{"paper_id":"8061b335-17dd-480f-8cb1-ce44db92a7da","body_text":"Submit Manuscript | http://medcraveonline.com\nAbbreviations: BBAT, Basic Body Awareness Therapy; \nCPP, Chronic Pelvic Pain; CNS, Central Nervous System; WHO, \nWorld Health Organization; ASOCOEN, Asociación Colombiana \nde Endometriosis e Infertilidad; BARS- MQE, Body Awareness \nRating Scale – Movement Quality And Experiences; BAS-I , Body \nAwareness Scale – Interview\nIntroduction\nEndometriosis is a disorder in which there is abnormal growth \nof endometrial tissue outside the uterine cavity, 1 causing a chronic \ninflammatory reaction that can lead to the formation of scar tissue \n(adhesions, fibrosis) within the pelvis and in other areas of the body. \nAs a result, intense pain can occur with or without menstruation \nand for long periods, along with fatigue, depression, and anxiety. 2 \nAccording to the World Health Organization (WHO), endometriosis is \na chronic disease that affects 10% of women and girls of reproductive \nage worldwide and is considered the most common cause of female \nchronic pelvic pain (CPP).\nAccording to Juan Diego Villegas and his team, chronic pelvic pain \nis defined as “pain present for more than 3 months, localized in the \nanatomical area of the pelvis, the anterior abdominal wall below the \nnavel, the perineum, the genital area, the lumbosacral region, or the \nhip.”3 Studies have shown that there is a vicious circle where chronic \npelvic pain produces psychological disorders (anxiety and depression) \nthat increase pelvic pain, and this increase, in turn, worsens the \nsymptoms of the psychological disorder. 4 Similarly, it is known that \nlevels of anxiety and depression are higher in patients with some \npathology associated with chronic pain,5 a recurrent predisposition in \npatients diagnosed with endometriosis.\nTo this day, there are various medical treatments for managing \nendometriosis; however, it often recurs, and pain management remains \na significant challenge as it is not always effective. Research has \nshown that these patients experience hypersensitivity in the central \nnervous system (CNS) due to the inflammation mechanisms triggered \nby endometriosis, causing normal bodily functions to be perceived \nas painful.6 Additionally, they may feel and interpret pains and other \nsensations more intensely in different parts of the body that are not \ndirectly related to the initial endometriosis. As a solution, patients \ndevelop compensatory and dysfunctional movement strategies that \nfurther exacerbate their discomfort.7 \nIn line with the above, women with endometriosis and chronic \npelvic pain experience consistent physical and mental exhaustion, 8 \nwhich is reflected in feelings of insecurity, frustration, lack of \nunderstanding, and social and occupational isolation. These effects \nhave repercussions on their quality of life and well-being and result in \nsocial, economic, and public health consequences. At the same time, \nit challenges women and their environments to navigate a chronic \nillness that can be highly disabling when not diagnosed early or \nInt J Complement Alt Med. 2024;17(2):50‒56. 50\n©2024 González-Barrera. This is an open access article distributed under the terms of the Creative Commons Attribution License, \nwhich permits unrestricted use, distribution, and build upon your work non-commercially.\nBasic Body Awareness Therapy in women with chronic \npelvic pain associated with endometriosis: case series\nVolume 17 Issue 2 - 2024\nPaula Andrea González-Barrera \nPhysiotherapy, Universidad del Rosario, School of Medicine and \nHealth Sciences, Colombia\nCorrespondence: Paula A González B, Bogota, Universidad del \nRosario, School of Medicine and Health Sciences, Colombia, T el \n+57 3212044171, Email \nReceived: February 16, 2024 | Published: March 08, 2024\nAbstract\nBackground and purpose: Endometriosis is one of the main causes of Chronic Pelvic Pain \n(CPP) in women. While conventional tools exist to address the disease, there is evidence \nof the need for psychotherapeutic and interdisciplinary approaches that comprehensively \ntreat and support patients, considering that their symptoms vary widely and affect not only \nphysical but also mental health. Therefore, the objective of this study is to evaluate the \neffectiveness of Basic Body Awareness Therapy (BBAT) in women with chronic pelvic pain \nassociated with endometriosis, aiming to provide them with a comprehensive approach to \ntheir symptoms based on body awareness, breathing, and balance.