The role of psychosocial factors in the interprofessional management of women with chronic pelvic pain: A systematic review

SGRK: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing—original draft, Writing—review & editing. CK: Data curation, Formal analysis, Investigation, Visualization, Writing —original draft, Writing—review & editing. MR: Conceptualization, Data curation, Methodology, Writing—review & editing. CAB: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Writing—review & editing.

None.

Starting with 1604 records after the search, 654 were duplicate records and were removed, reducing the number of records to 950. These were then screened so that only 11 remained, with one record not retrieved and so excluded. Finally, 10 records were assessed for eligibility. For various reasons, five records were eliminated, 19 , 20 , 21 , 22 , 23 limiting the final number of records to be included to five. 24 , 25 , 26 , 27 , 28 Details of the literature search and selection process can be found in Figure  2 . PRISMA flow diagram showing search and selection process. Table  1 shows the characterization of the five included studies according to the McMaster Critical Review Form for Quantitative Studies. 17 The studies were published between 2015 and 2021. Three of them used a before and after study design. 24 , 27 , 28 One was a randomized controlled trial 25 and one was a non‐randomized controlled trial. 26 All five studies had valid and reliable outcomes, but not all of them addressed clinical relevance. One study did not describe the intervention in detail. 24 Dropouts were reported and conclusions and implications were appropriately drawn. Critical appraisal of included studies using the Critical Review Form—Quantitative Studies. Abbreviations: N/A, not applicable; not add., not addressed; NRCT, non‐randomized controlled trial; RCT, randomized controlled trial. All five studies were set in tertiary care centers. The number of participants ranged from 9 to 33 women. Mean age of participants was between 40.6 ± 11.7 (± standard deviation) and 50.6 ± 14.5 years and the mean pain duration was between 6.2 ± 4.8 and 12.4 ± 10.5 years. The interventions in the selected studies consisted of different interprofessional approaches including medication, psychotherapy, physiotherapy, and/or occupational therapy, applied as group and/or individual treatment. These programs lasted for 3–22 weeks, whereas the frequency in most programs was one intervention unit per week. Of those reporting the number of and reasons for dropouts, Aboussouan et al. 24 reported six women dropping out due to incompletion of the program, Brünahl et al. 26 reported six dropouts (no information about their sex), and Katz et al. 27 reported that four women dropped out, Table  2 gives an overview of the studies. Description of sample, intervention, and dropouts. N  = 58 42.8 (12.8) 12.4 (10.5) 50/13.8/36.2 Retrospective analysis with complete cases only; N  = 70 women entered program N  = 49 GET + MT n  = 17 42.3 (9.6) 9.1 (7.8) 43.8/37.5/18.8 MT n  = 16 40.7 (11.7) 9.6 (5.4) 56.3/18.8/25.0 CG n  = 17 42.4 (6.2) 7.3 (5.4) 70.6/29.4/0 GET + MT: 6 weeks, 45 min, 1/week GET +2/week MT MT: soft‐tissue mobilization, myofascial release, deep pressure massage, muscle energy techniques; physiotherapist GET: education, individual prioritization of tasks; occupational therapist MT: 6 weeks, 45 min, 2/week Soft‐tissue mobilization, myofascial release, deep pressure massage, muscle energy techniques; physiotherapist Total sample including female and male patients N  = 60; only female patients n  = 33 CBT + PT: subsequent modules each 9 weeks, 4‐week break between modules PT: three group sessions 90 min, six individual session 60 min, education, heat applications, manual techniques, active exercise, workbook; physiotherapist CBT: nine group sessions 90 min, education, group discussions, progressive muscle relaxation, workbook; psychologists CBT + PT: n  = 13 CG: n  = 1 CBT + PT: only females n  = 19 48.6 (14.8) a 6.2 (4.8) a 37.1/37.1/25.7 a CG: only females n  = 14 50.6 (14.5) a 6.2 (4.8) a 45.5/27.3/27.3 a N  = 37 40.6 (11.7) 9.2 (8.3) 55.6/30.6/13.9 Retrospective analysis with complete cases only; N  = 45 women entered program 7 weeks, 1 day/week, total of 40 h Medical, clinical psychology, PT, occupational therapy Abbreviations: CBT, cognitive behavioral therapy; CG, control group; GET, graded exposure therapy; MT, manual therapy; PT, physiotherapy; RCT, randomized controlled trial; SD, standard deviation. Values from total sample including women and men. To summarize the current knowledge on psychosocial factors, the results of the included studies were divided into the three groups pain, depressive symptoms, and pain catastrophizing, fear, and anxiety. Table  3 summarizes the primary outcomes. Psychosocial outcomes. Abbreviations: BDI‐II, Beck Depression Inventory‐II (range 0–13); BPI, Brief Pain Inventory (range 0–10); CBT, cognitive behavioral therapy; CG, control group; DASS, Depression, Anxiety, and Stress Scale (range 0–42); FABQ‐PA, Fear‐Avoidance Beliefs Questionnaire‐Physical Activity (range 0–24); GAD‐7, Generalized Anxiety Disorder Scale (range 0–21); GET, graded exposure therapy; MT, manual therapy; not sig., not significant; NRS, Numeric Rating Scale (range 0–11); PASS, Pain Anxiety Symptoms Scale (range 0–100); PCS, Pain Catastrophizing Scale (range 0–52); PHQ‐9, Patient Health Questionnaire (range 0–27); PT, physiotherapy; SD, standard deviation; SF‐MPQ, Short‐Form McGill Pain Questionnaire (range 0–45); TSK, Tampa Scale of Kinesiophobia (range 17–68). For all instruments: higher scores indicate greater severity. Values from total sample including women and men. Estimated mean (standard error), subsample including only women. Pain was measured in all five included studies, though the measurements focused on different aspects of pain, such as pain perception or pain severity. In three studies, pain severity was decreased after the intervention. 24 , 25 , 28 Aboussouan et al. 24 and Twiddy et al. 28 did not report statistical significance, but the changes in the intervention group combining graded exposure and manual therapy in the study from Ariza‐Mateos et al. 25 were significant. In contrast, the changes in the manual therapy and the booklet control group were not significant. 25 Pain distress, pain perception, and pain interference were evaluated in one study each. 25 , 26 , 28 The measured pain‐related factor levels decreased after the intervention with statistical significance being reported only in Ariza‐Mateos et al. 25 Similar to pain severity, the intervention group with the combination of graded exposure and manual therapy changed significantly in pain interference whereas the changes in the other two groups (manual therapy only and booklet control group) did not reach significance. Three of the included studies 24 , 26 , 28 measured the changes in the expression of depressive symptoms before and after the intervention. Two of the studies used a combination of medication, psychotherapy, physiotherapy, and occupational therapy, 24 , 28 whereas the other used a combination of psychotherapy and physiotherapy. 26 In all three studies, expression of depressive symptoms could be reduced in the intervention group. In the study from Brünahl et al., 26 the expression of depressive symptoms increased in the treatment as usual control group. However, none of the studies reported statistical significance. Pain catastrophizing was assessed in two studies resulting in decreased levels 26 , 27 with Katz et al. reporting statistically significant changes. 27 Four studies 25 , 26 , 27 , 28 included measurements for either pain‐related fear or anxiety or generalized anxiety. Statistical significance was only reported in the studies from Ariza‐Mateos et al. and Katz et al. 25 , 27 Generalized anxiety was reduced in both the intervention and the control group after the intervention compared with the baseline; nonetheless, group differences were not reported. 26 Pain‐related fear or anxiety could be reduced in three studies 25 , 27 , 28 comparing after treatment measures with baseline, with significant mean changes according to Katz et al. 27 Although both the combination of graded exposure with manual therapy and manual therapy alone resulted in significant changes in fear‐avoidance beliefs, the measurements in the booklet control group did not yield significant measurements. 25

