The effectiveness of a biopsychosocial approach
Chloe Serrao outlines the application of a biopsychosocial approach to manage a case of provoked vestibulodynia and primary onset dyspareunia.
Dyspareunia, pain with sexual intercourse, is a common female condition, with a rising incidence observed among younger women (Danielsson et al 2003).
Dyspareunia can be the result of a specific disease; however, in the absence of proven infection or pathology, it may be the result of chronic pelvic pain syndrome (CPPS) (Engeler et al 2018).
Vestibulodynia is one of the most common CPPS associated with young women, and is pain in the vulva without clear cause for at least three months’ duration (Bornstein et al 2016).
Specifically, provoked vestibulodynia (PVD) is pain localised to the vestibule or entry of the vagina provoked only by contact and/or attempted insertion/penetration (Bornstein et al 2016), and is a common cause of dyspareunia.
Pain is defined by the International Association for the Study of Pain as the ‘unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’ (Doggweiler et al 2017).
In consideration of this definition, both the sensory and emotional components of pain must be evaluated when assessing a patient.
Multiple factors have been suggested to predispose and contribute to persistent pain in the pelvis, including biomedical and psychosocial factors (Engeler et al 2018, Bornstein et al 2016). In CPPS, such as PVD, involvement and changes within the central nervous system (CNS), termed central sensitisation, may contribute to persisting pain in the absence of pathology (Engeler et al 2018, Doggweiler et al 2017, Woolf 2011).
A biopsychosocial approach integrates central pain mechanisms with the multidirectional relationships of biomedical and psychosocial factors contributing to a patient’s pain presentation.
Assessment seeks to identify all potential pain mediators through a thorough holistic assessment, including the psychological factors, beliefs and expectations of the patient (Nijs et al 2013, Vandyken & Hilton 2017, Stein et al 2019) considered to contribute to the production and persistence of pain (Linton & Shaw 2011).
Multimodal physiotherapy treatments are effective in the management of PVD and dyspareunia (Vandyken & Hilton 2017, Stein et al 2019, Morin et al 2017).
Physiotherapy combined with cognitive behavioural therapy was found effective in improving pain and sexual functioning in women with PVD (Goldfinger et al 2016).
This case study presents a biopsychosocial approach to the management of a complex PVD and dyspareunia case, typically seen in clinical practice, utilising the Pain and Movement Reasoning Model (Jones & O’Shaughnessy 2014) to guide appropriate management, in achieving her goal of pain-free intercourse.
A 21-year old nulliparous female, with a healthy body mass index, was referred by a gynaecologist for physiotherapy management of PVD and primary onset dyspareunia on a background of dysmenorrhoea. No abnormality was detected on mucosal swabs.
She described primary onset dysmenorrhoea (commenced at 15 years) to be fairly well managed with the oral contraceptive pill (OCP), currently experiencing only 1–2 days of abdominal wall cramping with menstruation.
The gynaecologist had advised commencement of continual OCP use. The client was referred for physiotherapy management of her primary concerns of PVD and dyspareunia:
- Dyspareunia: primary onset (three years ago), painful attempts of intercourse, currently abstaining due to pain. Previous attempts of penetration resulting in stingy/burning pain, rated pain intensity on visual analogue scale (VAS) 0–10 (Boonstraet al 2008) as 6/10 on penetration, up to 10/10 with coitus, with post-coital dysuria 5/10 for one day. No issues with sexual desire, arousal and ability to orgasm, engaging in outercourse without pain.
- PVD: pain provoked at the vestibule with attempted intercourse and PAP smear, unable to use tampons due to pain rated 8/10. No other provoking factors.
- Constipation: evacuates daily with type 1–4 (Bristol stool scale), 1–2 times per week difficulty initiating and straining associated with harder stool. Low fluid intake (1 litre), healthy diet.
- Bladder/voiding function: no issues.
The patient’s goals were to be able to have enjoyable pain-free intercourse, have vaginal examinations (VE) and use tampons without pain.
The client reported currently living with her parents and studying communications and working part-time. Her reported varying stress levels (4–8/10) were related to university, financial limitations, relationship issues with her boyfriend, and presenting health concerns.
She disclosed that her first relationship, and attempts of intercourse, involved an unsupportive partner and episodes of sexual abuse.