\nMaterials and methods: A descriptive study, a case series type, was conducted involving \n8 women diagnosed with endometriosis with a duration ranging from 4 to 10 years and \npelvic pain symptoms ranging from 2 to 5 years. The intervention consisted of twelve \nphysiotherapy sessions based on Basic Body Awareness Therapy (BBAT), with a frequency \nof two sessions per week and a duration of two hours each.\nResults: The obtained data included both qualitative and quantitative information, among \nwhich it stands out that the patients decreased their average score on the Body Awareness \nScale – Interview (BAS-I) by 70.69%. Additionally, all movements assessed with the Body \nAwareness Rating Scale – Movement Quality and Experiences (BARS-MQE) showed \nimprovements ranging from 6.0% to 13.21%. This demonstrates an increase in body and \nmovement awareness, particularly in the ability to identify and differentiate the location \nand type of pain, enhancements in physical capacity, reduction in feelings of fear, guilt, and \nanger, and symptom control related to depression and anxiety.\nConclusion: BBAT is a useful and safe tool that can be beneficial for patients with \nendometriosis and CPP. It is crucial that the methodology be adapted to the specific needs \nof the population and culture, and that treatments be longer in terms of time and cycles to \nachieve lasting gains.\nKeywords: Basic Body Awareness Therapy, chronic pelvic pain, endometriosis, pain \nmanagement, awareness, movement awareness, physiotherapy\nInternational Journal of Complementary & Alternative Medicine\nCase Series\n Open Access\n\n\nBasic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case \nseries\n51\nCopyright:\n©2024 González-Barrera\nCitation: González-Barrera PA. Basic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case series. Int J Complement \nAlt Med. 2024;17(2):50‒56. DOI: 10.15406/ijcam.2024.17.00683\nmanaged comprehensively.9\nWhile conventional tools exist to address the disease, it is evident \nthat psychotherapeutic and interdisciplinary approaches are needed \nto comprehensively treat and support patients. 10 Similarly, women \nneed to develop coping mechanisms and adaptation strategies that \npromote their physical, mental, and emotional well-being and allow \nthem to navigate the illness as effectively as possible.8 For this \nreason, it is necessary to provide them with comprehensive tools that \naddress all dimensions and enable them to be present in their bodies, \nunderstanding and responding to their own needs.\nThere are a variety of body awareness strategies that treat \nindividuals suffering from multiple health problems associated with \nlong-term musculoskeletal disorders, chronic pain, psychosomatic \ndisturbances, and mental health disorders. 11–13 From the field of \nphysiotherapy, focusing on movement as its object of study and \nits specialization in mental health, the Basic Body Awareness \nTherapy (BBAT) methodology emerges. BBAT guides patients to \nfind resources to maintain functional movement through their own \nbody awareness and quality movement, thereby promoting physical, \nmental, and relational processes affected in such pathologies. This \npremise underlies the development of this research.\nBasic Body Awareness Therapy (BBAT) was created by Nordic \nphysiotherapists in the mid-20th century. It is a therapeutic strategy \nthat aims to improve movement quality through balance, breathing, \nand awareness, with the goal of optimizing the relationship between \nthe body and mind.14 It is based on the loss of contact of the individual \nwith their physical body, physiological and mental processes, and \nthe external environment and its social relationships, 15 leading to a \ndistorted perception of reality. Sessions are conducted individually \nand in groups, and being a comprehensive strategy, it requires an \ninitial analysis of the current state and the specific needs of the patient \nand/or group.\nToday, BBAT has a wealth of scientific research supporting its \neffectiveness in various disorders and health conditions in European \ncountries.13,16– 20  In recent years, significant efforts have been made \nto expand its reach to other continents and countries worldwide, \nespecially in Latin America, where there has been a recurring need for \ncomprehensive methodologies that address the human being from a \nbodily perspective and serve as a useful tool in processes that, in many \ncases, have not made significant progress with other conventional \ntreatments.21\nMaterials and methods \nDescriptive study, case series type, involving 8 women diagnosed \nwith endometriosis and experiencing pain for more than 3 months. \nThe treatment was conducted by a physiotherapist trained in BBAT, \nand participants were informed about the requirements for the process \nand the necessary commitment from the outset. Emphasis was also \nplaced on daily practice and at-home exercises.