This systematic review synthesizes the existing evidence of interprofessional management of women with CPP with the emphasis on psychosocial factors. A literature search was performed in six databases resulting in five included studies, two of them with a control group. The interprofessional programs applied in the studies were diverse in terms of involved professions and dosage. Not all studies analyzed statistical significance and/or clinical relevance of their observed changes, so the results must be treated with caution. Pain, pain catastrophizing, fear of pain, and fear‐avoidance beliefs could be significantly decreased. Depressive symptoms, generalized anxiety, pain perception, and pain related anxiety could also be decreased; however, significance was not reported. There is some evidence supporting the use of interprofessional multimodal approaches in women with CPP. Characteristics of pain, such as pain severity and pain interference, were measured in all five studies with a decrease after the intervention compared with before the intervention. However, only two studies had control groups allowing for discrimination of pain symptom alleviation due to the interprofessional intervention or due to the natural course of chronic pain. Many symptoms in chronic pain disorders are reduced or even diminished over time regardless of external influences. 29 Depressive symptoms, pain catastrophizing, fear, and anxiety could be reduced; nonetheless, similar to the pain characteristics measurements, control groups and reporting of statistical significance were missing. Pain‐related psychosocial factors and psychiatric comorbidities are frequent in women with CPP 30 , 31 and are emphasized as important in the development and maintenance of chronic pain disorders. 32 Hence, they need to be addressed in an effective interprofessional treatment strategy. 33 A further challenge in the evaluation of the influence of the interprofessional programs is the mutual influence of pain characteristics, depressive symptoms, fear, and other psychosocial factors. Targeting one factor has implications for the others 34 ; hence, changes in one factor cannot be interpreted without the others. In the studies reviewed, there was an outcome focus not only on depressive symptoms, catastrophizing cognitions, and fears, but also on pain sensation. There were positive changes in these factors, but no clear conclusions can be drawn. Interestingly, additional psychosocial factors such as quality of life, somatization and traumatic life experiences should be integrated more strongly into future research projects in order to investigate these important factors as well. 31 In contrast, the studies from Katz et al. 27 and Twiddy et al. 28 were not designed as trials focusing on the effect of the interprofessional program, rather they describe the implementation of the program and the first experiences with it. Hence, their reported results should be set in perspective. All five studies used different interprofessional treatment modalities with variety in the number of professions involved, content of the sessions, total number of sessions, their duration and frequency. However, the reporting of the specific programs in the studies is mainly superficial. Hence, the comparability of the different programs remains challenging, which was one of the reasons for refraining from a meta‐analysis. It is also challenging to replicate the program, underlining the need for more rigorous reporting of complex interventions like these interprofessional treatments. Furthermore, it should be mentioned that the studies were conducted in the tertiary care sector and therefore cannot be directly transferred to other sectors. Three of the studies 24 , 27 , 28 included only complete cases in their retrospective chart review. However, two of the studies reported the number of patients not included in the analysis and the reasons for their exclusion. 24 , 27 Out of eight and twelve women excluded from the analyses, respectively, four and six were excluded because of incompletion of the treatment. In the study from Brünahl et al., 26 one‐third of the patients allocated to the intervention group dropped out. Besides study‐related issues like not returning the outcome questionnaires, six patients dropped out because of absence in the therapy sessions. The programs in these studies consisted of either longer programs lasting several weeks with treatments once a week or shorter programs with treatments five times a week, which might be too stressful or too demanding for the patients with chronic pain. Brünahl et al. 26 reported that the satisfaction of the patients with the treatment was good, supporting—at least for this study—the assumption of the dropouts being the result of the administration mode of the intervention. Patients were more willing to participate in studies if the study could be integrated into their daily life. 35 Changing some of the on‐site sessions to online sessions might enhance adherence, especially in women, who are more likely to participate in online mental health interventions. 