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.

Psychiatric outcome after severe cardio-respiratory failure treated with extracorporeal membrane oxygenation: a case-series.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is increasingly used to save patients with severe cardiopulmonary failure at high risk of dying, but the long-term psychiatric outcome of the treatment has not been studied. METHODS: Twenty-eight adults who survived ECMO were subjected to psychiatric assessment 5 years after ECMO by means of interviews (MINI-Neuropsychiatric Interview and Montgomery-Åsberg Depression Rating Scale) and psychometrics [Neuroticism and social conformity (EPQ-N+L); General Health Questionnaire (GHQ), Hospital Anxiety Depression Scale; Aggression Questionnaire, Toronto Alexithymia Scale, and Giessener somatic symptom checklist (GBB)]. RESULTS: Fifteen patients (54%) suffered lifetime psychiatric disorders prior to ECMO. After ECMO, 11 subjects (39%) developed new psychiatric disorders, mostly organic mental (18%), obsessive-compulsive disorders (OCD) 15%, and/or post-traumatic stress disorders (PTSD) 11%. These 11 patients reported higher scores on Montgomery-Åsberg Depression Rating Scale (MADRS), GHQ, EPQ-N, and GBB. Disregarding the presence of psychiatric disorders at follow-up, ECMO patients reported high levels of distress, physical aggression, anger, and alexithymic traits. CONCLUSIONS: Severe life-threatening cardiovascular or pulmonary failure with subsequent ECMO is associated with an increased prevalence of long-term psychiatric disorders and distress. Studies addressing the etiology and prevalence of psychiatric consequences after ECMO are needed.

INSPIRE study: does stress management improve the course of inflammatory bowel disease and disease-specific quality of life in distressed patients with ulcerative colitis or Crohn's disease? A randomized controlled trial.

BACKGROUND: The use of stress management psychotherapy is hypothesized to produce greater improvement in disease course and disease-specific quality of life (IBDQ) compared to usual medical care alone in patients with ulcerative colitis (UC) or Crohn's disease (CD) showing high levels of stress (based on the Perceived Stress Questionnaire [PSQ]). METHODS: Fifty-eight patients with UC and 56 patients with CD who had experienced continuous disease activity or had relapsed over the previous 18 months, with an activity index for UC or CD ≥ 4, a PSQ ≥ 60, and without serious psychiatric disorders or other serious medical conditions were randomized to receive either treatment as usual (TAU) or TAU plus stress management psychotherapy. Psychotherapy consisted of three group sessions (psychoeducation, problem-solving, relaxation) and 6-9 individual sessions based on cognitive behavior therapy-related methods with 1-3 booster sessions at 6 and 12 months follow-up. Gastroenterologists blinded to intervention group assessed disease activity and course at baseline and at 3, 6, 12, and 18 months. Patients completed the IBDQ at baseline, 6, 12, and 18 months. RESULTS: The intervention did not improve disease or reduce relapse; however, it increased the IBDQ score (P = 0.009, mean differences 16.3 [SD 6.1]). On analysis of UC and CD separately, improvement of IBDQ was only found in the UC group. CONCLUSIONS: Stress management psychotherapy does not appear to improve disease course or reduce relapse in patients with IBD. It might improve quality of life, particularly in patients with UC.

Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy: results of a 1-year follow-up study.

OBJECTIVES: Chronic pelvic pain is a common source of disability among women in the western world. Here we report that 3 months of Mensendieck somatocognitive intervention in chronic pelvic pain patients was followed by continued improvements of outcomes at 1-year follow-up in a randomized, controlled study design. METHODS: Forty women with chronic pelvic pain unexplained by pelvic pathology were randomly assigned to 2 groups: (1) standard gynecologic treatment and (2) gynecologic treatment plus somatocognitive therapy aimed at reducing physical pain by changing posture, movement, and respiration patterns. A standardized Mensendieck test (SMT) of motor function (assessing posture, movement, gait, sitting posture, and respiration), a self-rating questionnaire assessing psychologic distress and general well-being (GHQ-30) and a visual analog score of pain (VAS) were obtained before, after 90 days of treatment and 1 year after inclusion. RESULTS: Patients treated by standard gynecologic treatment/supervision did not improve significantly at 1-year follow-up in any of the test modalities. By contrast, those who in addition received somatocognitive therapy had improved scores for all motor functions and pain, as well as GHQ-30 scores for coping, and anxiety-insomnia-distress. CONCLUSION: Mensendieck somatocognitive therapy combined with standard gynecologic care improves psychologic distress, pain experience, and motor functions of women with chronic pelvic pain better than gynecologic treatment alone. The effect lasted and even further improvement occurred 9 months after treatment.

