Exploring the Immediate Effects of an Online Self-Regulation Intervention on Pain, Affect, and Arousal in Women with Endometriosis: An Observational Study Protocol

Exploring the Immediate Effects of an Online Self-Regulation Intervention on Pain, Affect, and Arousal in Women with Endometriosis: An Observational Study Protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Exploring the Immediate Effects of an Online Self-Regulation Intervention on Pain, Affect, and Arousal in Women with Endometriosis: An Observational Study Protocol Marcelo de França Moreira, Marco Aurelio Pinho Oliveira This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5969427/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Endometriosis is a chronic condition that affects millions of women worldwide, causing significant pain, emotional distress, and impaired quality of life. Despite advances in biomedical treatments, many patients continue to experience persistent symptoms due to the complex interplay between biopsychosocial factors, shaped by the lived experience of endometriosis and further exacerbated by socioeconomic adversities common in middle- and low-income countries. Self-regulation, the ability to modulate physiological and psychological responses, addresses core mechanisms underlying emotional challenges and pain, potentially benefiting interconnected difficulties. This study aims to evaluate the immediate effects of an online self-regulation intervention that integrates smooth whole-body movements, postural stillness, and deep breathing, explicitly guiding participants to train adaptive psychological attitudes such as present-centered awareness, nonreactivity, and acceptance through body exercises. Methods This observational study employs a within-subject, repeated-measures design to assess pre-to-post-session changes in pain intensity, affect, and arousal in women with symptomatic endometriosis. Assessments include self-reported measures of pain, affective states, and psychological attitudes before and after each session. Statistical analyses will use weighted fixed-effects regression models to estimate immediate changes, adjusting for session and clinical predictors. Mixed-effects models will explore individual variability, accounting for repeated measures within participants. Mediation analysis will examine whether nonreactivity and acceptance explain intervention effects on pain and affective outcomes. Additionally, qualitative analysis will be conducted using thematic content analysis of self-reflexive reports to capture participants' spontaneous narratives regarding their engagement with the intervention and its perceived impact beyond predefined quantitative outcomes. Data collection began in August 2024 at the Endometriosis Outpatient Clinic of Pedro Ernesto University Hospital. Discussion By investigating the acute effects of a structured online self-regulation intervention, this study aims to provide insights into non-pharmacological strategies for managing endometriosis-related pain and emotional distress. Understanding the short-term impact of the intervention will help refine its delivery and inform future research on long-term effects. Given the limited accessibility of specialized pain management resources, particularly in low- and middle-income settings, this study may contribute to the development of scalable, low-cost therapeutic approaches. Figures Figure 1 Figure 2 Introduction Endometriosis is a chronic condition characterized by the presence of endometrial-like tissue outside the uterus, often resulting in pain, urinary and bowel symptoms, infertility, and significant impairments across multiple domains of quality of life for millions of women worldwide [ 1 ]. Despite considerable advances in understanding the pathophysiology of endometriosis, effectively managing its associated chronic pain and restoring well-being remain significant challenges [ 2 ]. These difficulties are partly due to the complex interaction between the condition's pathophysiological aspects and the unique psychosocial context that often accompanies it [ 3 – 5 ]. Women with endometriosis often endure prolonged uncertainty about the origins of their symptoms, the unpredictable nature of pain flares, and concerns about lesion recurrence, all of which can contribute to heightened anxiety, fear, and catastrophic thinking [ 6 , 7 ]. Additionally, the social stigma surrounding the condition and the frequent dismissal of symptoms—both in medical settings and personal relationships—exacerbate feelings of isolation and helplessness. These challenges are compounded by societal expectations related to femininity, motherhood, and marital roles, which can further erode social support and emotional well-being [ 2 , 8 ]. In low- and middle-income countries, these challenges are further intensified by overlapping vulnerabilities, including low income, limited health literacy, exposure to violence, long distances from treatment centers, and underfunded public health systems [ 9 – 11 ]. These factors not only restrict access to care but also amplify the biopsychosocial burden. In this context, maladaptive psychological coping and biological alterations often emerge, perpetuating a cycle of pain, stress, negative affect, and poorer functioning of key biological systems (e.g., autonomic-related immune-inflammatory functions) [ 5 , 12 – 15 ]. Contemporary therapeutic strategies for chronic pain emphasize addressing the unique mosaic of elements that contribute to each patient’s multidimensional perception of threat, treating patients individually to target the inferred specific contributors to their pain [ 16 ]. However, implementing this strategy can be problematic and have limitations, particularly in the abovementioned contexts. Providing personalized care and associated individualized treatments requires a substantial number of specialized healthcare professionals [ 17 ], a demand that can overwhelm public healthcare systems serving large patient populations [ 18 ]. Furthermore, for patients facing multiple interconnected factors—such as endometriosis symptoms combined with comorbidities, co-occurring pain conditions, and additional social sources of adversity—addressing each contributor through a combination of therapies may be both impractical and inaccessible. These challenges are particularly pronounced in the context of endometriosis, where clinicians face a scarcity of evidence-based therapeutic options to guide the development of effective treatment strategies [ 19 ]. Standard therapies, such as hormonal treatments and surgery, often offer limited efficacy [ 20 , 21 ] and fail to address the broad underlying biological processes and psychosocial factors that affect overall well-being [ 3 , 22 ]. The dominance of a biomedical view of pain in gynecology frequently results in an overreliance on pharmacological interventions, particularly opioids and surgical procedures [ 23 , 24 ]. These strategies carry considerable risks, including surgical complications, opioid overprescription, and severe adverse outcomes from the combined use of opioids and benzodiazepines [ 24 ]. An alternative approach to addressing this complex scenario involves targeting fundamental mechanisms that shape illness experience, life adversities, and well-being, such as self-regulation [ 25 ]. Self-regulation refers to the cognitive and physiological capacity to modulate behaviors, thoughts, and emotions to achieve adaptive states [ 26 ]. This approach aligns with transdiagnostic principles, addressing core mechanisms underlying emotional challenge and pain, potentially benefiting interconnected difficulties [ 27 ]. Focusing on shared pathways rather than isolated symptoms offers a sustainable framework for accessible, group-based interventions independent of the specific factors contributing to an individual’s pain. Self-regulation can be enhanced by promoting adaptive physiological and psychological changes, which can be facilitated through an integrative strategy, where these changes mutually reinforce one another [ 28 ]. On a physiological level, practices involving movement performed with specific skills, postural control, and breath regulation can promote a healthier state [ 29 – 32 ]. For instance, combining deep breathing with postural stillness and controlled, low-effort movement interposes maladaptive physical responses such as shallow breathing, muscle tension, movement avoidance, and restlessness [ 33 – 35 ]. Additionally, the diverse sensations elicited from posture, movement, and breath work offer a basis for training adaptive psychological attitudes like acceptance, nonreactivity, and attentional flexibility, contributing to improved coping strategies [ 36 – 38 ]. Based on this theoretical foundation, an online structured group-based intervention was developed and implemented as part of the multidisciplinary management of chronic pain in women with endometriosis at an Endometriosis Outpatient Clinic. The intervention integrates these physiological and psychological components into guided exercises, combining body posture, movement practices, breathwork, and mindfulness attitudes. This observational study aims to investigate the immediate effects of the intervention on pain, affect, and arousal. We hypothesize that most participants will experience immediate improvements in pain, affect, and arousal following each session. However, those with high baseline levels of anxiety, depression, or pain hypersensitivity (e.g., consistently reporting pain during gentle movements) may show more variable responses, including perceived symptom exacerbation during the initial sessions. This variability is expected given the sessions' emphasis on bodily sensations, combined with challenges in adapting to discomfort among individuals with heightened pain sensitivity and significant mental health difficulties. Understanding these possibilities is essential for refining future interventions, allowing for tailored strategies that enhance adaptability, minimize distress, and optimize therapeutic outcomes. Additionally, it is anticipated that the development of nonreactivity and acceptance will mediate some of the positive effects observed after each session. Method A within-subject repeated-measures observational design will be employed to examine the acute effects of each intervention session. This approach enables the assessment of symptom fluctuations in real-world conditions, capturing periods of intensified pain, distress, or negative affect—when self-regulation is most essential. Given the diverse therapeutic routines each woman undergoes as part of multidisciplinary care, assessing long-term trends or making between-subject comparisons is not feasible in this context. Instead, aligning with the study's focus on acute effects, each pre-post session dataset will be analyzed independently. The intervention became an integral part of the multidisciplinary care at the Endometriosis Outpatient Clinic of Pedro Ernesto University Hospital in June 2024, with data collection for the processes outlined in this observational study commencing as part of routine clinical care in August 2024. This study was conducted in accordance with the Declaration of Helsinki and approved by the Committee on Human Research at Rio de Janeiro State University (UERJ, Pedro Ernesto University Hospital, approval number 3.725.458). The requirement for written informed consent was waived by the Committee following ethical review and approval, as the study is observational, involves minimal risk, and all procedures and data collection were conducted as part of routine clinical care. Initially, some instruments—such as the Five Facets of Mindfulness Questionnaire, the Multidimensional Psychological Flexibility Inventory, and the Affect and Arousal Scales—were part of the clinical evaluation protocol but were not included in the original research protocol. As of January 27, 2025, these instruments are under review by the Committee on Human Research at Rio de Janeiro State University, pending formal approval for their incorporation into the research scope. Women are advised to participate in the online intervention for two months, attending the online training once a week; however, there are no restrictions on longer participation. Session attendance is recorded by registering participants in the video call. However, as this phase focused on understanding acute effects, absences and gaps between attended sessions were not considered. To ensure participants are adequately prepared to engage with the intervention, an initial onsite assessment with the intervention instructor is conducted. During this session, participants receive a brief educational overview of the multidimensional aspects of chronic pain and detailed instructions about the intervention’s purpose and structure. They are also informed that the assessments serve both to enhance management strategies and for research purposes, with assurances that their anonymity will be maintained throughout the process. This 45-minute to 1-hour session also provides guidance on organizing their environment for the sessions and managing the online format, including communication logistics such as joining a WhatsApp group and accessing the sessions. Patients are advised to adjust their medication schedule, ensuring that analgesics are not taken within 30 minutes before the sessions, considering the typical onset time for most analgesics. This recommendation is explained as a way to encourage participants to engage with the session exercises, allowing them to address their symptoms fluctuation in real-time. It is emphasized that this approach applies only during the session and aims to facilitate the development of alternative strategies for managing pain. Women are, however, encouraged to continue following the pharmacological treatment prescribed by their physicians and to make any adjustments in accordance with the physician-recommended plan as part of their comprehensive pain management strategy. Baseline variables are being collected by the gynecologist and other clinical staff during the first medical appointment. During each session, participants are invited to complete immediate pre- and post-session assessments using electronic forms sent