Effectiveness of graded motor imagery in paraplegics with chronic shoulder pain.

People with Spinal Cord Injury (SCI) using manual wheelchairs (MWC) have a greater reliance on their upper limbs to maintain their level of independence through daily activities, such as wheelchair propulsion and transfer which may result in shoulder pain. Shoulder pain in this population significantly affects independence and quality of life. Past literature suggests musculoskeletal pain is strongly associated with behaviors of pain catastrophizing and kinesiophobia.

Graded motor imagery (GMI) is a movement representation technique proven to be effective in various neurological and orthopaedic conditions, consisting three stages- implicit motor imagery (lateralization), explicit motor imagery, and mirror therapy which helps in cortical remapping that in turn reduces fear avoidance behavior, thus reducing pain.

OBJECTIVES

Primary objectives

To determine the effect of Graded Motor Imagery on pain reduction.

To determine the effect of Graded Motor Imagery on active range of motion (AROM) of shoulder.

To determine the effect of Graded Motor Imagery on disability of shoulder.

Secondary objectives

To determine the effect of Graded Motor Imagery on kinesiophobia.

To determine the effect of Graded Motor Imagery on Pain Catastrophization.

HYPOTHESIS

Null Hypothesis Ho-

•       There will be no significant difference between GMI with conventional treatment as compared to conventional treatment alone on pain reduction, AROM, disability, kinesiophobia and catastrophization in paraplegics with Shoulder pain.

Alternate Hypothesis H1-

•       There will be a significant difference between GMI with conventional treatment as compared to conventional treatment alone on pain reduction, AROM, disability, kinesiophobia and catastrophization in paraplegics with Shoulder pain.

 Material and Methods

This randomized controlled trial will be conducted on paraplegic patients experiencing chronic shoulder pain, recruited from the Indian Spinal Injury Centre, New Delhi. A total of 30 participants (15 in each group) will be included based on strict inclusion and exclusion criteria. Eligible individuals will be aged 18–60 years, diagnosed with paraplegia (T2–T12 level), and suffering from moderate shoulder pain (VAS-4 to 7) for minimum 1 month. Participants with history of trauma or surgery, diagnosed with inflammatory disorders, adhesive capsulitis and joint instability, analgesic use, or cognitive issues will be excluded.

Baseline assessments will cover pain (Wheelchair User’s Shoulder Pain Index -WUSPI), AROM (goniometry), disability (Disability of the Arm, Shoulder, and Hand scale -DASH), kinesiophobia (Fear avoidance belief questionnaire-FABQ), and pain catastrophization (Pain Catastrophizing Scale-PCS). Participants will be randomly assigned into a control group (conventional physical therapy) and an experimental group (conventional therapy + GMI). The intervention will be conducted for 40 minutes per session, three times a week for three weeks. Post-intervention assessments will follow the same outcome measures.

Statistical Analysis Plan:

Data will be analysed using SPSS v21.0. Normality will be tested with the Shapiro-Wilk test. Paired t-test or Wilcoxon test will be used for within-group comparisons, and independent t-test or Mann–Whitney U test for between-group comparisons.