\nIn the first and last sessions (individual sessions), the health status \nof each patient was assessed through the following tests:\n1. Body Awareness Rating Scale – Movement Quality and \nExperiences (BARS-MQE): A test composed of 12 movements \nthat allow evaluation of the patient’s movement quality in two \nparts. Each item provides quantitative and qualitative data.\na. Part 1. Quantitative: Movement is observed and evaluated. \nThe most healthy and functional movement is scored based on \nhow the movement is performed in relation to space, time, and \nenergy. It is scored on a scale from 1 to 7, where 1 is the most \npathological and disharmonious, 7 is the healthiest and most \nharmonious, and 4 is the midpoint of the scale where centering, \nbalance, breathing, and awareness exist.16, 22 Additionally, \nit provides a range from the biomechanical perspective \n(movement 1 to 3) to the physiological perspective (movement \n3 to 5) and from there to the psychological perspective.14\nb. Part 2. Qualitative: After completing the movement, the patient \nis invited to reflect on their movement awareness, asking them \n“How was this movement for you?” All responses are noted.22\n2. Body Awareness Scale – Interview (BAS-I):  Developed by \nphysiotherapist Gertrud Roxendal in 1997, it is a combination \nof items from the Comprehensive Psychopathological Rating \nScale (CPRS), created by Asberg,23 and bodily items included \nby Roxendal. It is a structured interview consisting of 20 items \ndivided into psychological, physiological, and bodily attitude \nsymptoms. Each item is rated on a scale of 4, where 0 indicates \nabsence of the symptom, and 3 represents the highest severity \nof the symptom.16, 24 A lower score in the post-evaluation \ncompared to the pre-evaluation indicates an improvement in \nthe individual’s body awareness and symptom management. \nThese tests yielded qualitative and quantitative data, allowing \nfor a comprehensive analysis of the changes perceived and not \nperceived by the patients, which will be presented and analyzed \nin the following section (Results).\nParticipants \nWomen affiliated with the Colombian Association of Endometriosis \nand Infertility (ASOCOEN) were recruited via email and social \nmedia. Inclusion criteria were: being of legal age, diagnosed with \nendometriosis, experiencing pelvic pain for more than 3 months, \nwilling to participate in a physiotherapy program in mental health, \nliving in Bogotá or its nearby surroundings, and being available on \nTuesdays and Saturdays from 10:00 am to 12:00 pm.\nWith the interested women who met the inclusion criteria, an \ninformative talk was conducted to explain the process. A total of ten \n(10) women enrolled, of which eight (8) decided to start the process \nand two (2) declined, leaving a total of 8 Colombian women aged \nbetween 36 and 46 years, diagnosed with endometriosis for 4 to 10 \nyears, and experiencing pain symptoms for 2 to 5 years. Additionally, \nit was observed that 4 out of the 8 women were diagnosed with anxiety \nand/or depression, and all reported pain in the pelvis and/or abdomen, \nlower back, and legs (Table 1).\nGroup therapy \nThe intervention consisted of ten (10) group BBAT sessions \nand two (2) individual sessions. In total, twelve (12) sessions were \nconducted between March and April 2023, with a frequency of two \nsessions per week and a duration of 120 minutes each.\nThe sessions were divided into three parts. In the first part, greetings \nwere exchanged, and reflections on the changes perceived after therapy \nwere discussed. In the second part, direct BBAT movements were \nperformed, including body scanning, stretching, spinal mobilizations, \nbreathing exercises, body-ground and chair relations, midline work, \ncentralization, weight transfer, and movement fluidity in supine, \nseated, and standing positions (Figure 1). Finally, feedback on the \nsessions was provided, along with some recommendations, and the \nsession concluded with a farewell.\n\nBasic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case \nseries\n52\nCopyright:\n©2024 González-Barrera\nCitation: González-Barrera PA. Basic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case series. Int J Complement \nAlt Med. 2024;17(2):50‒56. DOI: 10.15406/ijcam.2024.17.00683\nT able 1 Patient data\nPatient              Age Ocupation Diagnosis Pain? Where?