The INSPIRE study: do personality traits predict general quality of life (Short form-36) in distressed patients with ulcerative colitis and Crohn's disease?

OBJECTIVE: To assess the role of personality as a predictor of Short form-36 (SF-36) in distressed patients (perceived stress questionnaire, PSQ) with ulcerative colitis (UC) and Crohn's disease (CD). MATERIAL AND METHODS: Fifty-four patients with CD and 55 with UC (age 18-60 years) who had relapsed in the previous 18 months, i.e. with an activity index (AI) for UC or CD> or =4, PSQ> or =60, and without severe mental or other major medical conditions, completed the Buss-Perry Aggression Questionnaire (BPA), the Neuroticism and Lie scales of the Eysenck Personality Questionnaire (EPQ-N and -L), the Multidimensional Health Locus of Control Scale (LOC) (Internal (I), Powerful Other (PO), Chance (C)), the Toronto Alexithymia Scale (TAS) and the SF-36. RESULTS: Multiple linear regression analyses controlling for gender, age and clinical disease activity (AI) in separate analyses for UC and CD showed that the mental and vitality subscales were predicted by neuroticism in both UC and CD. The highest explained variance was 43.8% on the "mental" subscale in UC. The social function subscale was related to alexithymia only in UC, while the role limitation and pain subscales were related to personality in CD only. The physical function subscale related differently to personality in UC and CD. CONCLUSIONS: While mental and vitality subscales were predicted by neuroticism in both UC and CD, other subscales had different relationships to personality, suggesting different psychobiological interactions in UC and CD.

The INSPIRE study: are different personality traits related to disease-specific quality of life (IBDQ) in distressed patients with ulcerative colitis and Crohn's disease?

BACKGROUND: To explore the relationship between personality and disease-specific quality of life [Inflammatory Bowel Disease Questionnaire (IBDQ)] in distressed [Perceived Stress Questionnaire (PSQ)] patients with ulcerative colitis (UC) and Crohn's disease (CD). METHODS: Included in the study were 56 patients with UC and 54 patients with CD ranging in age from 18 to 60 years with a relapse in the previous 18 months, a UC or CD activity index 4, a PSQ 60, and without serious mental or other serious medical condition. The patients completed the Buss-Perry Aggression Questionnaire, the Neuroticism and Lie (social conformity/desirability) scales of the Eysenck Personality Questionnaire, the Multidimensional Health Locus of Control (LOC) Scale [Internal (I), Powerful Other (PO), Chance (C)], the Toronto Alexithymia Scale, and the IBDQ. RESULTS: In linear regression controlling for sex, education (years), and clinical disease activity (AI) in separate analyses of UC and CD patients, higher IBDQ score was related to less social conformity in CD and less neuroticism in UC; higher emotional function score was related to less neuroticism in both CD and UC and less PO-LOC in UC. Higher social function score was related to less social conformity in CD and lower I-LOC and PO-LOC in UC. Bowel function and systemic symptoms were unrelated to personality in either UC or CD. CONCLUSIONS: Although the emotional function subscale was related to neuroticism in both UC and CD, the social function subscale and total IBDQ were related to different personality traits in UC and CD. Personality traits should be taken into account when using IBDQ in studies.

Posture, movement patterns, and body awareness in women with chronic pelvic pain.

OBJECTIVE: Chronic pelvic pain (CPP) is a common cause of infirmity but is still poorly understood. We studied the clinical characteristics, including body awareness, of 60 women with this diagnosis compared to those of healthy controls in an effort to understand its pathophysiology and to develop a more efficient treatment protocol. METHODS: After prior gynecologic and psychometric evaluation, the women were examined with the Standardized Mensendieck Test to evaluate posture and movement patterns. Pain history and pain score were obtained, and patterns of muscular density, elasticity, and tenderness were determined by palpation. The body awareness of patients was assessed through clinical evaluation. RESULTS: Seventy percent of the patients had a history of trauma or infection of the genitourinary region. The average pain score (+/-S.D.) on a scale from 0 to 10 was 6.01+/-1.60. Nearly all patients had a dissociative pattern, with a lack of contact and control of large body regions. All scores for posture and movement patterns were significantly worse in patients than in healthy women. CONCLUSION: A specific pattern of pain, posture, movement, muscle pathology, and reduced awareness of one's own body was found in women with CPP. These findings may increase our understanding of, and may point toward new treatment strategies for, this disease.

