensity immediately after the experiment.
Diers et al. (2013) Case-control study Eighteen subjects with bilateral CBP were recruited through a joint- The subjects were exposed to two different kinds of stimuli of the NRS (0–10)
case management unit established by several pain research centers myofascial trigger points in the trapezius muscle: pressure and
in the southern part of Germany. electrical stimulation. The pressure was applied using an algometer
Inclusion criteria with an intensity of 7 or 8 on a NRS from 0 to 10 (the intensity was
● Pain experienced for a minimum of 12 months determined individually before the experiments). The electrical
Exclusion criteria stimulus was applied using a constant current stimulator and
● Neurological complications disposable needle electrodes. The stimulation intensity was
● Pregnancy determined at 70% above the pain threshold (also determined
● Psychosis before the experiments). During each of these two stimuli, the
● Cardiovascular diseases or use of a pacemaker subjects received four different kinds of visual feedback using
● Drug abuse a monitor in front of them:
● Allergy to plaster ● an unmodified image of the dorsum of the hand
● Current opioid intake ● an unmodified image of the back
Eighteen healthy control subjects (no further information about the ● an enlarged image of the back (a vertical contraction of 0.75)
recruitment) ● a downscaled feedback of the back (a horizontal contraction of 0.75)
Exclusion criteria were the same as listed above The stimuli and the different kinds of feedback were each applied in
a randomized order.
PHYSIOTHERAPY THEORY AND PRACTICE

(Continued )
11
 12

(Continued).
Pain intensity
Study Design Participants Intervention instrument
Diers, Löffler, Cross-sectional study Nineteen subjects with chronic back pain were recruited through The participants were instructed to lie in the prone position on NRS (0–10)
Zieglgänsberger, advertisements in medical and physical therapy practices. a massage table with a display mounted below the headrest. They
and Trojan, (2016) Inclusion criteria: were questioned about their pain intensity and unpleasantness
● Back pain of at least 6 months before and after they were shown different kinds of visual feedback
Exclusion criteria: on the monitor:
M. HEINRICH ET AL.

● Opioid medication ● an online real-time video of their own back

● Psychosis, major depression, bipolar disorder ● a video of another person’s back (same sex)
● a video of a book (neutral object)
● a picture of their own back
● keeping their eyes closed
The feedbacks were shown for a minute each in a randomized order
on five different days (always with one day of rest in between).

Löffler, Trojan, Cross-sectional study Nineteen CLBP patients who had experienced back pain for All patients were treated with a conventional massage therapy. NRS (0–10)
Zieglgänsberger, a minimum of 6 months During this treatment, patients received a real-time video feedback
and Diers, (2017) Exclusion criteria for all patients were opioid medication, psychosis, of their own back. The following were used as controls: watching
major depression or bipolar disorder and contraindication of a neutral object, video of another person of the same sex being
massage (e.g. thrombosis, arterial circulatory/obstructive disease, massaged, picture of the own back, and keeping their eyes closed.
cardiac insufficiency, acute injury of the back, inflammatory muscular These conditions were presented in randomized order on five
disease, high fever, tumors, chemotherapy/radiation therapy, acute separate days.
nerve compression syndrome and pregnancy).
Trapp et al. (2015) Randomized controlled Thirty patients from an orthopedic rehabilitation clinic suffering from All the subjects received treatment for about 6 h per day according NRS (0–10)
trial CLBP were recruited for this case-control study. All subjects had to the evidence-based modules for chronic back pain: this consisted
a history of at least 6 months of low back pain, were 18 years or of relaxation training, movement therapy, massage and pain
older and did not suffer from cognitive impairment (IQ> 85). They education. If necessary, psychological and social consultation was
had no history of psychiatric disorders or clinical signs of acute provided. The treatment took course during their stay at the clinic.
depression. No form of visual feedback was used during these therapeutic
modules.
The feedback group received an additional six sessions of 20 min,
distributed over 2 weeks. The researchers assessed the patient’s
TPDT at the height of L3 before each session. The patients were
asked to watch an image of their back recorded in real-time via
webcam while lying in the prone position on a massage therapy
table. The training sessions consisted of 10 stimulations in
a randomized order applied to the subjects slightly above and below
the individual threshold distance (±5 mm). Following each
stimulation visual feedback was turned on for the participants to
check whether their judgment was correct. After this, the subjects
had to alternately tilt their pelvis up and down on the left and the
right side for 10 min, using only their lumbar multifidi muscles.
Subjects had been previously instructed on how to perform this
movement by a physiotherapist. Visual feedback was affected by the
patients watching themselves on a computer screen via an installed
webcam. The control subjects received six additional 30-min
sessions, consisting of two units of physiotherapy, relaxation training
and movement training (walking) each.
Abbreviations: CBP – chronic back pain; CLBP chronic low back pain; IQ – intelligence quotient; NRS – numeric pain rating scale; TPDT – two-point discrimination therapy; VAS – visual analogue scale.