through a designated WhatsApp chat. Managed by a clinical staff, this chat is separate from the one used by the instructor for video call sessions, providing a specific channel to address any issues or questions related to form submission and data collection. Instruments and Measures Baseline Measures The baseline assessment includes sociodemographic and lifestyle variables, anxiety and depression levels, different types of endometriosis-related pain, fertility status, and previous standard treatments. These baseline measures are being collected as part of the clinic’s standard multidisciplinary assessment during the first patient appointment and recorded in the REDCap platform. Sociodemographic Variables Information on ethnicity, age, education, marital status, comorbidities, number of surgeries, duration of pain, infertility, and current medications is obtained through self-report using a structured questionnaire. The Body Mass Index (BMI) is calculated using the standard formula (weight in kilograms divided by height in meters squared). Monthly income is categorized, ranging from up to 2 minimum wages to more than 10 minimum wages. Lifestyle Lifestyle behaviors are evaluated through physical activity, alcohol consumption, and smoking habits. Physical exercise refers to any activity that improves physical fitness, while alcohol consumption includes any intake of alcoholic beverages, such as beer, wine, or spirits. Smoking is characterized as the regular use of tobacco products, measured by the average number of cigarettes smoked daily over the past six months. The frequency of physical exercise is assessed by asking participants how regularly they engage in physical activity, with response options ranging from "rarely" to "daily." Alcohol consumption frequency is evaluated with response options ranging from "none" to "four or more times per week." All lifestyle behaviors are self-reported. Endometriosis-Related Pain Endometriosis-related pain includes symptoms with varying characteristics associated with different functions, such as pain during or shortly after sexual intercourse (dyspareunia), dysmenorrhea (cyclic painful menstrual cramps), related to urination (dysuria), defecation, and non-cyclic pelvic pain. Additionally, two common patterns of pain radiation in this population are evaluated: pain radiating to the lower back and pain radiating to the thigh, leg, and foot. Pain intensity for these different symptoms is measured using the Numeric Pain Rating Scale (NPRS), where patients rate their average pain over the past month on a scale from 0 (no pain) to 10 (worst imaginable pain) [ 39 ]. Infertility Infertility is assessed by asking patients how long they have been trying to conceive through regular (two to three times a week), unprotected sexual intercourse without achieving pregnancy. Women are considered infertile if they have been attempting to conceive for 12 months or more without success [ 40 ]. Anxiety and Depression Symptoms Anxiety and depression symptoms are assessed using the Hospital Anxiety and Depression Scale (HADS), a validated self-report questionnaire designed to measure the severity of anxiety and depression in medical patients. The scale consists of 14 items, divided into two subscales: anxiety (HADS-A) and depression (HADS-D), with 7 items each. The anxiety subscale focuses on symptoms such as restlessness, fear, and worry, while the depression subscale assesses issues like anhedonia and feelings of sadness. Each item is rated on a four-point Likert scale, with total subscale scores ranging from 0 to 21. Higher scores indicate more severe symptoms of anxiety or depression. The Brazilian Portuguese version of HADS has demonstrated good internal consistency (Cronbach’s alpha > 0.80) and validity in various clinical populations [ 41 ]. Previous Treatments Information about previous treatments is collected during the first gynecological consult, where patients self-report previous hormonal and surgical treatments. Past treatment information is obtained from the REDCap database for patients who are restarting treatment after a previous consultation in the endometriosis outpatient clinic. Information on current standard medical treatment, psychological interventions, or physiotherapy is also recorded. Session-Based Self-Report Measures At the beginning and end of each intervention session, participants complete self-report assessments designed to capture their current pain and affective states, their adoption of nonreactivity and acceptance attitudes during the session, and their reflections on bodily sensations, emotions, and experiences through the self-reflective report. Details related to the session, such as instructions comprehension, physical and online environment, are also recorded. Pain Intensity Pain intensity is assessed using the Numeric Pain Rating Scale (NPRS), a widely used and validated tool for measuring subjective pain [ 39 ]. Participants rate their current pain level on an 11-point scale ranging from 0 ("no pain") to 10 ("worst pain you have ever experienced"). Given that each participant may experience multiple types of pain, such as dysmenorrhea, dysuria, dyschezia, dyspareunia, non-cyclic pelvic pain, as well as pain comorbidities, this unidimensional measure is designed to capture the combined effects of various pain characteristics. This approach accommodates the challenges of fluctuating pain types and their potential coexistence over time. Additionally, it reduces the burden of completing multiple measures during repeated assessments, improving patient compliance with the study protocol. Positive and Negative Affect Positive and negative affect are assessed using the validated Portuguese version of the short form of the Positive and Negative Affect Schedule (PANAS-SF) [ 42 ]. The PANAS-SF comprises 10 items, with five items measuring negative affect (e.g., depressed, upset, scared, nervous, afraid) and five items measuring positive affect (e.g., alert, excited, enthusiastic, inspired, determined). Participants rate how they currently feel on a scale from 1 ("not at all") to 5 ("extremely"), with higher scores indicating higher levels of the respective affect. Affect Valence and Arousal Affect is further assessed using the valence and arousal dimensions from Russell's Circumplex Model of Affect to capture a broader range of emotional changes, including states of calmness and neutrality. While PANAS captures emotions linked with higher arousal, such as alert, excited, and enthusiastic, it does not fully address states associated with calmness or low arousal, which are critical to evaluate given the self-regulation strategies cultivated in the sessions. For valence, participants are asked to indicate how pleasant or unpleasant they feel on a seven-point Likert scale ranging from 1 (Very Unpleasant) to 7 (Very Pleasant). For arousal, participants rate how activated or calm they feel, using a similar seven-point Likert scale, ranging from 1 (Very Calm) to 7 (Very Excited). This well-established approach categorizes emotional states across the circumplex space, capturing both hedonic tone (valence) and activation level (arousal), and has been validated in various psychological studies [ 43 – 45 ]. Participants Global Impression of Change on affect valence Given the absence of an established minimal clinically relevant change for arousal, positive affect, and negative affect, these variables are also assessed using the Participants' Global Impression of Change (PGIC) approach [ 46 ]. Participants are asked to evaluate their perceived change in emotional states immediately after each session. For positive emotions, the question is: "Since before the session, how would you rate your change in positive emotions?" For negative emotions, the question is similarly phrased: "Since before the session, how would you rate your change in negative emotions?" Response options for both questions include: "Much less," "Slightly less," "No change," "Slightly more," and "Much more." Psychological Attitudes During the Sessions Participants are required to report how much they are able to incorporate specific psychological attitudes, such as nonreactivity and acceptance, during their experiences with the session exercises. These attitudes reflect key components of mindfulness and psychological flexibility, which are hypothesized to play a role in mediating the intervention's effects on pain and affect [ 47 , 48 ]. Nonreactivity Nonreactivity is assessed using the Brazilian version of the Five Facets of Mindfulness Questionnaire (FFMQ), specifically focusing on the nonreactivity facet [ 49 ]. This facet includes seven items that evaluate the individual’s ability to allow thoughts and emotions to arise without reacting to them impulsively. Participants rate each item on a five-point Likert scale, ranging from 1 (never or very rarely true) to 5 (very often or always true). The total score ranges from 7 to 35, with higher scores indicating greater nonreactivity. Acceptance Acceptance is measured using the "Acceptance" dimension of the Multidimensional Psychological Flexibility Inventory (MPFI) [ 50 ]. This dimension includes two items: "I have been open to observing unpleasant thoughts and feelings without interfering with them" and "I have tried to make peace with my negative thoughts and emotions instead of resisting them." Responses are rated on a six-point Likert scale, ranging from never true (1) to always true (6), capturing how much participants adopt an accepting stance toward their experiences. Participants are asked to reflect on how often they exhibit these attitudes over the session. While some items in the FFMQ, such as nonreactivity, relate to acceptance, the MPFI's acceptance dimension was chosen for its more direct assessment of this construct. Variables Related to the Online Session Environment and Instruction Comprehension Session-related variables are assessed to evaluate how different aspects of the intervention setting may affect participants' engagement and the outcomes of the exercises [ 51 , 52 ]. The physical environment assesses the type of setting in which participants perform the online exercises, taking into account the presence and level of potential distractors. Participants answer the question, "In what environment did you perform the online exercises?" with options such as "In a quiet environment without interruptions," "In an environment with some distractions but I could follow along," or "In an environment with many distractions, it was difficult to concentrate." Instructions comprehension assesses how clear and understandable the instructions are for participants. Participants respond to the question, "Did you feel that the instructions provided were clear and understandable?" with response options, including "Totally clear, I had no doubts," "Mostly clear, I had small doubts but managed to understand," "Partially clear, I had difficulties at some points," "Slightly clear, I had much difficulty understanding," or "Confusing, I could not follow the instructions." Impact of environmental conditions assesses whether aspects such as the environment, audio quality, or internet connection affected the participants' ability to engage with the exercises. Participants answer the question, "During the exercises, did you feel that the conditions (environment, audio, internet) affected the quality of your involvement and the effects of the exercises?" with response options ranging from "No, conditions did not affect" to "Yes, conditions affected totally, I could not engage or benefit from the exercises." Self-Reflective Report The Self-Reflective Report aims to enhance participants' ability to perceive bodily sensations, emotions, and coping strategies during the sessions and articulate these experiences in words. By engaging in this reflective process, participants can refine their self-regulation skills and develop a deeper understanding of their coping mechanisms and patterns of reactions [ 53 , 54 ]. Participants are informed about the purpose of the report and their freedom to opt in or out of participation. Those who choose to participate respond to open-ended questions presented via Google Forms, allowing them to share their immediate experiences in their own words. For the pre-session reflection, participants are prompted to answer the following question: "How are you feeling at this moment? How do you perceive your emotions and your body right now? Take your time to describe any physical sensations, thoughts, or emotions that come to mind." After the session, the post-session reflection asks participants to respond to both the initial question and an additional prompt: "Now that the session is over, how are you feeling? How are your emotions, and how do you perceive your body? Talk about any changes you noticed compared to how you felt before the session." During selected sessions, participants are guided to reflect on their in-session experiences: "Describe your experience during the exercises in the session. What emotions and sensations did you notice throughout? Were there moments when you felt discomfort or difficulty? Talk about how you responded to these sensations—whether you tried to manage them in some way." The self-reflective report is required randomly during some sessions rather than every session to minimize excessive time spent on assessments and reduce participant burden. Additionally, this report provides the instructor with insights into the group's collective experience, enabling adjustments to session instructions that address common needs and improve overall guidance for the group. This is particularly important in the online format, where live conversations are limited due to participants being advised to mute their microphones to prevent environmental noise from disrupting the session. The study assessment sequence is summarized in Fig. 1 . Intervention The intervention was developed and delivered by a physiotherapist with extensive experience in pain management, movement-based therapies (including Somatic Education practices and Yoga), and mindfulness instruction. Participants receive a group WhatsApp reminder 30 minutes before each session and are invited to join an assessment 15 minutes prior to promote engagement and