Reliability and validity of a standardized Mensendieck physiotherapy test (SMT).

A standardized test was developed to evaluate posture, movement, gait, sitting posture, and respiration of patients with psychosomatic disorders, based on the Mensendieck principles of observation and analysis of motor function. To validate the test and to make a comprehensive body examination of a defined group of patients, it was applied in a study of women with chronic pelvic pain (CPP, ICD10 F45.4). Fifteen women with CPP and 15 matched, healthy controls were examined. Test subjects were video recorded and scored by three experienced Mensendieck physical therapists, blinded with respect to the selection of subjects. Scores from 0 (for least functional movement) to 7 (optimal function) were assigned to each test person according to a test manual. High intraclass correlations (ICC1.1 [corrected] ranging from 0.82 to 0.97) were found among the testers. The standardized Mensendieck test (SMT) discriminated well between women with CPP and the controls (sensitivity 0.9, specificity 0.7, mean values). The CPP patients scored significantly lower than the controls in all subtests (p < 0.01). The largest difference in scores were found for gait (patients 2.70 +/- 0.11, vs. control, 5.60 +/- 0.09) and respiration (patients 2.88 +/- 0.14, vs. control, 5.63 +/- 0.10). The results indicate that, in the hands of experienced Mensendieck therapists, the SMT is a reliable tool, demonstrating a good discriminative validity. Furthermore, it may turn out to be a useful instrument in the evaluation of patients with somatoform disorders. It may also point toward a possible therapeutic treatment approach to patients with CPP.

Mensendieck somatocognitive therapy as treatment approach to chronic pelvic pain: results of a randomized controlled intervention study.

OBJECTIVE: The etiology of chronic pelvic pain is disputed and multifactorial. We studied the effect of Mensendieck somatocognitive therapy aimed at reducing physical pain by changing posture, movement and respiration patterns combined with standard gynecological treatment. STUDY DESIGN: Women with chronic pelvic pain unexplained by pelvic pathology were randomized into 2 groups: (1) standard gynecological treatment and (2) gynecological treatment plus somatocognitive therapy. A Mensendieck test of motor function (posture, movement, gait, sitting posture, respiration) and a visual analogue score of pain were obtained before and after the 90-day treatment period. RESULTS: The test results of patients treated by standard gynecological measures were unchanged (nonsignificant). By contrast, the patients receiving somatocognitive therapy in addition improved scores by 25% to 60% for all motor functions (P < .01, largest improvement for respiration, up from average 2.98 [SEM 0.30] to 4.72 [0.37]), and pain scores reduced by 50% (down from 5.60 [0.40] to 2.89 [0.40], P < .01). CONCLUSION: Mensendieck somatocognitive therapy combined with standard gynecological care improved pain experience and motor functions of women with chronic pelvic pain better than gynecological treatment alone.

[Chronic pelvic pain in women]. / Kroniske bekkensmerter hos kvinner.

BACKGROUND: This paper reviews empirical and clinical evidence of the aetiology and treatment of medically unexplained chronic pelvic pain in women. MATERIAL AND METHODS: Clinical experience from an ongoing randomised treatment trial supplemented by computer-assisted reviews of studies obtained by a Premedline and Medline search (1996 to February 2002) and data from the Cochrane Database of Systematic Reviews and the EBM database of Abstracts of Reviews of Effectiveness. RESULTS: The aetiology of medically unexplained chronic pelvic pain is disputed but likely to be multifactorial. A history of interpersonal difficulties and a stressful life is common, and comorbid psychiatric disorders occur frequently. No treatment of choice emerges from the few controlled treatment trials, though a flexible biopsychosocial approach seems the most promising. INTERPRETATION: Empathic medical evaluation and follow-up within a biopsychosocial framework is recommended. Analgesic, hormonal and, if appropriate, surgical treatment can relieve pain. Additional benefits may be obtained by adding sensory awareness-directed physiotherapy aimed at changing painful muscle tensions, body attitude, movement pattern and dysfunctional respiration pattern. Co-morbid psychiatric disorders should be diagnosed and treated. Cognitive-behavioural stress management intervention aimed at improving coping with pain and current life-situation may be indicated in a subsample of patients.