36 Although interprofessional management for women with CPP is advocated in several international guidelines 1 , 2 , 37 no comprehensive systematic review about non‐surgical, non‐pharmacological interprofessional treatment is available. Hence, adequate comparison of this review with existing literature is not possible. Looking at systematic reviews summarizing monoprofessional non‐surgical, non‐pharmacological treatment approaches, physiotherapy 38 , 39 , 40 and psychotherapy 15 , 41 seem to have some effects. Nonetheless, the results of the monoprofessional reviews do not allow for implications about interprofessional therapy. It is striking that CPP is a common chronic pain condition in women, 3 but that the systematic literature search in this review yielded only five relevant studies addressing interprofessional treatment and psychosocial factors. There is no easy explanation for this obvious disparity. Looking at the current literature on chronic pain disorders with similar research questions, for example, on chronic back pain, 42 it is interesting to find important results in a recent network meta‐analysis regarding interprofessional therapeutic effects on psychosocial factors like fear avoidance, but the number of studies was much larger with 97 included studies. 42 One explanation for this low number of studies could be the lack of a general definition of CPP, 1 , 2 which may complicate research work on this topic 43 and may lead to different and individual classifications of pain subgroups 44 that are difficult to find in a systematic literature search. Additionally, research data addressing the multifactorial etiology of CPP with a focus on psychosocial factors are rare. 31 Another point may be that interprofessional study designs are more complex to implement than monoprofessional studies. 45 Monocausal conclusions are often not possible, and the occurrence of comorbid mental illnesses, especially depressive symptoms, can lead to high rates of dropouts and delays in data collection. 46 Urgent action is needed to improve the scientific data situation, especially in relation to the stated outcome parameters as well as other psychosocial outcome parameters such as quality of life. If we look at the interprofessional treatments, we can see that in the five investigated studies a combination of psychotherapy, especially cognitive behavioral therapy, and physiotherapy is often used. This is not surprising, as this is not only recommended in guidelines on chronic pain, 47 but seems also a promising combination in the current literature for other chronic pain disorders, like chronic back pain. 42 , 48 Although there is some evidence in favor of this interprofessional treatment, it is not possible to make a clear recommendation for this combination or any other combination for women with CPP on the basis of the present work. Further research is urgently needed in this area as well. Some limitations of this review have to be mentioned. A meta‐analysis could not be performed because of the study designs of the available studies. The studies were summarized narratively and a conclusion was drawn with the available information. However, this limitation stresses the need for more research in this field whereby the interprofessional management applied in future studies needs to be clarified and described in detail. Interprofessional management was searched only with synonyms and terms related to interprofessional, not with specific search terms for the different specialties like physiotherapy or psychotherapy. This might be a limitation by missing out some studies. Nonetheless, the focus of this review was on interventions, which defined themselves as complex interventions consisting of several professions working together in order to create an entity rather than professions working past each other. Hence, it was assumed that they would coin themselves interprofessional or something closely related to this. Moreover, the mention of specific specialties might result in narrowing the results to these specialties, leaving out the ones not named. The pain condition of interest—CPP—was searched only with the search terms “chronic pelvic pain” and “CPP”; using additional related search terms might have resulted in the inclusion of other studies. Nonetheless, according to international guidelines, CPP should be used as the overarching term including all subdivisions and conditions of chronic pain perceived in structures related to the pelvis. 1 Moreover, specific subdivision terms should only be used with evidence supporting their use. 1 For these reasons, search terms were limited to CPP covering all subdivisions and conditions regardless of body structure or organ. However, although CPP includes both primary and secondary CPP, no distinction was made between them in the search strategy, which might also be of relevance for the detection of potentially relevant studies. On the other hand, the review possesses several strengths. First, it followed a rigorous and comprehensive search strategy in different databases with two independent researchers selecting and appraising the literature. In addition, the data extraction was also conducted by two persons independently from each other. Second, in order to present a comprehensive overview of the available external evidence, all quantitative primary research studies were included. Although the uncontrolled or non‐randomized studies may contain some uncertainty about direction and magnitude of observed effects, their inclusion is recommended to capture all aspects about a specific healthcare intervention. 49 Third, the review focuses on psychosocial factors as outcome factors instead of pain itself. Several studies have stressed the important role of psychosocial factors in the development and maintenance of CPP as contributors and consequences. 9 , 10 , 50 , 51