Although she expressed that her current boyfriend is fairly understanding of her dyspareunia, she feels it is a strain on the relationship and is fearful that being unable to have penetrative intercourse will cause the relationship to breakdown.
The client reported a longstanding history of anxiety, with previous psychologist input, and currently feels highly anxious and fearful of any attempts of sex or VE.
She occasionally walks for exercise, reports herself as ‘not a keen exerciser’, watches television for relaxation, and reports good sleep. There was no other significant background history.
The client believes that her pain and inability to have sex is related to her anxiety/stress, fear of pain and her history of sexual abuse.
She also believes her strict upbringing has contributed to negative thoughts and a sense of guilt related to sex. She expressed a belief that she would never be able to have pain-free sex.
The Central Sensitisation Index (CSI), Depression Anxiety Stress Scale (DASS)-21 and Pain Catastrophising Scale (PCS) were utilised due to their validated psychometric properties within pain populations (Sleijser-Koehorst et al 2019, Neblett et al 2016, Henry & Crawford 2005), and ease of clinical use, self-administered.
A VE was not possible initially due to anxiety, rated 5/5 (on a 0–5 point VAS) while positioned crook-lying (Rosenbaum 2011).
A clear hypothesis of PVD, with supporting objective evidence (Engeler et al 2018), was limited initially due to an inability to perform a complete VE and assess PFM function, peripheral sensitivity and vulva-vaginal mucosa.
PFM dysfunction was indicated by trans-abdominal real-time ultrasound (TARTUS), demonstrating reduced relaxation suggestive of increased tension/tone, a factor found to contribute to dyspareunia and PVD in previous literature (Bornstein et al 2016, Benoit-Piau et al 2018, Morin et al 2017).
TARTUS assessment was employed, despite its limitations (Doggweiler et al 2017), as the more direct measures of PFM function, VE or trans-perineal RTUS were not possible initially due to the clinical presentation.
Anxiety-evoking images have previously been demonstrated to increase PFM activity (Both et al 2012), and considering that this client has moderate anxiety identified via the DASS (Henry & Crawford 2005), such a mechanism could potentially be contributing to her PFM dysfunction.
PFM dysfunction could be an instigator for her presenting problems or a compounding factor in response to fear avoidance (Stein et al 2019, Leeuw et al 2007, Thomten & Linton 2013).
A VE to confirm the suspicion of PFM dysfunction and the hypothesis of PVD was not possible on initial assessment due to high fear and anxiety.
A complete VE assessment would involve visual and digital assessment of PFM function for signs of altered tension/tone, abnormal movement and altered tenderness (Doggweiler et al 2017), assessing peripheral nerve sensitivity (Stein et al 2019), including Q-tip sensitivity testing (Doggweiler et al 2017), and integrity of vulvar-vaginal mucosa.
There is potential for increased vestibular mucosa sensitivity associated with her early commencement of the OCP at 15 years (Bornstein et al 2016).
Visceral cross-talk could allow for pain amplification between the uterus, bowel and likely PFM dysfunction (Vandyken & Hilton 2017).
Musculoskeletal imbalances are a potential contributing factor (Bornstein et al 2016, Stein et al 2019) with the client displaying a subconscious protective bracing pattern at the abdominal wall and pelvis with abdominal wall muscle, gluteal and adductor resting tension, tenderness to palpation and inappropriate co-activation with attempted PFM contraction.
This protective bracing pattern could be subconscious in response to anxiety and fear (with attempted VE and sex) and dysmenorrhoea, furthermore potentially contributing to an increase in PFM dysfunction.
Studies have demonstrated heighted peripheral and central sensitisation mechanisms in women with dysmenorrhoea (Slater et al 2015) and with PVD (Pukall et al 202), potentially contributing to this client’s pain presentation, with increased central sensitivity identified by the CSI (Neblett et al 2016).
Significant psychosocial factors were identified by psychometric tools, reported patient history and beliefs, and high rating fear with attempted VE.
The presence of psychosocial factors, particularly catastrophisation and fear avoidance (Linton & Shaw 2011), as identified in this client, are considered important predictors of pain severity and disability in women with PVD (Desrochers et al 2010, Benoit-Piau et al 2018).