ensure schedule adherence; participants are advised not to join the session more than five minutes after it has started to avoid disrupting the group’s focused atmosphere. The assessments (questionnaire and self-reflective report exercise) are explained as aiming to provide an opportunity for communication with the instructor outside the structured exercise period, which is conducted with participants remaining silent while also helping to enhance their ability to perceive and articulate sensations and emotional states. The weekly online group sessions, attended by 5–10 participants, are guided by real-time verbal instructions, with the physiotherapist practicing the exercises alongside the group throughout the entire session, offering both auditory guidance and continuous visual support. While individualized adaptations are not incorporated into the core protocol, participants are encouraged to self-adjust movement amplitude and breathing based on comfort. Sessions take place in participants’ homes via a secure video conferencing platform, requiring only a quiet space with sufficient room for movement. No specialized equipment is necessary, and exercises are designed to be performed in both standing and seated positions, making the intervention accessible to participants with different physical abilities. The physiotherapist follows a structured session guide detailing exercise sequences, timing, and key instructions to maintain intervention fidelity. Each component and its integration into the session are described below and summarized in Table 1 . Table 1 Core Components of the Intervention Component Description Postural Stillness Practiced in seated or standing pauses, allowing participants to perceive stillness in contrast to movement and become aware of automatic motor reactions or physical expressions of emotional and pain states. These pauses provide opportunities to identify and reformulate maladaptive or unconscious motor behaviors. Additionally, stretch positions are incorporated, directing attention to specific body areas where stretch sensations arise, promoting attentional regulation. Deep Breathing Practiced both independently and in coordination with movement, deep breathing is intended to enhance interoceptive awareness and engage autonomic modulation, supporting calmness and physiological adaptability. Movement Performed across multiple body planes, movements are integrated with breath control and executed with minimal effort. The practice is designed to refine attentional flexibility, motor control, and sensorimotor accuracy. Additionally, it encourages participants to overcome movement avoidance, excessive muscle tone, rigidity, or protective muscle guarding, facilitating greater ease and adaptability in movement. Psychological Attitude The body’s practice elicits a range of somatosensory and interoceptive sensations and emotions, both pleasant and unpleasant, providing an opportunity to cultivate acceptance, nonreactivity, and present-centered awareness. This is encouraged by guiding participants to observe bodily sensations without resistance, suppression, or excessive cognitive elaboration. Movement Characteristics - Participants are guided to perform movements with deliberate pacing and smoothness, characterized by slow execution, fluid transitions, and the avoidance of abrupt changes in speed or direction. Effort is dynamically adjusted to the minimum required for each movement, reducing unnecessary stiffness. These characteristics are intended to enhance body awareness, flexible attention to sensations, and motor control while also addressing maladaptive motor behaviors, such as rigidity or unaware rapid movements, often linked with anxiety, threat perception, and restlessness [ 36 , 55 – 57 ]. Movements are performed across multiple body planes, including sagittal, frontal, horizontal, and rotational planes. This design allows participants to address fears and avoidance behaviors associated with specific directions and body parts, providing opportunities to reformulate their responses [ 58 , 59 ]. Postural Stillness - During Postural stillness exercises, participants are guided to achieve a balance where postures are both stable and relaxed, releasing automatic adjustments and enhancing muscle tension awareness and tone control [ 53 , 60 ]. In neutral positions (sitting or standing), participants are encouraged to perceive the entire body—its form, volume, and weight—and to notice the sensation of stillness, contrasting it with the sensation of movement. In stretch positions, attention is directed to specific body parts where stretch sensations are present, promoting attentional regulation and encouraging participants to observe these sensations without reacting. During the slow return from non-neutral positions, participants are guided to notice the gradual reduction in stretch sensations, deepening their body awareness. Deep Breathing - The deep breathing component begins with participants perceiving the sensations of their natural breath, followed by instructions to lengthen their inhalation through the nostrils and exhalation through the mouth. During inhalation, they are guided to reduce effort and allow air to enter slowly and for an extended time, while exhalation emphasizes decelerating the release of air [ 61 ]. Breath movements primarily engage the abdomen, expanding to the chest only at the end of each cycle. Participants refine their breathing comfort and effort levels with each breath, ensuring alignment with their capacity. Deep breathing supports autonomic regulation, potentially enhancing parasympathetic tone and interoceptive awareness [ 62 , 63 ]. Mindful Attitudes - Acceptance is trained by observing bodily sensations evoked during exercises—pleasant or unpleasant—without resistance or a desire to change them. Participants engage with the experience without striving to achieve specific outcomes. Nonreactivity is developed through calmly receiving sensations without altering movement or posture characteristics in response to discomfort, pain, or restlessness. Present-centered awareness is practiced by guiding participants to sustain an interest in the details of body sensations that arise during stillness, movement trajectories, and deep, low-effort breathing. Letting go of cognitive elaboration is also encouraged by educating participants about distraction as a natural mental activity, emphasizing that it should be noticed and attention patiently redirected to bodily sensations. This approach aims to cultivate presence and minimize overthinking [ 54 , 64 ]. Integration of Components into Structured Sessions - Sessions begin with landing attention into the body, a brief exercise (~ 3 minutes) guiding participants to focus on physical sensations, such as contact with support surfaces, body weight, and volume. This transition helps participants shift from their previous tasks to a state of body-centered awareness. Participants are then guided through deep breathing exercises (~ 5 minutes), followed by a transition into the core of the session, which consists of movement-based exercises intertwined with postural stillness (~ 25 minutes). Movement exercises progress from small, localized motions to broader, whole-body exercises, involving approximately 5–8 repetitions of 3–4 regional movements and 3–4 whole-body movements (engaging multiple body parts). Most movement exercises are integrated with deep breathing. However, for exercises involving a very large range of motion, coordination with deep breathing is not emphasized to prevent discomfort from increased respiratory effort [ 65 ]. Movement exercises integrated with deep breathing aim to promote coordination and facilitate interoceptive awareness that encourages a positive emotional experience [ 30 , 62 ]. Three postural stillness exercises are interwoven throughout each session, involving stretch-based or neutral postures (e.g., sitting or upright positions without active stretch). During these exercises, participants are encouraged to adopt a natural breath with minimal effort. Alternating movement and stillness aim to facilitate awareness of distinct bodily qualities and associated reactions [ 28 ]. The session concludes similarly to how it begins, with a brief seated exercise (~ 3 minutes) guiding participants to focus on physical sensations, such as contact with support surfaces, body weight, and volume. However, this concluding exercise emphasizes releasing any residual effort in the body and breath, inviting participants to extend this sense of ease into a psychological attitude of non-striving—accepting their current state without the need to change or control it [ 66 ]. The entire session lasts approximately 35–40 minutes. A random transcription of three sessions is available in the supplementary material, providing examples that illustrate how the core components are integrated into each session. While the components of this intervention overlap with elements found in mindfulness, somatic education, yoga, and tai chi, these approaches are typically embedded within broader philosophical systems (e.g., Yoga and Tai Chi) and incorporate complex bodily and psychological practices [ 56 ]. In research settings, many intervention protocols adopt an implicit guidance style common to these traditions, where key elements—such as movement fluidity, effort regulation, embodied attention, and stillness—are not explicitly instructed but are instead expected to develop naturally through practice. This implicit structure makes it difficult to delineate which specific components contribute to therapeutic effects. To avoid the imprecision of equating distinct interventions under the broad label of "Mindful Movement," we deliberately refrain from using this term. Unlike mindfulness-based practices, which do not emphasize explicit movement training or breath manipulation, our intervention incorporates structured guidance for movement characteristics and breath regulation. Additionally, mindfulness protocols typically include components such as inquiry and psychoeducation, which are not part of the present intervention [ 54 ]. This distinction helps refine the hypothesized therapeutic pathway, ensuring that the specific mechanisms underlying intervention effects can be more precisely examined or inferred. Statistical Analysis Variability in the number of attended sessions and the different points at which participants begin their assessments lead to differences in both the total number of completed sessions and the specific session numbers at which assessments are conducted (see Fig. 2 ). The primary analysis employs a weighted fixed-effects regression model for both continuous and categorical outcomes to ensure that participants with more observations do not disproportionately influence the results, accounting for this variability [ 67 ]. For continuous outcomes, multiple linear regression models will examine pre-post session changes in pain intensity, arousal, valence, positive affect, and negative affect, with each outcome analyzed separately. For categorical outcomes, fixed-effects logistic regression will be used to assess the likelihood of improvement per session, applying inverse probability weighting to balance contributions from individuals with varying numbers of attended sessions while preserving within-subject effects. Proportions of improvement, worsening (defined as a one-point change in the scales), or stability (no change) will be reported as descriptive statistics, and chi-square tests will supplement the analysis by exploring categorical response distributions across sessions. To examine factors influencing session-by-session changes, both session-related and participant-related predictors will be included in the models. Session-related predictors include "Environment" (ordinal, capturing the quality of internet, audio, and physical setting), "Instructions Comprehension" (ordinal, reflecting participants’ understanding of session instructions), and "Number of Previous Sessions" attended. Baseline clinical characteristics include Baseline Depression Level, Baseline Anxiety Level (both continuous), and Previous Standard Treatment Failure (categorized as hormonal, surgical, combined treatment, or no prior treatment). Commonly used sociodemographic covariates (e.g., age, education, socioeconomic status) will not be included in the models, as the study focuses on immediate within-subject changes, minimizing the influence of stable individual differences. Missing data within a session (e.g., missing pre- or post-session scores) will initially result in session exclusion, but sensitivity analyses using a mixed-effects model will assess the robustness of results under different missing data assumptions. Effect sizes will be reported using standardized beta coefficients [ 68 ]. Adjusted R-squared values will be used to assess model fit. Continuous variables will be summarized using means and standard deviations or medians and interquartile ranges, depending on distribution, while categorical variables will be reported as frequencies and percentages A logistic regression model will assess the likelihood of participation based on baseline characteristics to evaluate whether systematic differences exist between participants who complete assessments and those who do not [ 69 ]. The model will include anxiety, depression, number of endometriosis-related pain symptoms, comorbidities, education level, and income as predictors. To further explore potential biases, interaction terms will be incorporated (e.g., anxiety × depression) to test whether combined psychosocial factors impact participation likelihood. Odds ratios (ORs) with 95% confidence intervals will quantify the relative risk of non-participation for each predictor. Model discrimination will be evaluated using the area under the ROC curve (AUC), with values ≥ 0.70 indicating acceptable classification performance. Sample Size Calculation Sample size calculations were performed in R using the pwr.f2.test function from the pwr package [ 70 ]. The design assumes each pre-post pair represents an independent change outcome. The calculation accounts for three predictors included in the model. Assuming a medium effect size (f² = 0.15), a significance level (α = 0.05), and a power of 0.80, the required sample size is 77 participants. This ensures sufficient power to detect a change of at least one point on the outcome scales. Sensitivity Analyses Mixed-effects models will complement the primary analysis by incorporating all pre-post session assessments to examine individual variability and session effect consistency [ 71 ]. These models will account for both within-subject (session-to-session) and between-subject differences, allowing for a more precise estimation of intervention effects while preserving individual trajectories. Fixed effects will include session-related predictors (e.g., environment quality, instruction comprehension, number of previous sessions) and baseline clinical characteristics (e.g., baseline depression and anxiety levels, prior treatment failure). Random intercepts will be used to account for baseline differences across participants, ensuring that each individual has a personalized starting level for outcomes of interest (e.g., pain, affect). This adjustment controls for pre-session variability that might influence session effects. Random slopes will model individual deviations in the relationship between predictors and outcomes, allowing session-related factors (e.g., number of previous sessions) to exert differential effects across participants. Cross-level interactions between baseline clinical characteristics and session-related predictors will be explored to assess individual susceptibility to session effects. All available pre-post session assessments will be included under the assumption that data are missing at random, leveraging the ability of mixed models to handle incomplete datasets without requiring imputation. Given the hierarchical structure of the data, sessions will be modeled as repeated measures nested within participants, allowing for the estimation of both within-person and between-person effects. Mediator Analysis The mediating roles of nonreactivity (FFMQ) and acceptance (MPFI) in the relationship between the intervention and changes in outcomes (e.g., pain, arousal, valence, positive affect, and negative affect) will be analyzed using a multilevel mediation approach that reflects the structure of the data [ 72 ]. The primary focus is on within-session mediation, examining how session-related levels of nonreactivity and acceptance—assessed immediately after each session—account for intervention effects on pre-to-post changes in outcomes. Specifically, the model will estimate: (1) the effect of the intervention on nonreactivity and acceptance as experienced during the session, and (2) the extent to which these session-related mediator levels predict pre-to-post session changes in outcomes. Indirect effects will be calculated as the product of these pathways. Additionally, session-to-session variations in these mediators will be modeled to capture within-person indirect effects across repeated sessions. Between-person differences in mediation effects will also be explored but are not the primary focus. Given the shared underlying construct of nonreactivity and acceptance, a composite score integrating both variables will be explored as an additional mediator to expand variability and strengthen statistical power, addressing the limited range of the individual scales. This composite will be computed using standardized averages or factor scores based on shared variance between the two measures. Bayesian mediation modeling or rank-based methods will also be explored to further enhance the robustness of parameter estimation. Analysis of Qualitative Data from the Self-Reflective Report The qualitative data obtained from the Self-Reflective Report will undergo thematic analysis to explore how participants subjectively experience their bodies and emotions before the session, describe perceived shifts post-session, and engage with discomfort during the exercises. The coding process will follow an inductive-deductive approach, incorporating both emerging themes from the data and concepts from self-regulation frameworks [ 73 ]. Pre-session responses will be analyzed to identify bodily sensations (e.g., tension, fatigue, discomfort, ease), emotional states (e.g., anxiety, frustration, calmness), and cognitive-affective framing (e.g., resistance, openness, anticipation). Post-session responses will be examined individually and comparatively to assess subjective accounts of both positive and negative experiences, such as relief, relaxation, vitality, safety, emotional clarity, lingering discomfort, increased distress, frustration, or fatigue. In-session reflections will be analyzed to capture participants' attitudes toward challenges, including avoidance, acceptance, engagement, or frustration, as well as strategies used to manage discomfort, such as breath regulation, attentional shifts, withdrawal, or suppression. These examples illustrate potential themes but do not limit the scope of analysis, allowing for additional emergent themes to be identified. Because participants may struggle to maintain present-moment awareness in their reports—often shifting toward interpretations, explanations, or descriptions of past or future concerns and situations—the analysis will assess the extent to which responses remain confined to immediate bodily and emotional sensations as an indicator of present-centered awareness. Additionally, themes related to cognitive shifts away from the present moment will be examined separately, capturing the types of interpretations, anticipated concerns, or past experiences participants bring into their reflections. This will provide insight into the content of these interpretations and concerns and how frequently participants spontaneously move away from describing present experiences. Qualitative data will be organized into a structured dataset to track thematic patterns over time, with individual case summaries as a basic method for examining consistency or variability across sessions. Each participant's responses will be compiled chronologically, with pre-, post-, and in-session reflections categorized per session. Themes will be coded at both the session level (capturing intra-session experiences) and the participant level (assessing patterns over multiple sessions). The frequency and variability of key themes will be analyzed to ensure the consistency of the participants' experiences. Integration of Qualitative and Quantitative Data To triangulate qualitative findings with quantitative measures, a mixed-methods approach will be used to compare thematic categories with pre-post changes in pain intensity, affect, and arousal scores. A convergent design will be applied, in which qualitative and quantitative data are analyzed separately and then integrated for comparison [ 74 ]. Qualitative themes emerging from post-session reflections will be systematically compared with session-level changes in quantitative measures to identify meaningful patterns of correspondence or divergence. For example, qualitative reports of reduced discomfort, emotional relief, or positive expectation may correspond with decreased pain intensity or positive affect increases. Likewise, reports of exacerbated distress, frustration, or difficulty engaging with the exercises may be examined concerning increases in pain intensity, negative affect, or arousal levels. These represent potential patterns of alignment, but the analysis will remain open to additional, emergent relationships between subjective reports and quantitative outcomes. A quantitative coding approach will be applied to selected qualitative categories, such as "change in bodily perception," "emotional relief," or "difficulty maintaining present-moment awareness," transforming them into categorical or ordinal variables. These converted variables will then be incorporated into statistical analyses (e.g., mixed-effects models) to assess their association with session-level quantitative changes [ 75 ]. Patterns of correspondence and divergence will be examined. Cases where qualitative descriptions of bodily and emotional shifts align with quantitative changes will be analyzed for consistency across participants and sessions. Conversely, cases where subjective reports indicate improvement despite stable or worsening quantitative scores (or vice versa) will be examined to explore potential discrepancies between experiential and measured changes. Discussion The observational study outlined in this protocol aims to evaluate the immediate effects of an online self-regulation intervention on pain, affect, and arousal in women with symptomatic endometriosis. The study addresses critical gaps in endometriosis pain management by exploring underdeveloped therapeutic pathways beyond lesion-focused frameworks within a middle-income public health setting [ 2 , 19 ]. By targeting psychological attitudes (e.g., attentional flexibility, nonreactivity, and acceptance) [ 54 , 64 ] and adaptive physiological states (e.g., movement practices, postural stillness, and breath regulation) [ 31 , 53 , 62 , 63 ], the intervention seeks to mitigate maladaptive cognitive-affective responses, reframe pain-related behaviors, and enhance patients' ability of self-regulation [ 25 , 26 , 57 ]. Conventional care strategies for endometriosis predominantly emphasize etiology-focused approaches, such as hormonal therapies and surgical interventions. While these treatments address certain biological aspects of the disease, they often neglect the complicated interplay between pain mechanisms and psychosocial factors, leaving many patients underserved [ 19 , 76 ]. This protocol highlights the importance of integrating self-regulation as a transdiagnostic therapeutic mechanism, addressing interconnected emotional, physiological, and behavioral contributors to pain in a comprehensive manner [ 25 , 77 ]. Such an intervention's unified framework creates opportunities for synergistic effects, amplifying its potential impact on participants' well-being. While much of the existing research in endometriosis pain management focuses on long-term outcomes, this study prioritizes the consistency and relevance of acute effects. In the context of endometriosis, where women often experience sudden and severe pain flares, understanding immediate intervention effects is critical [ 3 , 78 ]. These findings will provide valuable insights into the intervention's capacity to offer real-time symptom relief and equip patients with strategies to manage fluctuating pain and emotional distress effectively. Methodological Strengths This study demonstrates several methodological strengths that support its aim of evaluating immediate intervention effects in a resource-constrained public health setting. The repeated-measures within-group design captures acute changes effectively and enhances causal inference by observing temporal relationships between the intervention and outcomes [ 79 , 80 ]. By minimizing between-subject variability and focusing on immediate pre- to post-session changes, this approach reduces the influence of natural symptom fluctuations and provides a nuanced understanding of how the intervention addresses pain and emotional distress during critical moments, such as pain flares. Adopting an online format represents another significant strength, improving accessibility for participants who may face geographical, logistical, or financial barriers to in-person sessions [ 81 , 82 ]. This format is particularly relevant in middle-income countries, where public health systems are often strained, and regular travel to treatment centers may be prohibitive [ 83 ]. Finally, the intervention's adaptability to accommodate a high patient influx without requiring increased session complexity is an important feature. By maintaining consistent session content, the protocol enables participants to join groups with lower delay, minimizing wait times and making the intervention more feasible within public health contexts [ 10 ]. These methodological elements contribute to advancing the understanding and implementation of scalable interventions for chronic pain conditions in resource-limited settings. Limitations and Future Directions While the study protocol demonstrates a robust methodological foundation, several limitations should be considered. The absence of a traditional control group limits the ability to definitively attribute observed changes exclusively to the intervention, as placebo effects, desirability bias or other uncontrolled factors cannot be entirely excluded [ 84 ]. While the within-group repeated-measures design reduces between-subject variability and enhances temporal inference [ 80 ], its capacity to rule out external influences is inherently limited. Participants with high baseline levels of anxiety, depression, or pain sensitivity may exhibit variable responses, including occasional worsening of outcomes [ 85 ]. These variations emphasize the need for adaptive intervention strategies that accommodate diverse participant needs, such as tailored session adjustments or additional support for more vulnerable individuals [ 16 ]. Additionally, the intervention is structured to integrate participants immediately after physician assessments, avoiding long waitlists. While this ensures broad accessibility and aligns with public health system constraints, it lacks the opportunity to progressively increase the complexity of exercises, which may limit the long-term development of the self-regulation skills being trained [ 86 ]. Furthermore, the protocol does not include structured evaluations of adherence to self-management strategies outside the intervention sessions, leaving a critical gap in understanding how well participants sustain these practices in their daily lives. Future research should explore the intervention's long-term impact by monitoring participants over extended periods, providing insights into the sustainability of outcomes and the potential for reducing recurrent pain flares, associated emotional distress and well-being improvement. Future studies should incorporate randomized controlled trials or innovative approaches, such as cross-over or N-of-1 trials, to complement the current findings. These designs could provide additional insights into the intervention's efficacy while balancing the strengths of within-person approaches for understanding individual variability. Expanding the application of this intervention to diverse settings, including low-resource environments, and examining its scalability and feasibility in these contexts would also provide critical data for broader implementation. Declarations Availability of data and materials: The datasets used and/or analyzed during this study will be publicly available on ZENODO upon acceptance of the primary study. Competing interests: The authors declare that they have no competing interests Funding sources: This study received no funding Clinical trial number: not applicable. Ethics approval and consent to participate: This study was conducted in accordance with the Declaration of Helsinki and approved by the Committee on Human Research at Rio de Janeiro State University (Pedro Ernesto University Hospital, approval number [Approval Number]). The requirement for written informed consent was waived by the Committee following ethical review and approval, as the study is observational, involves minimal risk, and all procedures and data collection were conducted as part of routine clinical care. Author contributions We state that all listed authors contributed to the preparation of the manuscript as follows: Marcelo de França Moreira - Conceptualization, Investigation, Writing-Original draft preparation. Marco Aurelio Pinho Oliveira - Conceptualization, Writing-Original draft preparation. All authors commented on the manuscript. References de C Williams AC, McGrigor H. A thematic synthesis of qualitative studies and surveys of the psychological experience of painful endometriosis. BMC Womens Health. 