\nPatient 1 44 Independent Endometriosis, myomatosis Yes Stomach, pelvis. \nPatient2                            46 Independent Endometriosis, anxiety Yes Stomach, buttocks, head. \nPatient 3 39 Biomedical Engineer Endometriosis Yes Pelvis, legs. \nPatient 4 37 Independent Endometriosis, myomatosis, anxiety, severe depression  Yes Plevic pain. \nPatient 5 43 Lawyer Endometriosis, anxiety Yes Stomach, pelvis, legs. \nPatient 6 44 Home – Housewife Endometriosis, anxiety, depression  Yes Stomach, pelvis, legs. \nPatient 7 36 Social worker Endometriosis, adenomyosis Sacroiliitis, lumbar disc disease Yes Throughout the body. \nPatient 8 36 Certified Public Accountant Deep endometriosis, diffuse adenomyosis, arterial hypertension. Yes Stomach, back, pelvis. \nFigure 1 Supine, seated, and standing positions.\nEthics \nWritten informed consent was obtained from each patient, \ninforming them of the purpose of the process, the tests to be performed \nin the first and last sessions, and the implications of participating in it. \nAdditionally, the use of anonymity through the noun “patient (x)” was \nexplained to them, with the aim of safeguarding and respecting their \nprocess and personal data. Similarly, a written informed consent for \nthe use of image and video rights for academic purposes was signed.\nResults\nThe sessions were structured so that each group member could \nparticipate individually in the movements while also sharing and \nreflecting with the other participants. Overall, all participants showed \nand perceived improvement in their body awareness, movement \nquality, and pain perception. This was evidenced both quantitatively \nand qualitatively in the tests applied and analyzed below: BAS-I and \nBARS-MQE.\nQuantitative results \nAfter completing the group sessions, all eight patients showed a \nsignificant decrease in their total score on the Body Awareness Scale \n– Interview (Figure 2), with an overall average of 70.69% and a range \nbetween 57.14% and 87.80%. Thus, relevant changes were observed \nin the three psychological, physiological, and bodily attitude items, \nparticularly in the following sub-items:\n• Psychological items: feelings of anxiety, concerns about trivial \nmatters, low mood, and difficulty with concentration.\n• Physiological items: hypochondriacal ideation, muscle tension, \naches and pains, and sleep disturbances.\n• Bodily attitude items: body description.\nSimilarly, changes were observed in the BARS-MQE scale \nconsidering the pre- and post-evaluation. In this case, changes were \nnoted in relation to participants’ body awareness in various postures, \nas well as their movement quality expressed as improved perception, \nsensitivity, and awareness of their own body and movement, alongside \nfree and rhythmic breathing, increased postural stability, and the ability \nto maintain an upright position and listen to the changes, signals, and \nlimits of their own body. Below is the group average per movement \n(Figure 3), where greater changes were evident in Movement M.1, \nwith an average of 13.21%, and lesser change in Movement M.7 with \n6.0%\nFigure 2 Pre- and post-intervention BAS-I results.\nFigure 3 Group average BARS per movement.\n\n\nBasic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case \nseries\n53\nCopyright:\n©2024 González-Barrera\nCitation: González-Barrera PA. Basic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case series. Int J Complement \nAlt Med. 2024;17(2):50‒56. DOI: 10.15406/ijcam.2024.17.00683\nQualitative results\nThe main qualitative findings obtained from the Body Awareness \nRating Scale – Movement Quality and Experiences (BARS-MQE) \nwill be presented through four categories: a) Physical perceptions, \nb) Characteristics of body awareness, c) Self-awareness, categories \ntaken from the research “Meeting current needs in mental health \nphysical therapy: a qualitative study of students’ experiences” by \nCristina Bravo and her team25; and d) Change in attitude towards \noneself, the environment, and pain, also with quotes alluding to the \nreflections expressed by the patients, representing each category.\nThe first three categories refer to the quality of movement \nexperiences perceived by the patients during the sessions, while the \nlast category describes changes in attitude towards themselves, their \nenvironment, and symptoms of pain. \n1. Physical perceptions:  alludes to the biomechanical and \nphysiological perspectives experienced in movement, including \npain, balance, bodily perceptions, coordination, elasticity, \ntrajectory, and movement form (spatial and temporal aspects of \nhuman movement).\na. Pain: “pain in the pelvis and abdomen” (patient 3), “I felt pain \nin the neck and lower back” (patient 4), “the pain lingers over \ntime”, “I feel a lot of pain all over my body” (patient 8), “pain \nin the ankles due to poor posture” (patient 6).