A conceptual model for managing sexual pain with somatocognitive therapy in women with provoked vestibulodynia and implications for physiotherapy practice.

Somatocognitive therapy is a multimodal physiotherapy treatment developed in the early 2000s to alleviate the burden of chronic pelvic pain. In recent years, somatocognitive therapy has been further developed to treat women with provoked vestibulodynia. This prevalent gynecological pain condition is a subgroup of chronic pelvic pain and the most common form of vulvodynia. Provoked vestibulodynia is a neglected multifactorial pain condition of unknown cause, adversely affecting women's sexual life, relation to their partners and their psychological health. Pain is located at the vulvar vestibule and is provoked by touch or pressure such as sexual intercourse. In the management of sexual pain, somatocognitive therapy combines bodily exploration, pain education, cognitive coping strategies and structured homework to improve sexual function and reduce pain. To support these processes, developing a sound therapeutic alliance with the patient is essential. The aim of this article is to provide a conceptual model for managing provoked vestibulodynia with somatocognitive therapy, including a theoretical rational for this treatment. We base our conceptual model on the biopsychosocial model, i.e., considering the complex interplay of biomedical, emotional/cognitive, psychosexual and interpersonal factors in provoked vestibulodynia management. In addition, implications for practice and a detailed description of somatocognitive therapy for provoked vestibulodynia will be provided, to allow replication in clinical practice and in clinical trials.

Feasibility and acceptability of somatocognitive therapy in the management of women with provoked localized vestibulodynia-ProLoVe feasibility study.

BACKGROUND: Provoked vestibulodynia (PVD) is a prevalent chronic pain condition especially among young women. Pain is localized to the vulvar vestibule and is provoked by touch or pressure, such as penetrative intercourse. PVD can have profound consequences, adversely affecting a woman's sexual life, relation to her partner, and her psychological health. There is an urgent need for well-designed randomized clinical trials (RCTs) to identify the most effective interventions for this neglected women's health condition. AIMS: The primary aim of this study is to assess the feasibility of undertaking a full-scale RCT of somatocognitive therapy (SCT), a multimodal physiotherapy intervention, for women with PVD. The secondary aim is to evaluate the implementation and acceptability of SCT and its potential treatment effectiveness in PVD. In the full-scale RCT, SCT will be compared to standard PVD treatment. METHODS: A multimethod feasibility study with a single-arm before-after trial and qualitative interviews. Ten women with PVD, aged 18-33 were recruited from the Vulva Clinic at Oslo University Hospital. The intervention took place at Oslo Metropolitan University. Participants were assessed at baseline, post-treatment, and the 8-month follow-up with the tampon test and self-report questionnaires. The main feasibility outcomes were evaluation of recruitment rate, adherence to assessment tools, and follow-up rate. The participants' experiences with the primary outcome and the intervention were explored with semi-structured interviews. RESULTS: Ten out of 18 eligible patients were recruited over 11 weeks. None were lost to follow-up. Adherence to self-report questionnaires was excellent. Adherence to tampon tests and to the reporting of treatments was good, whereas adherence to the 14-day diary was poor. No adverse events were reported. The tampon test was suboptimal as a primary outcome. SCT was found to be an acceptable treatment, based on Global Perceived Effect scores and the participants' experiences. CONCLUSION: The findings suggest that it is feasible to deliver a full-scale RCT of the SCT intervention for women with PVD. Some changes are suggested to optimize the protocol, such as increasing recruitment sites, change of primary outcome measures, and adding a booster session. TRIAL REGISTRATION: ClinicalTrials.gov NCT04208204 . Retrospectively registered on December 23, 2019.

Treating gynecological pain: key factors in promoting body awareness and movement in somatocognitive therapy (SCT). A case study of a physiotherapy student´s treatment approaches.

BACKGROUND: Longstanding gynecological pain affects large numbers of women in the Western world. Somatocognitive therapy (SCT), a hybrid of cognitive psychotherapy and physiotherapy, is an evidence-based approach that has been successfully applied in the treatment of women suffering from such disorders, for example chronic pelvic pain (CPP) and provoked vestibulodynia (PVD), both demanding pain conditions. The curriculum of Oslo Metropolitan University's Mensendieck physiotherapy bachelor's program includes SCT training for the management of PVD. PURPOSE: The purpose of this study is to describe and explore the content of a SCT session based on a body and mind approach as performed by a physiotherapy student at a student outpatient clinic. METHODS: A video-based case study of the student-patient encounter was undertaken midway through an SCT treatment course and subjected to content analysis. FINDINGS: Three categories illustrating the learning process of body awareness, associated with the three-phase SCT were identified: 1) demystifying genital and chronic pain; 2) concentration, and body and mind experiences; and 3) patience, persistence, and willingness to change. CONCLUSION: The observation of the somatocognitive therapy session illustrates the value of an empathic relationship with the patient, in order to encourage her to explore body sensations and become familiar with the vulvar area. The therapy engages the patient in understanding pain mechanisms, thus educating her to overcome the fear of pain.