2024;24:50. As-Sanie S, Black R, Giudice LC, Gray Valbrun T, Gupta J, Jones B, et al. Assessing research gaps and unmet needs in endometriosis. Am J Obstet Gynecol. 2019;221:86–94. Moreira MF, Oliveira MAP. Exploring the interplay between catastrophizing and endometriosis pain through two-wave and intensive longitudinal data. Pain Med. 2024. https://doi.org/10.1093/pm/pnae132. Moreira M de F, Gamboa OL, Pinho Oliveira MA. Cognitive-affective changes mediate the mindfulness-based intervention effect on endometriosis-related pain and mental health: A path analysis approach. Eur J Pain. 2023. https://doi.org/10.1002/ejp.2149. Moreira M de F, Oliveira MAP. Bringing endometriosis to the road of contemporary pain science. BJOG. 2025. https://doi.org/10.1111/1471-0528.18096. Zarbo C, Brugnera A, Frigerio L, Malandrino C, Rabboni M, Bondi E, et al. Behavioral, cognitive, and emotional coping strategies of women with endometriosis: a critical narrative review. Arch Womens Ment Health. 2018;21:1–13. Todd J, Pickup B, Coutts-Bain D. Fear of progression, imagery, interpretation bias, and their relationship with endometriosis pain. Pain. 2023;164:2839–44. De Ruddere L, Craig KD. Understanding stigma and chronic pain: a-state-of-the-art review. Pain. 2016;157:1607–10. Borders AEB, Grobman WA, Amsden LB, McDade TW, Sharp LK, Holl JL. The relationship between self-report and biomarkers of stress in low-income reproductive-age women. Am J Obstet Gynecol. 2010;203:577.e1–8. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38:976–93. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–22. Bailey T, Shahabi L, Tarvainen M, Shapiro D, Ottaviani C. Moderating effects of the valence of social interaction on the dysfunctional consequences of perseverative cognition: an ecological study in major depression and social anxiety disorder. Anxiety Stress Coping. 2019;32:179–95. Weber CS, Thayer JF, Rudat M, Wirtz PH, Zimmermann-Viehoff F, Thomas A, et al. Low vagal tone is associated with impaired post stress recovery of cardiovascular, endocrine, and immune markers. Eur J Appl Physiol. 2010;109:201–11. Lischke A, Jacksteit R, Mau-Moeller A, Pahnke R, Hamm AO, Weippert M. Heart rate variability is associated with psychosocial stress in distinct social domains. J Psychosom Res. 2018;106:56–61. Williams DP, Joseph N, Hill LK, Sollers JJ 3rd, Vasey MW, Way BM, et al. Stereotype threat, trait perseveration, and vagal activity: evidence for mechanisms underpinning health disparities in Black Americans. Ethn Health. 2019;24:909–26. Simpson P, Holopainen R, Schütze R, O’Sullivan P, Smith A, Linton SJ, et al. Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review. Phys Ther. 2021;101. Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, et al. Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial. JAMA Neurol. 2018;75:808–17. McHugh RK, Murray HW, Barlow DH. Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behav Res Ther. 2009;47:946–53. Johnson S, Bradshaw A, Bresnahan R, Evans E, Herron K, Hapangama DK. Biopsychosocial approaches for the management of female chronic pelvic pain: A systematic review. BJOG. 2024. https://doi.org/10.1111/1471-0528.17987. As-Sanie S, Till SR, Schrepf AD, Griffith KC, Tsodikov A, Missmer SA, et al. Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain. Am J Obstet Gynecol. 2021;225:568.e1–568.e11. Zajec V, Mikuš M, Vitale SG, D’alterio MN, Gregov M, Šarić MJ, et al. Current status and challenges of drug development for hormonal treatment of endometriosis: a systematic review of randomized control trials. Gynecol Endocrinol. 2022;38:713–20. de França Moreira M, Gamboa OL, Pinho Oliveira MA. Association between severity of pain, perceived stress and vagally-mediated heart rate variability in women with endometriosis. Women Health. 2021;61:937–46. Vercellini P, Barbara G, Abbiati A, Somigliana E, Viganò P, Fedele L. Repetitive surgery for recurrent symptomatic endometriosis: what to do? Eur J Obstet Gynecol Reprod Biol. 2009;146:15–21. Lamvu G, Soliman AM, Manthena SR, Gordon K, Knight J, Taylor HS. Patterns of prescription opioid use in women with endometriosis: Evaluating prolonged use, daily dose, and concomitant use with benzodiazepines. Obstet Gynecol. 2019;133:1120–30. Linton SJ. A Transdiagnostic Approach to Pain and Emotion. J Appl Biobehav Res. 2013;18:82–103. Williams PG. Self-regulation, executive functioning, and neurovisceral integration. Pain. 2010;151:5–6. Sauer-Zavala S, Gutner CA, Farchione TJ, Boettcher HT, Bullis JR, Barlow DH. Current Definitions of “Transdiagnostic” in Treatment Development: A Search for Consensus. Behav Ther. 2017;48:128–38. Taylor AG, Goehler LE, Galper DI, Innes KE, Bourguignon C. Top-down and bottom-up mechanisms in mind-body medicine: development of an integrative framework for psychophysiological research. Explore . 2010;6:29–41. Tang Y-Y, Ma Y, Fan Y, Feng H, Wang J, Feng S, et al. Central and autonomic nervous system interaction is altered by short-term meditation. Proc Natl Acad Sci U S A. 2009;106:8865–70. Zheng Y-L, Wang D-X, Zhang Y-R, Tang Y-Y. Enhancing Attention by Synchronizing Respiration and Fingertip Pressure: A Pilot Study Using Functional Near-Infrared Spectroscopy. Front Neurosci. 2019;13:1209. Russell TA, Arcuri SM. A Neurophysiological and Neuropsychological Consideration of Mindful Movement: Clinical and Research Implications. Front Hum Neurosci. 2015;9:282. Zautra AJ, Fasman R, Davis MC, Craig ADB. The effects of slow breathing on affective responses to pain stimuli: an experimental study. Pain. 2010;149:12–8. Franklin AR, Mathersul DC, Raine A, Ruscio AM. Restlessness in generalized anxiety disorder: Using actigraphy to measure physiological reactions to threat. Behav Ther. 2021;52:734–44. Van Damme S, Van Ryckeghem DML, Wyffels F, Van Hulle L, Crombez G. No pain no gain? Pursuing a competing goal inhibits avoidance behavior. Pain. 2012;153:800–4. Jafari H, Gholamrezaei A, Franssen M, Van Oudenhove L, Aziz Q, Van den Bergh O, et al. Can slow deep breathing reduce pain? An experimental study exploring mechanisms. J Pain. 2020;21:1018–30. Kerr CE, Sacchet MD, Lazar SW, Moore CI, Jones SR. Mindfulness starts with the body: somatosensory attention and top-down modulation of cortical alpha rhythms in mindfulness meditation. Front Hum Neurosci. 2013;7:12. Khalsa SS, Adolphs R, Cameron OG, Critchley HD, Davenport PW, Feinstein JS, et al. Interoception and Mental Health: A Roadmap. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. 2018;3:501–13. Schmalzl L, Kerr CE, editors. Neural mechanisms underlying movement-based embodied contemplative practices. Frontiers Media SA; 2016. Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M. Systematic review of endometriosis pain assessment: how to choose a scale? Hum Reprod Update. 2015;21:136–52. Nnoaham KE, Hummelshoj L, Kennedy SH, Jenkinson C, Zondervan KT, World Endometriosis Research Foundation Women’s Health Symptom Survey Consortium. Developing symptom-based predictive models of endometriosis as a clinical screening tool: results from a multicenter study. Fertil Steril. 2012;98:692–701.e5. Castro MMC, Quarantini L, Batista-Neves S, Kraychete DC, Daltro C, Miranda-Scippa Â. Validade da escala hospitalar de ansiedade e depressão em pacientes com dor crônica. Rev Bras Anestesiol. 2006;56:470–7. Galinha IC, Pereira CR, Esteves F. Versão reduzida da escala portuguesa de afeto positivo e negativo - PANAS-VRP: Análise fatorial confirmatória e invariância temporal. PSICOLOGIA. 2014;28:53–65. Russell JA. A circumplex model of affect. J Pers Soc Psychol. 1980;39:1161–78. Posner J, Russell JA, Peterson BS. The circumplex model of affect: an integrative approach to affective neuroscience, cognitive development, and psychopathology. Dev Psychopathol. 2005;17:715–34. Remington NA, Fabrigar LR, Visser PS. Reexamining the circumplex model of affect. J Pers Soc Psychol. 2000;79:286–300. Anvari F, Lakens D. Using anchor-based methods to determine the smallest effect size of interest. J Exp Soc Psychol. 2021;96:104159. Åkerblom S, Perrin S, Rivano Fischer M, McCracken LM. Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: the contributions of psychological flexibility. J Behav Med. 2021;44:111–22. Teper R, Inzlicht M. Meditation, mindfulness and executive control: the importance of emotional acceptance and brain-based performance monitoring. Soc Cogn Affect Neurosci. 2013;8:85–92. Barros VV de, Kozasa EH, Souza ICW de, Ronzani TM. Validity evidence of the brazilian version of the five facet mindfulness questionnaire (FFMQ). Psic: Teor e Pesq. 2014;30:317–27. Flórido S, Cunha M, Carreiras D, Galhardo A. Adaptação da Versão Portuguesa do Multidimensional Psychological Flexibility Inventory para Adolescentes: Estrutura Fatorial e Propriedades Psicométricas. Rev Iberoam Diagn Eval - Aval Psicol. 2024;72:55. Mohr DC, Schueller SM, Montague E, Burns MN, Rashidi P. The behavioral intervention technology model: an integrated conceptual and technological framework for eHealth and mHealth interventions. J Med Internet Res. 2014;16:e146. Sun JC-Y, Rueda R. Situational interest, computer self-efficacy and self-regulation: Their impact on student engagement in distance education. Br J Educ Technol. 2012;43:191–204. Mehling WE, Wrubel J, Daubenmier JJ, Price CJ, Kerr CE, Silow T, et al. Body Awareness: a phenomenological inquiry into the common ground of mind-body therapies. Philos Ethics Humanit Med. 2011;6:6. Crane RS, Brewer J, Feldman C, Kabat-Zinn J, Santorelli S, Williams JMG, et al. What defines mindfulness-based programs? The warp and the weft. Psychol Med. 2017;47:990–9. Kerr CE, Agrawal U, Nayak S. The Effects of Tai Chi Practice on Intermuscular Beta Coherence and the Rubber Hand Illusion. Front Hum Neurosci. 2016;10:37. Schmalzl L, Crane-Godreau MA, Payne P. Movement-based embodied contemplative practices: definitions and paradigms. Front Hum Neurosci. 2014;8:205. Tang Y-Y, Ma Y, Wang J, Fan Y, Feng S, Lu Q, et al. Short-term meditation training improves attention and self-regulation. Proc Natl Acad Sci U S A. 2007;104:17152–6. Garcia-Toro M, Aguilar-Latorre A, Garcia A, Navarro-Guzmán C, Gervilla E, Seguí A, et al. Mindfulness skills and experiential avoidance as therapeutic mechanisms for treatment-resistant depression through mindfulness-based cognitive therapy and lifestyle modification. Front Psychol. 2023;14:1008891. Jensen MP, Ehde DM, Day MA. The Behavioral Activation and Inhibition Systems: Implications for Understanding and Treating Chronic Pain. J Pain. 2016;17:529.e1–529.e18. Sullivan MB, Erb M, Schmalzl L, Moonaz S, Noggle Taylor J, Porges SW. Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience. Front Hum Neurosci. 2018;12:67. Ma X, Yue Z-Q, Gong Z-Q, Zhang H, Duan N-Y, Shi Y-T, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Front Psychol. 2017;8:874. Weng HY, Feldman JL, Leggio L, Napadow V, Park J, Price CJ. Interventions and Manipulations of Interoception. Trends Neurosci. 2021;44:52–62. Halbert JD, Baban B, vanTuyll D, Barnes V, Thayer J, Kapuku GK. BREATH ATTENTION MEDITATION ENHANCES PARASYMPATHETIC ACTIVITY AND INCREASES ANTI-INFLAMMATION MARKERS. In: PSYCHOSOMATIC MEDICINE. LIPPINCOTT WILLIAMS & WILKINS TWO COMMERCE SQ, 2001 MARKET ST, PHILADELPHIA …; 2019. p. A99–A99. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8:163–90. Wan L, Van Diest I, De Peuter S, Bogaerts K, Oyen N, Hombroux N, et al. Repeated experiences of air hunger and ventilatory behavior in response to hypercapnia in the standardized rebreathing test: effects of anxiety. Biol Psychol. 2008;77:223–32. Lindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and Acceptance Theory (MAT). Clin Psychol Rev. 2017;51:48–59. Robins JM, Hernán MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology. 2000;11:550–60. Nieminen P, Lehtiniemi H, Vähäkangas K, Huusko A, Rautio A. Standardised regression coefficient as an effect size index in summarising findings in epidemiological studies. ebph. 2013;10. Maldonado G, Greenland S. Simulation study of confounder-selection strategies. Am J Epidemiol. 1993;138:923–36. PWR. Baayen RH, Davidson DJ, Bates DM. Mixed-effects modeling with crossed random effects for subjects and items. J Mem Lang. 2008;59:390–412. Preacher KJ, Zyphur MJ, Zhang Z. A general multilevel SEM framework for assessing multilevel mediation. Psychol Methods. 2010;15:209–33. Braun V, Clarke V. Thematic analysis: A practical guide. bpsqmip. 2022;1:46–50. Robinson P. Designing and conducting mixed methods research. Aust N Z J Public Health. 2007;31:388. van Grootel L, Balachandran Nair L, Klugkist I, van Wesel F. Quantitizing findings from qualitative studies for integration in mixed methods reviewing. Res Synth Methods. 