\nb. Bodily perceptions:  “I felt that I released the jaw tension” \n(patient 1), “my belly is a balloon that expands” (patient 2), “I \nconnected with myself regarding present sensations” (patient 3), \n“the heart beats strongly and the breathing accelerates”, “I can \nfollow the midline throughout the movement”, “my intestine \nmoves” (patient 8), “when stretching in the star position I felt \nthat I illuminated the space more and the light that came out \nwas green”, “I feel anchored to the floor, the breathing flows \nwith me and my movements” (patient 5).\nc. Balance: “I felt that I don’t have the same balance walking to \nthe right side as to the left” (patient 5), “I have better balance \nmoving to the left side than the right” (patient 1), “I remember \nthat the first day I could hardly move because I felt very dizzy, \nand look today I can move without fear of falling and without \nfeeling that dizziness or vertigo that overwhelmed me” (patient \n5).\nd. Coordination: “coordinating the cross movement, left arm \nwith right leg and vice versa, is complex and even more so \nwhen the speed increases” (patient 3). “I have to concentrate a \nlot to achieve the movement I want and not get lost” (patient 8).\ne. Elasticity: “before, I felt a lot of stiffness in my hands, it was \nhard for me to open them, now I feel my arms loose and the \nmovement very fluid” (patient 1), “I feel more relaxed, calm, \nand like I grew haha” (patient 2), “I feel that the left arm \nstretches much more than the right” (patient 8).\nf. Trajectory and shape: “I perceive that every day I can stretch \nmore and more, and the tensions I felt before are decreasing” \n(patient 1), “I felt the movements more fluid and larger” \n(patient 5).\n2. Characteristics of body awareness: refers to the experience of \nbody awareness in relation to being present in the body, emotional \nfactors, and concentration.\na. Emotions in the body: “I felt that my body releases and rests” \n(patient 8), “I perceive many emotions in my chest, sometimes \nI feel like I’m suffocating, but I breathe and concentrate on \ndoing the exercises and they pass” (patient 5), “I perceive \nmany pleasant sensations when stretching completely” (patient \n2), “I am much more aware of the presence of emotions in my \nphysical body” (patient 4), “on a scale of 1 to 10, I came with \ndepression at 8 and I’m leaving with a 3, anxiety at 9 and now \nI’m at a 4” (patient 6).\nb. Embodied presence:  “I perceived parts of my body that I \ndidn’t before” (patient 4), “my feet are like a suction cup in \nrelation to the ground” (patient 2), “I felt a little overwhelmed \nwhen I realized that I wasn’t following the rhythm of the sound \n“M” from the other participants” (patient 4).\nc. Concentration: “I find it too difficult to concentrate when \nwe say the letter “M”, it’s like my sound doesn’t connect with \nthe group’s” (patient 4), “I find it hard to stop talking and \nexpressing” (patient 5), “I perceive that by concentrating on \nthe breath, the movement becomes more fluid” (patient 2).\n3. Self-awareness: refers to the awareness that patients have in \nrelation to the present person and unity in movement.\na. Consciousness: “I really wasn’t present in my body, I wasn’t \naware of how I move and the postures I carry every day, what \na relief to feel myself” (patient 8), “I am even more aware \nof taking care of my physical body, but also the mental one” \n(patient 6), “I felt how the breath accompanied the movement” \n(patient 7), “now I am aware of parts of the body that I had \nforgotten” (patient 3), “I was disconnected from the sensitive \npart of feeling my physical body, not from the emotion” \n(patient 7).\nb. Awareness of time:  “while I’m in therapy, time stops, it’s a \nspace for me outside of everyday life” (patient 6).\nc. Self-relationship: “many times I felt like I didn’t connect with \nthe world and even less with myself, today I feel like I’m me \nall the time... I feel different being in the same body” (patient \n5), “when I entered through that door and connected with what \nwas happening here in therapy, the world disappeared and time \nstopped” (patient 2), “it was very hard for me to leave home to \ncome here, I even doubted it, but once I took the step for my \nwell-being everything flowed” (patient 4), ... “I stopped being \na robot, I learned not to burden myself and to feel vulnerable” \n(patient 7).