Sexual abuse has been associated with PVD and dyspareunia (Engeler et al 2018) with increased psychological distress and poorer sexual functioning in women who perceive a link between their history of abuse and their dyspareunia (Leclerc et al 2010), as expressed by this client.
Partner support is another potential mediator to her presentation, with research suggesting reduced partner support is associated with increased pain catastrophisation (Benoit-Piau et al 2018).
Psychosocial factors may be an instigator and/or a facilitator for her persistent pain (Jones & O’Shaughnessy 2014).
There is potential that her pain and beliefs surrounding sex are impacting her normal sexual function, further contributing to pain and psychological distress (Thomten & Linton 2013, Basson 2005).
The assessment findings through graduated exposure to VE confirmed the hypothesis of PVD, with allodynia and hyperaesthesia to light touch of the vestibule and vaginal entrance (Bornstein et al 2016, Doggweiler et al 2017), and the presence of PFM dysfunction, resting tension, pain on palpation and incomplete relaxation.
There is compelling evidence supporting pain education in reducing pain and catastrophisation and improving patient outcomes (Louw et al 2011).
This was repeatedly addressed, with varied delivery including pictures, examples and metaphors (Louw et al 2011) (including online education resources) given her pain severity and psychosocial factors.
Education regarding PFM, sexual function, and her misconceptions/ beliefs were also regularly addressed (Nijs et al 2013, Morin et al 2017).
Empathy and motivational interviewing skills were employed, which are considered critical in pain management (Vandyken & Hilton 2017).
The psychosocial context of the patient’s treatment, the placebo effect, including language and positive expectation of treatment, have been shown to induce CNS changes to assist with improved patient outcomes (Benedetti et al 2011).
Combined multidisciplinary input, including from the psychologist and gynaecologist, was paramount given her psychometric outcome measures (OCMs), and has been demonstrated to be effective for patients with PVD/dyspareunia (Vandyken & Hilton 2017, Goldfinger et al 2016) and recommended by clinical guidelines (Engeler et al 2018).
Regular communication with the multidisciplinary team ensured patient-centred care. A sexual therapist review was encouraged in light of her beliefs surrounding sex (Basson 2005); however, this was declined.
In line with the psychologist, strategies to calm the CNS and reduce psychosocial factors and tension were encouraged, including relaxation breathing and mindfulness (PFM visualisation relaxation CD), exercise (client enjoyed walking), pelvic stretches and yoga (also aimed to reduce external pelvic and PFM tension), stress management (gratitude diary) and body scanning for tension (Vandyken & Hilton 2017, Stein et al 2019, Goldfinger et al 2016).
Graduated exposure to achieve VE was employed using an anxiety rating scale 0–5 as a guide to progression (Rosenbaum 2011).
Throughout assessment and treatment, relaxation breathing and visualisation of PFM relaxation and positive associations were employed to reduce anxiety and ensure client control.
Physical and emotional presence was encouraged throughout this process to reduce the risk of patient disassociation (Rosenbaum 2011).
Multimodal treatment techniques were employed, including biofeedback, PFM down-training exercises, soft-tissue massage (STM) (of abdominal wall, hip musculature and PFM) and dilator therapy, which have been demonstrated to show benefit in the management of PVD and dyspareunia (Stein et al 2019, Morin et al 2017, Goldfinger et al 2016, Murina et al 2008).
Prolonged muscle tension can result in reduced blood flow, creating tension myalgia, allodynia and hyperaesthesia (Woolf 2011); therefore treatment techniques are aimed at achieving improved muscular, fascial, neural and visceral tissue movement to reduce sensitivity and pain (Stein et al 2019).
Discussion and reflection
The client attended 14 sessions over 12 months, with continuing attendance. She has achieved her goal of return to sex, although she reports tightness on penetration and is therefore continuing to attend to attain symptom-free sex.
Despite the tightness, she reports no sexual dysfunction with desire, arousal or orgasm.
Other goals included tampon use, which she has attempted once and described as tolerable with some tightness, but is irregular due to continual OCP.
Her goal of being able to tolerate a VE has been achieved repeatedly with both physiotherapist and gynaecologist, without anxiety and pain.
A biopsychosocial approach to management, utilising psychometric screening tools and the Pain and Movement Reasoning Model (Jones & O’Shaughnessy 2014), was effective in facilitating individualised management and, importantly, attainment of the client’s goals.