2020;11:413–25. de França Moreira M, Oliveira MAP. Endometriosis pain or its “phantom” pain? The elephant in the room of research. BJOG. 2024. https://doi.org/10.1111/1471-0528.17927. Thayer JF, Hansen AL, Saus-Rose E, Johnsen BH. Heart rate variability, prefrontal neural function, and cognitive performance: the neurovisceral integration perspective on self-regulation, adaptation, and health. Ann Behav Med. 2009;37:141–53. Coxon L, Lugt C, Horne AW, Evans E, Abreu-Mendes P, Arendt-Nielsen L, et al. Symptom flares in women with chronic pelvic pain: Questionnaire study within a cohort study (translational research in pelvic pain (TRiPP)). BJOG. 2024. https://doi.org/10.1111/1471-0528.17915. Howard MC, Hoffman ME. Variable-centered, person-centered, and person-specific approaches: Where theory meets the method. Organ Res Methods. 2018;21:846–76. Hamaker EL. Why researchers should think “within-person”: A paradigmatic rationale. In: Mehl MR, editor. Handbook of research methods for studying daily life (pp. New York, NY, US: The Guilford Press, xxvii; 2012. p. 43–61. Sullivan MB, Hill K, Ballengee LA, Knoblach D, Fowler C, Haun J, et al. Remotely delivered psychologically informed Mindful Movement physical therapy for pain care: A framework for operationalization. Glob Adv Integr Med Health. 2023;12:27536130231209751. Sohl SJ, Tooze JA, Wheeler A, Zeidan F, Wagner LI, Evans S, et al. Iterative adaptation process for eHealth Mindful Movement and Breathing to improve gynecologic cancer surgery outcomes. Psychooncology. 2019;28:1774–7. Murray LK, Metz K, Callaway K. Transdiagnostic therapeutic approaches: A global perspective. Global Mental Health and Psychotherapy. 2019;:25–46. Ho AMH, Phelan R, Mizubuti GB, Murdoch JAC, Wickett S, Ho AK, et al. Bias in Before-After Studies: Narrative Overview for Anesthesiologists. Anesth Analg. 2018;126:1755–62. de França Moreira M, Gamboa OL, Oliveira MAP. Daily interaction between meditation and endometriosis pain and the mindfulness effect on pain interference in activities throughout a brief mindfulness-based intervention. Mindfulness . 2024. https://doi.org/10.1007/s12671-024-02381-y. Milbocker KA, Smith IF, Klintsova AY. Maintaining a dynamic brain: A review of empirical findings describing the roles of exercise, learning, and environmental enrichment in neuroplasticity from 2017-2023. Brain Plast. 2024;9:75–95. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5969427","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":417827101,"identity":"3d24f63d-1b47-4633-969d-26a5cc5330d1","order_by":0,"name":"Marcelo de França Moreira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYDAC5gMMDAkMzPwM7GCuDRAzNh7Aq4UtAaxFsoEZzE0DaWkgrIUBoeUwmMSrRbeNO3XDwx3WEgaHeQ8+/PHnvN3a9sNAW2psonFpMTvGu+1G4pl0oBa+ZGPettvJ284kArUcS8ttwKXlfi9QS9vhOoPDPGbSjA23k80OALUwNhzGrQVsS9thoC085j9//DmXbHb+IfFazBh42A7Ymd0gzpZ0CcnDPMbSvG3JCWY3gLYk4PMLUMvNn23WEnzHeww//vhjZ292Pv3hgw81Nji1YIBEsMoEYpWDgD0pikfBKBgFo2BkAAAgA2dkqmBeSwAAAABJRU5ErkJggg==","orcid":"","institution":"State University of Rio de Janeiro","correspondingAuthor":true,"prefix":"","firstName":"Marcelo","middleName":"de França","lastName":"Moreira","suffix":""},{"id":417827102,"identity":"6ce4430e-60d4-464a-85ba-dcf2d10098d8","order_by":1,"name":"Marco Aurelio Pinho Oliveira","email":"","orcid":"","institution":"State University of Rio de Janeiro","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"Aurelio Pinho","lastName":"Oliveira","suffix":""}],"badges":[],"createdAt":"2025-02-06 02:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5969427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5969427/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76874417,"identity":"7068e559-bb78-4e7c-a22c-60cef0ed5bed","added_by":"auto","created_at":"2025-02-21 15:53:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1526790,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart depicting the assessment sequence of the study.\u003c/p\u003e\n\u003cp\u003eBaseline assessment is conducted by the gynecologist and assistant. Pre- and post-session repeated measures are collected and supported online by the assistant. Post-session assessments include questions on nonreactivity (FFMQ) and acceptance (MPFI), which assess psychological attitudes during the session, as well as a self-reflective report on how participants experienced and responded to session challenges. NRPS = Numeric Rating Pain Scale; HADS = Hospital Anxiety and Depression Scale; PANAS-SF = Positive and Negative Affect Schedule – Short Form; FFMQ = Five Facet Mindfulness Questionnaire; MPFI = Multidimensional Psychological Flexibility Inventory.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5969427/v1/6cc89ae95b315fa40308b6ee.png"},{"id":76873367,"identity":"279bba39-c432-4f2a-b05d-c48b4117caaf","added_by":"auto","created_at":"2025-02-21 15:45:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":307201,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical Rollout and Data Collection Timeline of the Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePanel A: Overview of participant enrollment and session attendance in the intervention. Each participant completes a baseline assessment before starting weekly group sessions. The timeline illustrates variability in session attendance and assessment completion. \"Pre-Post Assessment Completed\" indicates sessions with both pre- and post-session assessments completed, \"Pre-Post Assessment Missed\" denotes attended sessions without completed assessments, and \"Not Participated\" refers to sessions not attended.\u003c/p\u003e\n\u003cp\u003ePanel B: The Session Assessment Heatmap shows assessment data availability for analysis. Rows represent participants (P1–P5), and columns represent sessions (S1–S4). Blue (✓) indicates sessions with completed assessments, while (x) indicates sessions with incomplete assessments. Red indicates missed assessments, and gray indicates sessions not attended. The \"Data for Analysis\" column lists sessions available for analysis.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5969427/v1/e9972d152d4f3540c433e222.png"},{"id":76877001,"identity":"d3434075-e629-4c9e-a3ee-33df05906cd1","added_by":"auto","created_at":"2025-02-21 16:18:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2225498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5969427/v1/f4cef34b-9a47-4778-b883-97740792ad78.pdf"},{"id":76874415,"identity":"00a02870-f895-4947-9632-57816f2c19b1","added_by":"auto","created_at":"2025-02-21 15:53:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26203,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5969427/v1/c295799069141ff31c698f47.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExploring the Immediate Effects of an Online Self-Regulation Intervention on Pain, Affect, and Arousal in Women with Endometriosis: An Observational Study Protocol \u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a chronic condition characterized by the presence of endometrial-like tissue outside the uterus, often resulting in pain, urinary and bowel symptoms, infertility, and significant impairments across multiple domains of quality of life for millions of women worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite considerable advances in understanding the pathophysiology of endometriosis, effectively managing its associated chronic pain and restoring well-being remain significant challenges [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These difficulties are partly due to the complex interaction between the condition's pathophysiological aspects and the unique psychosocial context that often accompanies it [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWomen with endometriosis often endure prolonged uncertainty about the origins of their symptoms, the unpredictable nature of pain flares, and concerns about lesion recurrence, all of which can contribute to heightened anxiety, fear, and catastrophic thinking [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, the social stigma surrounding the condition and the frequent dismissal of symptoms\u0026mdash;both in medical settings and personal relationships\u0026mdash;exacerbate feelings of isolation and helplessness. These challenges are compounded by societal expectations related to femininity, motherhood, and marital roles, which can further erode social support and emotional well-being [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In low- and middle-income countries, these challenges are further intensified by overlapping vulnerabilities, including low income, limited health literacy, exposure to violence, long distances from treatment centers, and underfunded public health systems [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These factors not only restrict access to care but also amplify the biopsychosocial burden. In this context, maladaptive psychological coping and biological alterations often emerge, perpetuating a cycle of pain, stress, negative affect, and poorer functioning of key biological systems (e.g., autonomic-related immune-inflammatory functions) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContemporary therapeutic strategies for chronic pain emphasize addressing the unique mosaic of elements that contribute to each patient\u0026rsquo;s multidimensional perception of threat, treating patients individually to target the inferred specific contributors to their pain [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, implementing this strategy can be problematic and have limitations, particularly in the abovementioned contexts. Providing personalized care and associated individualized treatments requires a substantial number of specialized healthcare professionals [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], a demand that can overwhelm public healthcare systems serving large patient populations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, for patients facing multiple interconnected factors\u0026mdash;such as endometriosis symptoms combined with comorbidities, co-occurring pain conditions, and additional social sources of adversity\u0026mdash;addressing each contributor through a combination of therapies may be both impractical and inaccessible.\u003c/p\u003e \u003cp\u003eThese challenges are particularly pronounced in the context of endometriosis, where clinicians face a scarcity of evidence-based therapeutic options to guide the development of effective treatment strategies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Standard therapies, such as hormonal treatments and surgery, often offer limited efficacy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and fail to address the broad underlying biological processes and psychosocial factors that affect overall well-being [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The dominance of a biomedical view of pain in gynecology frequently results in an overreliance on pharmacological interventions, particularly opioids and surgical procedures [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These strategies carry considerable risks, including surgical complications, opioid overprescription, and severe adverse outcomes from the combined use of opioids and benzodiazepines [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn alternative approach to addressing this complex scenario involves targeting fundamental mechanisms that shape illness experience, life adversities, and well-being, such as self-regulation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Self-regulation refers to the cognitive and physiological capacity to modulate behaviors, thoughts, and emotions to achieve adaptive states [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This approach aligns with transdiagnostic principles, addressing core mechanisms underlying emotional challenge and pain, potentially benefiting interconnected difficulties [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Focusing on shared pathways rather than isolated symptoms offers a sustainable framework for accessible, group-based interventions independent of the specific factors contributing to an individual\u0026rsquo;s pain.\u003c/p\u003e \u003cp\u003eSelf-regulation can be enhanced by promoting adaptive physiological and psychological changes, which can be facilitated through an integrative strategy, where these changes mutually reinforce one another [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. On a physiological level, practices involving movement performed with specific skills, postural control, and breath regulation can promote a healthier state [\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. For instance, combining deep breathing with postural stillness and controlled, low-effort movement interposes maladaptive physical responses such as shallow breathing, muscle tension, movement avoidance, and restlessness [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Additionally, the diverse sensations elicited from posture, movement, and breath work offer a basis for training adaptive psychological attitudes like acceptance, nonreactivity, and attentional flexibility, contributing to improved coping strategies [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on this theoretical foundation, an online structured group-based intervention was developed and implemented as part of the multidisciplinary management of chronic pain in women with endometriosis at an Endometriosis Outpatient Clinic. The intervention integrates these physiological and psychological components into guided exercises, combining body posture, movement practices, breathwork, and mindfulness attitudes. This observational study aims to investigate the immediate effects of the intervention on pain, affect, and arousal.