\n4. Attitude change towards oneself, the environment, and pain: \nrefers to the perceived changes in attitude towards themselves, \nthe environment in which they live, and their pain. This includes \nperspectives on their diagnosis and hope regarding it. \na. Attitude towards oneself:  “BBAT made me value my body \nmuch more today, to take care of it like the most sacred temple I \nhave” (patient 7), “today I thank myself for challenging myself \nto be here, to want to keep learning and improving my well-\nbeing, leaving home to come to therapy has been worth it, it’s \nnot a sacrifice” (patient 4), “it awakened a new ... patient 3 ... I \nhad silenced a lot before” (patient 3).\nb. Attitude towards their environment:  “Before starting \nthe process, I felt a lot of frustration because people didn’t \nunderstand the physical pain and discomfort I have to deal \nwith daily. Today, I understand that only I can feel it, and it \ndepends on me to set limits and take care of myself” (patient \n8). “I felt very insecure talking to people, and thanks to sharing \nand reflections with my peers, today I feel I can speak up and \n\nBasic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case \nseries\n54\nCopyright:\n©2024 González-Barrera\nCitation: González-Barrera PA. Basic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case series. Int J Complement \nAlt Med. 2024;17(2):50‒56. DOI: 10.15406/ijcam.2024.17.00683\ntrust more” (patient 1), “Empathy was key in my process, thank \nyou for helping me believe in myself, in my body, and in those \naround me” (patient 5), “These therapies have truly been an \nopportunity to meet people who feel like me, frustration and \nanger at society’s lack of understanding of our condition. \nEmpathy has made this a rewarding experience” (patient 2). \n“Without fear of success” (patient 3). “I understood that each \nof us feels differently but that we are much more united than a \ndiagnosis” (patient 3), “It helped me realize that I am not alone \nin this journey” (patient 6).\nc. Attitude towards pain:  “I have learned that pain is not a \nlimitation to do what I want. Thank you for reminding me of \nthe importance of moving consciously” (patient 1). “The pain \nhas increased so far, but I feel I can identify exactly where it \nhurts and manage it with this tool” (patient 4). “I wasn’t aware \nthat the stress of my job was affecting my pre-existing pain with \nthe diagnosis. Today, I know I have tools like breathing and \nmovement to manage it” (patient 8). “The pain has decreased a \nlot; now it’s only located in my abdomen” (patient 4). “When I \nam aware of my movements, the pain and discomfort decrease, \nand I am also able to release and let go” (patient 5), “I feel \nlike I broke barriers, lost fears by feeling my body through the \npain, I grew a lot by facing the pain, by feeling where it was \nspecifically and not generalized” (patient 7). \nThe qualitative and quantitative data refer to the success of \nthe therapy in the process with the patients, as they demonstrate \na significant improvement in the four dimensions: physical, \nphysiological, psychological, and existential/relational. Likewise, \nthey are reflected in the positive comments towards the therapy \nprocess and the relationship with their bodies and environment. At \nthe same time, there is a change in attitude towards the diagnosis and \nhow to face it through tools like BBAT, despite directly and indirectly \nassociating the methodology with other techniques such as yoga and \nChi Kung. \nDiscussion \nThrough the conducted study, the aim is to determine the \neffectiveness of BBAT in women experiencing chronic pelvic pain \nassociated with a diagnosis of endometriosis. The goal is to provide \nthese women with a physiotherapeutic strategy that addresses their \nsymptoms comprehensively and from their own resources. This is \ncrucial considering the vicious cycle wherein chronic pelvic pain \neventually leads to a psychological disorder that exacerbates the pain, \nfurther worsening the symptoms of the psychological disorder.4\nOne of the most relevant findings is the increased perception of \npain in relation to the ability to identify and differentiate the location \nand type of pain. This translates into an enhanced awareness of their \nbody and movement, as also concluded in the study “Pain requires \nprocessing - How the experience of pain is influenced by Basic Body \nAwareness Therapy in patients with long-term pain.” They expressed \nthat BBAT is useful for individuals to process their pain because \nthey confront it rather than ignore it. This is because they perform \nmovements without any imposed standards; instead, they execute \nthem as best as possible using their own resources salutogenesis.26, 27\nSimultaneously, other patients reported a decrease in pain in the \nsense that they perceived greater control over it, as well as a change in \nattitude and approach towards it. This finding aligns with a previous \nstudy in physiotherapy with women experiencing chronic pelvic \npain, where they expressed that “the pain itself is no longer the main \nproblem, but rather the behavioral consequences generated by the \npain.” 