Utilisation of the CSI, DASS and PCS allowed identification of increased central sensitivity, catastrophisation and affective and cognitive factors in the presenting client, which facilitated the inclusion of treatment strategies specifically to target these psychosocial factors to achieve her goals.
This required re-assessment with these tools, at multiple intervals, to maintain a clear understanding of the peripheral and central pain mediators (Vandyken & Hilton 2017) in guiding ongoing management.
Pain education, positive expectation of treatment and highlighting contributing psychosocial factors were critical for this client, demonstrated by her psychometric OCMs (Nijs et al 2013, Louw et al 2011, Benedetti et al 2011).
Pain education has been demonstrated to be the most effective modality to improve pain levels (Louw et al 2011) and was addressed frequently and in varied format.
Multimodal physiotherapy interventions combined with targeted strategies to reduce psychosocial factors was aimed at creating a break in the fear avoidance cycle that had been encouraged over the last three years with painful attempts at tampon use and intercourse.
The graduated exposure strategy was employed to eliminate the fear and anxiety (fear avoidance) with attempted VE (Rosenbaum 2011), which has been demonstrated in previous research to contribute to PVD symptomology and pain intensity (Benoit-Piau et al 2018).
There is a lack of robust randomised controlled studies investigating physiotherapy interventions for the management of dyspareunia and PVD, particularly PFM STM and dilator therapy; however, the available studies demonstrate benefit in the use of these interventions based on an individualised assessment (Vandyken et al 2017, Stein et al 2019, Morin et al 2017, Rosenbuam 2011, Murina et al 2008).
Psychosocial factors, particularly stress and anxiety, impacted considerably to the client’s progress.
A management milestone was client recognition of the impact of stress and anxiety on her body, specifically sensitivity/pain and PFM tension.
This recognition resulted in a reduction of her fear/anxiety of pain, identifying that the pain was not dangerous and that she could change it with strategies such as relaxation breathing, which further encouraged her appreciation for prescribed home-based strategies aimed at calming the CNS.
Multidisciplinary input was crucial for this client’s success, namely psychological input.
Medical management remained unchanged; however, given her health-related anxiety, contact with multiple professionals confirming the same diagnosis and management was reassuring and likely contributed to her improved outcomes.
Ongoing management and supported independence (Vandyken & Hilton 2017) is crucial for this client given her potential for catastrophisation, and increased central sensitivity, CSI Part B positive (Neblett et al 2016).
The client has achieved penetrative intercourse, although is not yet symptom-free.
Ongoing education and support in trouble-shooting any potential relapses in dyspareunia/PVD and problem-solving their causes is highly important, due to her history of catastrophisation and fear and ongoing stress and anxiety identified by the DASS, to prevent a repeated cycle of fear avoidance (Leeuw et al 2007).
Limitations of this case study include consideration of additional psychometric tools, specially assessing coping and self- efficacy.
These psychosocial factors have also been shown to impact a patient’s prognosis with musculoskeletal pain (Sleijser-Koehorst et al 2019). While intervention techniques were aimed at improving these psychosocial factors, without a specific OCM, demonstrated improvements were not measured.
The client is continuing attendance and therefore the OCMs and results presented are not final.
This case study demonstrates the effectiveness of a biopsychosocial approach for the management of dyspareunia and PVD.
Success with this approach was anticipated, with previous literature demonstrating the impact of both biomedical and psychological factors on pain and PVD symptomology (Desrochers et al 2010, Benoit-Piay et al 2018, Morin et al 2017).
Targeted multimodal interventions, including graduated exposure, PFM STM and dilator therapy (Morin et al 2017, Goldfinger et al 2016, Rosenbaum 2011, Murina et al 2008), were successful in achieving the patient’s goal of pain-free intercourse.
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The client provided consent for the publication of her case. Email email@example.com for references.
Chloe Serrao, MACP, is a registrar undertaking Fellowship of the Australian College of Physiotherapists by Clinical Specialisation in the women’s, men’s and pelvic health discipline. An APA Continence and Women’s Health Physiotherapist, Chloe holds a Master of Clinical Physiotherapy (Curtin University 2014), practises at Body Logic Physiotherapy and lectures on the postgraduate Continence and Women’s Health physiotherapy course at Curtin University.
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