\u003c/p\u003e \u003cp\u003eWe hypothesize that most participants will experience immediate improvements in pain, affect, and arousal following each session. However, those with high baseline levels of anxiety, depression, or pain hypersensitivity (e.g., consistently reporting pain during gentle movements) may show more variable responses, including perceived symptom exacerbation during the initial sessions. This variability is expected given the sessions' emphasis on bodily sensations, combined with challenges in adapting to discomfort among individuals with heightened pain sensitivity and significant mental health difficulties. Understanding these possibilities is essential for refining future interventions, allowing for tailored strategies that enhance adaptability, minimize distress, and optimize therapeutic outcomes. Additionally, it is anticipated that the development of nonreactivity and acceptance will mediate some of the positive effects observed after each session.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eA within-subject repeated-measures observational design will be employed to examine the acute effects of each intervention session. This approach enables the assessment of symptom fluctuations in real-world conditions, capturing periods of intensified pain, distress, or negative affect\u0026mdash;when self-regulation is most essential. Given the diverse therapeutic routines each woman undergoes as part of multidisciplinary care, assessing long-term trends or making between-subject comparisons is not feasible in this context. Instead, aligning with the study's focus on acute effects, each pre-post session dataset will be analyzed independently.\u003c/p\u003e \u003cp\u003e The intervention became an integral part of the multidisciplinary care at the Endometriosis Outpatient Clinic of Pedro Ernesto University Hospital in June 2024, with data collection for the processes outlined in this observational study commencing as part of routine clinical care in August 2024. This study was conducted in accordance with the Declaration of Helsinki and approved by the Committee on Human Research at Rio de Janeiro State University (UERJ, Pedro Ernesto University Hospital, approval number 3.725.458). The requirement for written informed consent was waived by the Committee following ethical review and approval, as the study is observational, involves minimal risk, and all procedures and data collection were conducted as part of routine clinical care. Initially, some instruments\u0026mdash;such as the Five Facets of Mindfulness Questionnaire, the Multidimensional Psychological Flexibility Inventory, and the Affect and Arousal Scales\u0026mdash;were part of the clinical evaluation protocol but were not included in the original research protocol. As of January 27, 2025, these instruments are under review by the Committee on Human Research at Rio de Janeiro State University, pending formal approval for their incorporation into the research scope.\u003c/p\u003e \u003cp\u003eWomen are advised to participate in the online intervention for two months, attending the online training once a week; however, there are no restrictions on longer participation. Session attendance is recorded by registering participants in the video call. However, as this phase focused on understanding acute effects, absences and gaps between attended sessions were not considered.\u003c/p\u003e \u003cp\u003eTo ensure participants are adequately prepared to engage with the intervention, an initial onsite assessment with the intervention instructor is conducted. During this session, participants receive a brief educational overview of the multidimensional aspects of chronic pain and detailed instructions about the intervention\u0026rsquo;s purpose and structure. They are also informed that the assessments serve both to enhance management strategies and for research purposes, with assurances that their anonymity will be maintained throughout the process. This 45-minute to 1-hour session also provides guidance on organizing their environment for the sessions and managing the online format, including communication logistics such as joining a WhatsApp group and accessing the sessions.\u003c/p\u003e \u003cp\u003ePatients are advised to adjust their medication schedule, ensuring that analgesics are not taken within 30 minutes before the sessions, considering the typical onset time for most analgesics. This recommendation is explained as a way to encourage participants to engage with the session exercises, allowing them to address their symptoms fluctuation in real-time. It is emphasized that this approach applies only during the session and aims to facilitate the development of alternative strategies for managing pain. Women are, however, encouraged to continue following the pharmacological treatment prescribed by their physicians and to make any adjustments in accordance with the physician-recommended plan as part of their comprehensive pain management strategy.\u003c/p\u003e \u003cp\u003eBaseline variables are being collected by the gynecologist and other clinical staff during the first medical appointment. During each session, participants are invited to complete immediate pre- and post-session assessments using electronic forms sent through a designated WhatsApp chat. Managed by a clinical staff, this chat is separate from the one used by the instructor for video call sessions, providing a specific channel to address any issues or questions related to form submission and data collection.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInstruments and Measures\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eBaseline Measures\u003c/h2\u003e \u003cp\u003eThe baseline assessment includes sociodemographic and lifestyle variables, anxiety and depression levels, different types of endometriosis-related pain, fertility status, and previous standard treatments. These baseline measures are being collected as part of the clinic\u0026rsquo;s standard multidisciplinary assessment during the first patient appointment and recorded in the REDCap platform.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eSociodemographic Variables\u003c/h3\u003e\n\u003cp\u003eInformation on ethnicity, age, education, marital status, comorbidities, number of surgeries, duration of pain, infertility, and current medications is obtained through self-report using a structured questionnaire. The Body Mass Index (BMI) is calculated using the standard formula (weight in kilograms divided by height in meters squared). Monthly income is categorized, ranging from up to 2 minimum wages to more than 10 minimum wages.\u003c/p\u003e\n\u003ch3\u003eLifestyle\u003c/h3\u003e\n\u003cp\u003eLifestyle behaviors are evaluated through physical activity, alcohol consumption, and smoking habits. Physical exercise refers to any activity that improves physical fitness, while alcohol consumption includes any intake of alcoholic beverages, such as beer, wine, or spirits. Smoking is characterized as the regular use of tobacco products, measured by the average number of cigarettes smoked daily over the past six months. The frequency of physical exercise is assessed by asking participants how regularly they engage in physical activity, with response options ranging from \"rarely\" to \"daily.\" Alcohol consumption frequency is evaluated with response options ranging from \"none\" to \"four or more times per week.\" All lifestyle behaviors are self-reported.\u003c/p\u003e\n\u003ch3\u003eEndometriosis-Related Pain\u003c/h3\u003e\n\u003cp\u003eEndometriosis-related pain includes symptoms with varying characteristics associated with different functions, such as pain during or shortly after sexual intercourse (dyspareunia), dysmenorrhea (cyclic painful menstrual cramps), related to urination (dysuria), defecation, and non-cyclic pelvic pain. Additionally, two common patterns of pain radiation in this population are evaluated: pain radiating to the lower back and pain radiating to the thigh, leg, and foot. Pain intensity for these different symptoms is measured using the Numeric Pain Rating Scale (NPRS), where patients rate their average pain over the past month on a scale from 0 (no pain) to 10 (worst imaginable pain) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInfertility\u003c/h2\u003e \u003cp\u003eInfertility is assessed by asking patients how long they have been trying to conceive through regular (two to three times a week), unprotected sexual intercourse without achieving pregnancy. Women are considered infertile if they have been attempting to conceive for 12 months or more without success [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnxiety and Depression Symptoms\u003c/h3\u003e\n\u003cp\u003eAnxiety and depression symptoms are assessed using the Hospital Anxiety and Depression Scale (HADS), a validated self-report questionnaire designed to measure the severity of anxiety and depression in medical patients. The scale consists of 14 items, divided into two subscales: anxiety (HADS-A) and depression (HADS-D), with 7 items each. The anxiety subscale focuses on symptoms such as restlessness, fear, and worry, while the depression subscale assesses issues like anhedonia and feelings of sadness. Each item is rated on a four-point Likert scale, with total subscale scores ranging from 0 to 21. Higher scores indicate more severe symptoms of anxiety or depression. The Brazilian Portuguese version of HADS has demonstrated good internal consistency (Cronbach\u0026rsquo;s alpha\u0026thinsp;\u0026gt;\u0026thinsp;0.80) and validity in various clinical populations [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003ePrevious Treatments\u003c/h3\u003e\n\u003cp\u003eInformation about previous treatments is collected during the first gynecological consult, where patients self-report previous hormonal and surgical treatments. Past treatment information is obtained from the REDCap database for patients who are restarting treatment after a previous consultation in the endometriosis outpatient clinic. Information on current standard medical treatment, psychological interventions, or physiotherapy is also recorded.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSession-Based Self-Report Measures\u003c/h2\u003e \u003cp\u003e At the beginning and end of each intervention session, participants complete self-report assessments designed to capture their current pain and affective states, their adoption of nonreactivity and acceptance attitudes during the session, and their reflections on bodily sensations, emotions, and experiences through the self-reflective report. Details related to the session, such as instructions comprehension, physical and online environment, are also recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePain Intensity\u003c/h2\u003e \u003cp\u003ePain intensity is assessed using the Numeric Pain Rating Scale (NPRS), a widely used and validated tool for measuring subjective pain [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Participants rate their current pain level on an 11-point scale ranging from 0 (\"no pain\") to 10 (\"worst pain you have ever experienced\").\u003c/p\u003e \u003cp\u003eGiven that each participant may experience multiple types of pain, such as dysmenorrhea, dysuria, dyschezia, dyspareunia, non-cyclic pelvic pain, as well as pain comorbidities, this unidimensional measure is designed to capture the combined effects of various pain characteristics. This approach accommodates the challenges of fluctuating pain types and their potential coexistence over time. Additionally, it reduces the burden of completing multiple measures during repeated assessments, improving patient compliance with the study protocol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePositive and Negative Affect\u003c/h2\u003e \u003cp\u003ePositive and negative affect are assessed using the validated Portuguese version of the short form of the Positive and Negative Affect Schedule (PANAS-SF) [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The PANAS-SF comprises 10 items, with five items measuring negative affect (e.g., depressed, upset, scared, nervous, afraid) and five items measuring positive affect (e.g., alert, excited, enthusiastic, inspired, determined). Participants rate how they currently feel on a scale from 1 (\"not at all\") to 5 (\"extremely\"), with higher scores indicating higher levels of the respective affect.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAffect Valence and Arousal\u003c/h2\u003e \u003cp\u003eAffect is further assessed using the valence and arousal dimensions from Russell's Circumplex Model of Affect to capture a broader range of emotional changes, including states of calmness and neutrality. While PANAS captures emotions linked with higher arousal, such as alert, excited, and enthusiastic, it does not fully address states associated with calmness or low arousal, which are critical to evaluate given the self-regulation strategies cultivated in the sessions.\u003c/p\u003e \u003cp\u003e For valence, participants are asked to indicate how pleasant or unpleasant they feel on a seven-point Likert scale ranging from 1 (Very Unpleasant) to 7 (Very Pleasant). For arousal, participants rate how activated or calm they feel, using a similar seven-point Likert scale, ranging from 1 (Very Calm) to 7 (Very Excited). This well-established approach categorizes emotional states across the circumplex space, capturing both hedonic tone (valence) and activation level (arousal), and has been validated in various psychological studies [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eParticipants Global Impression of Change on affect valence\u003c/h2\u003e \u003cp\u003eGiven the absence of an established minimal clinically relevant change for arousal, positive affect, and negative affect, these variables are also assessed using the Participants' Global Impression of Change (PGIC) approach [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Participants are asked to evaluate their perceived change in emotional states immediately after each session. For positive emotions, the question is: \"Since before the session, how would you rate your change in positive emotions?\" For negative emotions, the question is similarly phrased: \"Since before the session, how would you rate your change in negative emotions?\" Response options for both questions include: \"Much less,\" \"Slightly less,\" \"No change,\" \"Slightly more,\" and \"Much more.