In this systematic literature review, interprofessional treatment methods for CPP in women with an outcome focus on psychosocial factors were analyzed. Interestingly, although interprofessional treatment strategies for women with CPP are recommended in existing guidelines, 1 , 2 , 37 the evidence in the current literature is scarce. In addition, the effect on psychosocial factors remains unclear. In summary, according to the current literature, it is not possible to name an appropriate interprofessional treatment method for clinical routine. More research is urgently needed determining the best practice interprofessional treatment option for women with CPP.

Chronic pelvic pain (CPP) in women is a multifaceted pain disorder, which has a minimum pain duration of 6 months and can affect different organ systems and pain regions in the pelvic area. 1 , 2 Prevalence rates for women in the general population are high, and range from 4% to 26.6%. 3 Because of the complex clinical appearance of CPP, it is not possible to give a general definition of this disorder. 1 , 2 Furthermore, etiological or maintaining aspects can be very different and can range from biological to psychological factors. 2 In the clinical routine, detailed diagnostic processes are particularly important and are reflected in the need for different and complementary medical specialties such as gynecology, urology, psychosomatics, and physiotherapy in order to identify possible explanations but also not to overlook rare diseases. 1 , 2 , 4 , 5 , 6 , 7 , 8 Besides somatic factors, psychosocial factors like anxiety or depressive symptoms can be involved in the development and maintenance of CPP. 2 Even mental illnesses such as somatoform disorder can play an important role. 8 Furthermore, psychosocial and biological factors may interact with or even mutually enhance each other. 9 , 10 Therefore, for several decades, attempts have been made to overcome mind/body dualism and to move towards a more integrated approach to CPP. 11 , 12 Unfortunately, research data addressing psychosocial factors in this field are still rare. 2 , 11 In 2010, the World Health Organization published the Framework for Action on Interprofessional Education & Collaborative Practice. 13 This shows the importance of collaboration between the health professions, for example, in mental health settings. 13 Against this background, it becomes clear that it is not sufficient to have only an interprofessional diagnostic approach. Interprofessionality is relevant for therapeutic concepts, 1 , 2 , 14 but research data addressing the therapeutic effects on psychosocial factors especially seem to be inconsistent or not comprehensively researched. 2 , 15 Therefore, the aim of this research work is to provide a systematic and structured overview of the science‐based interprofessional treatment options for CPP in women with the psychosocial outcome measures: pain, depressive symptoms, and anxiety symptoms (pain catastrophizing, fear, and anxiety). Interprofessionality was defined in the context of this review as the collaboration of at least two health professions.