Somatocognitive therapy of women with provoked vulvodynia: a pilot study.

BACKGROUND AND AIMS: Provoked vestibulodynia (PVD) is a common persistent pain state among women in the Western world, causing dyspareunia, psychological distress and challenges against fertility. Therapies aimed at relieving pain (physiotherapy) and psychological distress (psychotherapy) are often recommended, sometimes in multimodal combinations. We have previously developed somatocognitive therapy (SCT) as a multimodal intervention, administered by a physiotherapist, to a different group of patients with gynecological pain, i.e. chronic (unprovoked) pelvic pain (CPP, also referred to as low abdominal pain). In a randomized, controlled study this intervention was shown to reduce pain experience and improve motor function or body awareness. Here we present the results of a clinical follow-up pilot study with 30 women with PVD, applying SCT administered by third year bachelor students in physiotherapy. Main outcome was pain experience, secondary outcomes were psychological distress and motor functions of the patients. METHODS: Thirty women diagnosed with PVD were recruited from a tertiary university hospital clinic of gynecology, and included in the follow-up pilot study at an out-patient physiotherapy clinic. Each patient participated in 10-14 therapy sessions over 6 weeks. The students were supervised by an experienced physiotherapist with extensive background in this clinical area, who also performed two clinical sessions with each of the patients at the end of the treatment period. Before therapy, the patients were evaluated for pain experience (visual analogue scale of pain, VAS), psychological distress (Tampa scale of kinesiophobia, TSK) and General Health Questionnaire (GHQ-30) as well as body function (standardized Mensendieck test, SMT). Statistical analyzes were performed by using the average ± standard deviation, statistical significance of changes calculated by means of the t-test. RESULTS: Average pain score before therapy were 7.77 ± 1.98, after 6 weeks of intervention 4.17 ± 2.07 and at 6 months' follow-up 1.66 ± 1.08 (average ± standard deviation), changes being significant below p < 0.01 level. Secondary outcome variables assessing psychological distress and sub optimal motor patterns were also significantly improved. For example, anxiety and depression scores were reduced by approximately 40%, and respiration pattern score improved by almost 80%. CONCLUSIONS: Multimodal somatocognitive therapy reduced levels of pain and psychological distress, and improved motor functions in women with PVD after 6 weeks of interventions. All variables were further improved at 6 months' follow-up. Thus, somatocognitive therapy may be a useful treatment option for patients with PVD. However, there are limitations to this study, since there was no control group, and suboptimal blinding during assessment of the data. IMPLICATIONS: Somatocognitive therapy may be a useful tool when treating PVD patients. More studies, in particular RCTs, should be performed to further evaluate this intervention and corroborate the results from this pilot study.

Pain, psychological distress and motor pattern in women with provoked vestibulodynia (PVD) - symptom characteristics and therapy suggestions.

BACKGROUND AND AIMS: Provoked vestibulodynia (PVD) represent a longstanding pain syndrome that affects large numbers of women worldwide. However, no standardized guidelines for PVD treatment exist. In a cross-sectional pilot study we examined 30 PVD patients on multidimensional parameters including pain, psychological distress and quality of movement, in order to obtain a broader understanding of the somatic and psychological symptoms in PVD, and for the future to develop better interventions. Additionally, we compare the findings to previously published results regarding the same parameters in women with chronic pelvic pain (CPP). METHODS: Thirty women with PVD recruited from a tertiary care university clinic of gynecology were assessed for demographic data, pain intensity (VAS), psychological distress (GHQ-30 and Tampa scale of Kinesophobia) and quality of movement (standardized Mensendieck test, SMT). RESULTS: Average age of the PVD women was 24.7±3.60 years, 60% of them were in permanent relationships, all were nulliparous, none had been subjected to surgical procedures, 100% were working full or part time and 90% were educated to at least undergraduate level. Mean VAS score was 7.77±1.97 (mean±SD), kinesiophobia 24.4±3.95 and anxiety domain of GHQ-30 9.73±4.06. SMT scores were particularly low for the domains of respiration and gait (less than 50% of optimal scores). CONCLUSIONS: PVD women display reduced quality of movement, especially for gait and respiration patterns, increased level of anxiety and high average pain scores. These findings are similar to what we have previously reported in CPP patients. However, in contrast to CPP group, PVD women are on average younger, have higher work participation, higher education level and have not been subjected to surgical procedures. IMPLICATIONS: Since PVD women display similar, although somewhat less severe, symptom profile than CPP, we suggest that a multidimensional approach to treatment, such as "somatocognitive therapy" should be investigated in this group as it has previously been shown to be promising in treatment of CPP.

Somatocognitive therapy in the management of chronic gynaecological pain. A review of the historical background and results of a current approach.