21 This indicates that managing symptoms related to central \nsensitization, which many patients experience, will yield better \nresults.3 Therefore, when these symptoms are identified and managed \nproperly, patients gain confidence in their bodies and seek strategies to \naddress their symptoms globally rather than separately. This may even \nimprove their body image through the postural model of the body, \nperceptions, attitudes, emotions, and relationships with their own \nbody and environment. 28\nThe participants expressed a heightened awareness of their bodies \nand what occurs around each position and conscious movement. \nThis improvement is reflected in their physical abilities, expressed \nbiomechanically and physiologically as enhanced elasticity, \nform, energy, and freedom of movement. They also experienced \nincreased balance, coordination, and endurance, as well as mental \ncapacities related to feelings of calmness, relaxation, or heaviness. 29 \nThis suggests that engaging in this practice for a short period, as \nCristina Bravo found in her study of BBAT with students, 16 enables \nindividuals to connect with their own bodies. However, achieving a \ncomplete learning process for quality movement requires many more \ninterventions over time because it is necessary to establish the ability \nto perform conscious movements voluntarily.30\nSimilarly, it was observed that symptoms related to depression \nand anxiety were managed as individuals became aware of them \nand recognized their own resources for handling them, such as free \nand conscious breathing. This technique, as James Nestor describes \nin his book “Breath: The New Science of a Lost Art,” 31“allows \nfor the expansion of the lungs, the development of the diaphragm, \noxygenating the body, penetrating the autonomic nervous system, \nstimulating the immune response, and readjusting the chemical \nreceptors in the brain”. This brings about significant changes in the \npsychological sphere, manifested in the intervention as pain and \nmuscle tension management, changes in perception of emotions and \nsensations within the body, enthusiasm for therapy, and an increase in \nhope and coping with the illness.32,33\nIn terms of the psychosocial and existential dimension, the patients \nreferred to empathy and group cohesion as the tools that allowed them \nto gain confidence in the therapy, their peers, and the process itself, \nindispensable variables for the development of other therapeutic \nfactors.34 These factors impact feelings of acceptance and respect \nfor each other’s process, mutual assistance, and support.  35 This led \nto a decrease in feelings of fear, guilt, and anger, and broke down \nfeelings of isolation, actions that, as Monica Mattsson and colleagues \nsuggest, 28 open the door to discussing hidden issues and experiences \nthat have physical and psychological impacts. Addressing these issues \ncontributes to the reduction of symptoms, including chronic pain and \nthose related to mental disorders.20\nSimilarly, the participants emphasized the importance of having \ntools like BBAT accessible to everyone. To achieve this, it is crucial \nto continue fostering comprehensive spaces and policies grounded in \nprevention and health promotion, 36 as well as timely diagnosis and \ntreatment that focus on a person-centered approach to well-being \nand a biopsychosocial model of care necessary for these chronic \nconditions.37 It’s not just about chronic pelvic pain, adhesions, and \nphysical discomfort, but also about the mental health problems and \ndisorders that develop and require accurate diagnosis and treatment. \nThis underscores the need for guarantees in respecting patients’ \nrights and their quality of life, as well as a broader and more complex \nconceptualization of the individual and their disorder.38\nIt is essential to emphasize the need to evaluate both the intrinsic \nand extrinsic factors of the target population in order to design \n\nBasic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case \nseries\n55\nCopyright:\n©2024 González-Barrera\nCitation: González-Barrera PA. Basic Body Awareness Therapy in women with chronic pelvic pain associated with endometriosis: case series. Int J Complement \nAlt Med. 2024;17(2):50‒56. DOI: 10.15406/ijcam.2024.17.00683\nviable and adaptable sessions that address current needs and those \nthat arise during the interventions. Similarly, recognizing the \nimportance of