The authors declare that they have no competing interests.

A systematic literature review was performed between January 2023 and June 2023. The review was registered in PROSPERO (CRD42023391008) and was performed in accordance with the PRISMA guidelines. 16 A comprehensive database search was performed by two independent researchers (SGRK and MR) in Medline (via PubMed), Web of Science, Cochrane Library, PEDro, CINAHL, and PsycINFO from inception to February 2023. The final search string was determined using preliminary searches with various search term combinations. Chronic pelvic pain and its abbreviation CPP were combined with synonyms for interprofessional therapies and terms for female patients whereas the search terms within each group were linked with the Boolean operator OR and between the groups with AND. The searchstring was applied across the databases with the exception of PEDro, where chronic pelvic pain and CPP, respectively, were only combined with synonyms for interprofessional therapies. No restrictions were applied during the database searches. Figure  1 illustrates for the search strategy and the search strings for the different databases, which are shown in the Supporting Information (Table  S1 ). Search terms and Boolean operators. Studies were eligible if they were quantitative primary research published in English. Chronic pelvic pain had to be defined according to or comparable with the guidelines of the European Association of Urology with pain being perceived in structures related to the pelvis. 1 The study population had to consist of female adult patients (age ≥18 years) or, in the case of female and male patients, at least allow for a separate analysis. The interprofessional intervention was operationalized as a multimodal intervention with at least two different professions applying the different treatment elements, which had to be considered as western medicine (conventional medicine as distinct from complementary or alternative forms of medicine). Studies with surgical approaches or eastern medicine (traditional Chinese medicine, eg acupuncture, herbology) as part of the interprofessional intervention were excluded. In addition, studies with interprofessional diagnostic procedures only but not with interprofessional treatment were excluded. Furthermore, single case studies were considered ineligible. The outcomes of the studies must include at least one of the psychosocial factors pain, depressive symptoms, pain catastrophizing, fear, or anxiety to be included. Pain with its characteristics was operationalized as psychosocial factors due to multidimensional experience of pain including affective‐motivational and social dimensions. 5 The outcome criteria were specified during the preliminary searches after registration in PROSPERO. Therefore, the outcomes of interest in the final review diverge from the entry in the register. Studies were selected using a two‐step approach. After removal of duplicates, two independent researchers (SGRK and MR) screened results according to titles and abstracts. Consensus was reached on which articles should be retrieved in full text. Articles were obtained using online accesses and library services. If the articles could not be obtained or specific information regarding eligibility was missing in the article, authors were contacted directly. The available full texts were then checked using the predefined eligibility criteria by two independent authors (SGRK and CK) and discussed until consensus was reached. In case of disagreement, a third researcher (CAB) was involved. The methodological quality of the included studies was assessed with the McMaster Critical Review Form for Quantitative Studies 17 following the respective guidelines. 18 This tool is applicable to different quantitative study types and covers the eight domains purpose, literature, design, sample, outcomes, intervention, results, and conclusions. Each item could be graded with “yes” or “no” and in some cases, the options “not addressed” or “not applicable” were available. The critical review form was not designed with a sum score; hence, no scores were assigned to the items. Two researchers (SGRK and CK) rated the studies; any discrepancies were discussed with a third researcher (CAB). Studies were not excluded based on their critical appraisal. Using a customized Microsoft Excel spreadsheet, the following data were extracted from the included studies by two independent researchers (SGRK and CK): date and place of study, study type, sample description (number of participants, mean age, mean pain duration, marital status), intervention description (type and dosage of treatment, participating profession), control description (if applicable), psychosocial outcome measures (name of assessment, baseline and post‐treatment values, significance), dropouts. Point estimates were harmonized across studies with one digit after the decimal point. Disagreement was resolved through involvement of a third researcher (CAB). Primary outcomes for the review were psychosocial factors measured with valid and reliable assessments. Due to the heterogeneity of the included studies, completing a meta‐analysis was not deemed appropriate. The heterogeneity refers, among others, to the various study types, the distinctions among the interprofessional approaches, and to the different outcome parameter and assessment techniques. Hence, a narrative synthesis of the extracted data was conducted. The results of the studies were grouped according to the psychosocial outcome measures pain, depressive symptoms, and pain catastrophizing, fear, and anxiety.

Table S1: Click here for additional data file.