Graded exposure and manual therapy in chronic pelvic pain
Chronic pelvic pain (CPP) is often a debilitating condition experienced by women of all ages. Like many chronic conditions, this can lead to significant fear avoidance behaviours which ultimately result in varying degrees of disability.
The women in this study were treated with graded exposure therapy in addition to manual therapy which resulted in significant improvements in their fear avoidance beliefs, pain and disability.
A total of 49 women with CPP for >6 months and kinesiophobia were recruited from a gynaecological service in Spain and were randomly allocated into one of three groups:
- Patient-centered graded exposure therapy (GET) added to manual therapy (6 sessions of GET + 12 sessions of manual therapy);
- Manual therapy (12 sessions);
- Control (received booklet about CPP).
Graded exposure therapy involved the participant identifying their five most fearful movements and re-introducing them to such movements in a graded manner over a six-week period. The manual therapy component included soft tissue mobilizations and myofascial release (20 mins), deep-pressure massage (10 mins) and muscle energy techniques (10 mins).
Prior to and after the intervention period, all participants were assessed with a variety of outcome measures focusing on:
- Fear avoidance beliefs;
- Pain interference with activities of daily living;
- Severity of pain;
- Level of disability.
The results indicate a significant improvement in all outcomes in the manual therapy with added GET group (within group difference) and compared to the other groups (between group difference) immediately following the intervention period and at three months follow-up. The manual therapy group demonstrated significant improvements in all outcomes except pain interference compared to the control group at three months follow-up.
Based on this study, manual therapy can lead to significant improvements for women with chronic pelvic pain however the addition of graded exposure therapy is likely to result in superior benefits.
Expert opinion by Ann Le
This study highlights the importance of being patient-centered when managing any patient, especially those with a chronic condition.
All patients in the graded exposure group were managed differently (as their fearful movements varied) which may be a critique of this study in terms of standardization of treatment, but it is more realistic of a real life clinical scenario and was still able to demonstrate significant benefits to the patients in the group.
A clearer description of the location and type of manual therapy techniques used in this study would have been beneficial for the reader.
> From: Ariza-Mateos et al., Arch Phys Med Rehabil 100 (2019) 9-16. All rights reserved to American Congress of Rehabilitation Medicine. Click here for the online summary.