a co-therapist or the need to complement the treatments \nbeing carried out by the patients, for their well-being as guided \nby Sophia Vinogradov and Irvin D. Yalom in their Brief Group \nPsychotherapy Guide.34 Additionally, acknowledging the significance \nof multidisciplinary work is crucial. It may happen that during our \nsession, other situations come to light that require support from other \nareas outside our expertise but are important in the patient’s process, \nsuch as gynecology, psychology, psychiatry, social work, nutritionists, \namong others.39\nTherefore, after the experience with the patients, the \nimplementation of BBAT therapy, and the analysis of the quantitative \nand qualitative results obtained, it is clear that there will always be \nexternal factors that, in one way or another, as therapists, we cannot \ncontrol and directly or indirectly affect the process. For example, the \nlimited resources available to patients to undergo comprehensive, \nmultidisciplinary, and multimodal treatment,3 which are required on a \nlarge scale for these chronic diseases. Similarly, the inefficiency of the \nhealthcare system regarding guaranteeing the fulfillment of patients’ \nrights also plays a significant role.\nTherefore, the work of physiotherapists goes far beyond just an \nintervention, as processes like these speak to the need to continue \ncreating strategies that help women understand their illness and \naccompany them on their path of adaptation, acceptance, and \ntreatment.8 This opens the doors to a world of possibilities to address, \nwhere the current needs of patients serve as the basis for building \nnational and international projects and policies that respond to them. \nAdditionally, conducting research and initiatives to evaluate and \ngenerate integrative, innovative, and more efficient approaches is \ncrucial. \nA larger sample size is required to uncover more significant \nrelationships in the data. Additionally, a method or software for a more \nin-depth analysis of the qualitative and quantitative data is needed in \nterms of sensitivity, accuracy, and bias. Particularly, addressing biases \nrelated to qualitative data obtained through applied tests is crucial. \nResponses may lean towards general agreement or disagreement with \npeers rather than reflecting the individual’s own true and genuine \nopinion. This potential bias needs careful consideration, as it can \ndirectly impact the study results.\nConclusion\nThe results of the tests demonstrate changes in learning, body \nawareness, and movement quality of the patients, attributed to the \nrigorous work in each of the sessions, the monitoring and control of \nthe execution of each movement, the adaptation of the methodology \nto socio-cultural factors, and the specific needs of the patients. These \nfactors allowed for the enhancement of both individual and group \nprocesses of the patients, leading to successful outcomes. Thus, the \nmental health program focused on BBAT has had an impact on the \nlives of patients requiring physiotherapeutic support to improve their \nmovement quality through learning from their own experiences and \nbodily resources. However, it is crucial for the methodology to adapt \nto the specific needs of the population and culture.\nIt is considered necessary for treatments to be longer in terms of \nduration and cycles to achieve lasting gains. Specifically for these \npatients, working on body awareness may not reduce the adhesions \ncaused by endometriosis itself, but it does contribute to managing \nother symptoms associated with it, such as chronic pelvic pain and its \ndirect relationship with mental disorders. Moreover, it reinforces self-\nconfidence and eradicates fear of movement and feelings of isolation. \nSimilarly, it allows patients to better perceive and understand their \nbodies, a fundamental strategy for choosing better treatments and \ntools according to their individual needs.\nAcknowledgments \nI would like to express my gratitude to each of the participants in \nthe study and to the Continuing Education program, the International \nCertification in Basic Body Awareness Therapy (BBAT) from the \nEscuela Colombiana de Rehabilitación, especially to Instructor \nDaniel Catalán Matamoros for his guidance and support throughout \nthis process.\nConflicts of interest\nThe author reports no conflict of interest.\nFunding\nNone.\nReferences\n1. Wedel Herrera K. Chrinic pelvic pain. Revista Médica Sinergia . \n2018;3(5).\n2. Organización Mundial de la Salud. Endometriosis. \n3. Villegas Echeverri D, López Jaramillo JD, Herrera-Betancourt AL, \nLópez Isanoa JD. 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