Historic background and development of our somatocognitive approach Mensendieck physiotherapy of the Oslo School is a tradition of physiotherapy founded by the American physician Bess Mensendieck, a contemporary and fellow student of Sigmund Freud at the Paris School of Neurology. It builds on the principles of functional anatomy and the theories of motor learning. We have further developed the theory and practice from this physiotherapy tradition, challenged by the enormous load of patients with longstanding, incapacitating pain on western health care systems, by seeking to incorporate inspirational ideas from body oriented dynamic psychotherapy and cognitive psychotherapy. We developed somatocognitive therapy as a hybrid of physiotherapy and cognitive psychotherapy by focusing on the present cognitive content of the mind of the patient, contrary to a focus on analysis of the subconscious and interpretation of dreams, and acknowledging the important role of the body in pain-eliciting defense mechanisms against mental stress and negative emotions. The core of this somatocognitive therapy (1) To promote awareness of own body, (2) graded task assignment related to the motor patterns utilized in daily activities, (3) combined with an empathic attitude built on dialogue and mutual understanding, and emotional containment and support. The goal is for the patient to develop coping strategies and mastery of own life. In addition, (4) manual release of tensed muscles and applied relaxation techniques are important. Methods and results of an illustrative study One area in particular need of development and research is sexual pain disorders. We have applied this somatocognitive therapy in a randomized, controlled intervention study of women with chronic pelvic pain (CPP).Wesummarize methods and results of this study. Methods 40 patients with CPP were included in a randomized, controlled intervention study. The patients were randomized into (1) a control group, receiving treatment as usual (Standard Gynecological Treatment, STGT) and (2) a group receiving STGT + Mensendieck Somatocognitive Therapy (MSCT). The patients were assessed by means of Visual Analogue Scale of Pain (VASP), Standardized Mensendieck Test (SMT) for analysis of motor patterns (posture, movement, gait, sitting posture and respiration), and General Health Questionnaire (GHQ-30) assessing psychological distress, at baseline (inclusion into study), after three months of out-patient therapy and at 1 year follow-up. RESULTS: The women averaged 31 years, pain duration 6.1 years, average number of previous surgical procedures 1.8 per women. In the STGT group, no significant change was found, neither in pain scores, motor patterns or psychological distress during the observation period. In the group receiving STGT + MSCT, significant reduction in pain score and improvement in motor function were found at the end of therapy, and the significant improvement continued through the follow-up (64% reduction of pain scores, and 80% increase in the average score for respiration, as an example of motor pattern improvement). GHQ scores were significantly improved for anxiety and coping (p < 0.01). Conclusions Somatocognitive therapy is anewapproach that appears to be very promising in the management of chronic gynecological pain. Short-term out-patient treatment significantly reduces pain scores and improves motor function. Implications Chronic pelvic pain in women is a major health care problem with no specific therapies and poor prognosis. A novel, somatocognitive approach has documented positive effects. It is now studied by other clinical researchers in order to reinforce its evidence base.

Recovering from provoked vestibulodynia: Experiences from encounters with somatocognitive therapy.

Although provoked vestibulodynia (PVD) represents a significant challenge for many young women in the Western world, little is known about how these women experience therapeutic efforts. The aim of this paper is to enhance our knowledge of the way that the therapeutic process is experienced by women with PVD undergoing somatocognitive therapy (SCT). The study enhances insight into this recently developed therapy through a detailed description of the physiotherapy approach. The empirical data are based on interviews with six women who participated in SCT. The empirical data analysis is guided by thematic analysis. Our findings demonstrate how the women experience SCT as a bodily process of wholeness. The process of wholeness relates to new experiences in the women's own bodies, awareness of muscular and mental tension and relaxation, breathing patterns, and perceptions focusing on pain. The findings are presented as three interrelated themes: 1) sensitizing the body as an interconnected unit; 2) incorporating the painful pubic region into the body; and 3) developing a new understanding of oneself. The women who participated in this study found that SCT contributed significantly to the process of their recovery from PVD.

Treating gynecological pain: the experiences of bachelor students in physiotherapy performing somatocognitive therapy.

BACKGROUND: Longstanding gynecological pain affects large numbers of women in the Western world. In recently published studies, we have found that a hybrid of physiotherapy and cognitive psychotherapy called somatocognitive therapy (SCT) ameliorates physical symptoms and psychological distress. In this paper, we report on the experiences of undergraduate physiotherapy students performing the therapy to patients with provoked vestibulodynia (PVD). AIM: The study aimed to investigate the nature of the collaborative interaction between female physiotherapy students and patients with PVD, focusing on critical factors for the students' learning of professional skills through SCT applied on patients suffering from an especially demanding pain condition. METHODS: In a qualitative study design, data were collected from two group interviews with four female students in pairs, and subjected to a thematic analysis. RESULTS: We found that students perceive the patient encounter as critical incidents in the sense of strong emotional encounters. From the data material, there emerged a four-step process ranging from distance to proximity, highlighting factors that influence the development of professional skills. The four steps are defined respectively as: (1) the students' prejudices; (2) identification and empathy; (3) senses of responsibility in the therapeutic relationship and (4) collaborative engagement for change. COMMENTS: Contrary to expectations, the students experienced the application of this combined approach (SCT) as an interesting and rewarding way of working with patients, and that they had achieved skills and a sufficient set of tools to cope with the challenges that patients with longstanding gynecological pain represent.