\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePsychological Attitudes During the Sessions\u003c/h2\u003e \u003cp\u003e Participants are required to report how much they are able to incorporate specific psychological attitudes, such as nonreactivity and acceptance, during their experiences with the session exercises. These attitudes reflect key components of mindfulness and psychological flexibility, which are hypothesized to play a role in mediating the intervention's effects on pain and affect [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eNonreactivity\u003c/h2\u003e \u003cp\u003eNonreactivity is assessed using the Brazilian version of the Five Facets of Mindfulness Questionnaire (FFMQ), specifically focusing on the nonreactivity facet [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This facet includes seven items that evaluate the individual\u0026rsquo;s ability to allow thoughts and emotions to arise without reacting to them impulsively. Participants rate each item on a five-point Likert scale, ranging from 1 (never or very rarely true) to 5 (very often or always true). The total score ranges from 7 to 35, with higher scores indicating greater nonreactivity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eAcceptance\u003c/h2\u003e \u003cp\u003eAcceptance is measured using the \"Acceptance\" dimension of the Multidimensional Psychological Flexibility Inventory (MPFI) [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. This dimension includes two items: \"I have been open to observing unpleasant thoughts and feelings without interfering with them\" and \"I have tried to make peace with my negative thoughts and emotions instead of resisting them.\" Responses are rated on a six-point Likert scale, ranging from never true (1) to always true (6), capturing how much participants adopt an accepting stance toward their experiences. Participants are asked to reflect on how often they exhibit these attitudes over the session. While some items in the FFMQ, such as nonreactivity, relate to acceptance, the MPFI's acceptance dimension was chosen for its more direct assessment of this construct.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eVariables Related to the Online Session Environment and Instruction Comprehension\u003c/h2\u003e \u003cp\u003eSession-related variables are assessed to evaluate how different aspects of the intervention setting may affect participants' engagement and the outcomes of the exercises [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The physical environment assesses the type of setting in which participants perform the online exercises, taking into account the presence and level of potential distractors. Participants answer the question, \"In what environment did you perform the online exercises?\" with options such as \"In a quiet environment without interruptions,\" \"In an environment with some distractions but I could follow along,\" or \"In an environment with many distractions, it was difficult to concentrate.\"\u003c/p\u003e \u003cp\u003eInstructions comprehension assesses how clear and understandable the instructions are for participants. Participants respond to the question, \"Did you feel that the instructions provided were clear and understandable?\" with response options, including \"Totally clear, I had no doubts,\" \"Mostly clear, I had small doubts but managed to understand,\" \"Partially clear, I had difficulties at some points,\" \"Slightly clear, I had much difficulty understanding,\" or \"Confusing, I could not follow the instructions.\"\u003c/p\u003e \u003cp\u003eImpact of environmental conditions assesses whether aspects such as the environment, audio quality, or internet connection affected the participants' ability to engage with the exercises. Participants answer the question, \"During the exercises, did you feel that the conditions (environment, audio, internet) affected the quality of your involvement and the effects of the exercises?\" with response options ranging from \"No, conditions did not affect\" to \"Yes, conditions affected totally, I could not engage or benefit from the exercises.\"\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSelf-Reflective Report\u003c/h2\u003e \u003cp\u003e The Self-Reflective Report aims to enhance participants' ability to perceive bodily sensations, emotions, and coping strategies during the sessions and articulate these experiences in words. By engaging in this reflective process, participants can refine their self-regulation skills and develop a deeper understanding of their coping mechanisms and patterns of reactions [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants are informed about the purpose of the report and their freedom to opt in or out of participation. Those who choose to participate respond to open-ended questions presented via Google Forms, allowing them to share their immediate experiences in their own words. For the pre-session reflection, participants are prompted to answer the following question: \"How are you feeling at this moment? How do you perceive your emotions and your body right now? Take your time to describe any physical sensations, thoughts, or emotions that come to mind.\" After the session, the post-session reflection asks participants to respond to both the initial question and an additional prompt: \"Now that the session is over, how are you feeling? How are your emotions, and how do you perceive your body? Talk about any changes you noticed compared to how you felt before the session.\" During selected sessions, participants are guided to reflect on their in-session experiences: \"Describe your experience during the exercises in the session. What emotions and sensations did you notice throughout? Were there moments when you felt discomfort or difficulty? Talk about how you responded to these sensations\u0026mdash;whether you tried to manage them in some way.\" The self-reflective report is required randomly during some sessions rather than every session to minimize excessive time spent on assessments and reduce participant burden.\u003c/p\u003e \u003cp\u003eAdditionally, this report provides the instructor with insights into the group's collective experience, enabling adjustments to session instructions that address common needs and improve overall guidance for the group. This is particularly important in the online format, where live conversations are limited due to participants being advised to mute their microphones to prevent environmental noise from disrupting the session. The study assessment sequence is summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eThe intervention was developed and delivered by a physiotherapist with extensive experience in pain management, movement-based therapies (including Somatic Education practices and Yoga), and mindfulness instruction. Participants receive a group WhatsApp reminder 30 minutes before each session and are invited to join an assessment 15 minutes prior to promote engagement and ensure schedule adherence; participants are advised not to join the session more than five minutes after it has started to avoid disrupting the group\u0026rsquo;s focused atmosphere.\u003c/p\u003e \u003cp\u003e The assessments (questionnaire and self-reflective report exercise) are explained as aiming to provide an opportunity for communication with the instructor outside the structured exercise period, which is conducted with participants remaining silent while also helping to enhance their ability to perceive and articulate sensations and emotional states. The weekly online group sessions, attended by 5\u0026ndash;10 participants, are guided by real-time verbal instructions, with the physiotherapist practicing the exercises alongside the group throughout the entire session, offering both auditory guidance and continuous visual support. While individualized adaptations are not incorporated into the core protocol, participants are encouraged to self-adjust movement amplitude and breathing based on comfort.\u003c/p\u003e \u003cp\u003eSessions take place in participants\u0026rsquo; homes via a secure video conferencing platform, requiring only a quiet space with sufficient room for movement. No specialized equipment is necessary, and exercises are designed to be performed in both standing and seated positions, making the intervention accessible to participants with different physical abilities. The physiotherapist follows a structured session guide detailing exercise sequences, timing, and key instructions to maintain intervention fidelity. Each component and its integration into the session are described below and summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCore Components of the Intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostural Stillness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePracticed in seated or standing pauses, allowing participants to perceive stillness in contrast to movement and become aware of automatic motor reactions or physical expressions of emotional and pain states. These pauses provide opportunities to identify and reformulate maladaptive or unconscious motor behaviors. Additionally, stretch positions are incorporated, directing attention to specific body areas where stretch sensations arise, promoting attentional regulation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeep Breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePracticed both independently and in coordination with movement, deep breathing is intended to enhance interoceptive awareness and engage autonomic modulation, supporting calmness and physiological adaptability.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMovement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerformed across multiple body planes, movements are integrated with breath control and executed with minimal effort. The practice is designed to refine attentional flexibility, motor control, and sensorimotor accuracy. Additionally, it encourages participants to overcome movement avoidance, excessive muscle tone, rigidity, or protective muscle guarding, facilitating greater ease and adaptability in movement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychological Attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe body\u0026rsquo;s practice elicits a range of somatosensory and interoceptive sensations and emotions, both pleasant and unpleasant, providing an opportunity to cultivate acceptance, nonreactivity, and present-centered awareness. This is encouraged by guiding participants to observe bodily sensations without resistance, suppression, or excessive cognitive elaboration.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eMovement Characteristics -\u003c/b\u003e Participants are guided to perform movements with deliberate pacing and smoothness, characterized by slow execution, fluid transitions, and the avoidance of abrupt changes in speed or direction. Effort is dynamically adjusted to the minimum required for each movement, reducing unnecessary stiffness. These characteristics are intended to enhance body awareness, flexible attention to sensations, and motor control while also addressing maladaptive motor behaviors, such as rigidity or unaware rapid movements, often linked with anxiety, threat perception, and restlessness [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Movements are performed across multiple body planes, including sagittal, frontal, horizontal, and rotational planes. This design allows participants to address fears and avoidance behaviors associated with specific directions and body parts, providing opportunities to reformulate their responses [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003ePostural Stillness\u003c/b\u003e - During Postural stillness exercises, participants are guided to achieve a balance where postures are both stable and relaxed, releasing automatic adjustments and enhancing muscle tension awareness and tone control [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. In neutral positions (sitting or standing), participants are encouraged to perceive the entire body\u0026mdash;its form, volume, and weight\u0026mdash;and to notice the sensation of stillness, contrasting it with the sensation of movement. In stretch positions, attention is directed to specific body parts where stretch sensations are present, promoting attentional regulation and encouraging participants to observe these sensations without reacting. During the slow return from non-neutral positions, participants are guided to notice the gradual reduction in stretch sensations, deepening their body awareness.\u003c/p\u003e \u003cp\u003e\u003cb\u003eDeep Breathing -\u003c/b\u003e The deep breathing component begins with participants perceiving the sensations of their natural breath, followed by instructions to lengthen their inhalation through the nostrils and exhalation through the mouth. During inhalation, they are guided to reduce effort and allow air to enter slowly and for an extended time, while exhalation emphasizes decelerating the release of air [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Breath movements primarily engage the abdomen, expanding to the chest only at the end of each cycle. Participants refine their breathing comfort and effort levels with each breath, ensuring alignment with their capacity. Deep breathing supports autonomic regulation, potentially enhancing parasympathetic tone and interoceptive awareness [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u003cb\u003eMindful Attitudes -\u003c/b\u003e Acceptance is trained by observing bodily sensations evoked during exercises\u0026mdash;pleasant or unpleasant\u0026mdash;without resistance or a desire to change them. Participants engage with the experience without striving to achieve specific outcomes. Nonreactivity is developed through calmly receiving sensations without altering movement or posture characteristics in response to discomfort, pain, or restlessness. Present-centered awareness is practiced by guiding participants to sustain an interest in the details of body sensations that arise during stillness, movement trajectories, and deep, low-effort breathing. Letting go of cognitive elaboration is also encouraged by educating participants about distraction as a natural mental activity, emphasizing that it should be noticed and attention patiently redirected to bodily sensations. This approach aims to cultivate presence and minimize overthinking [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntegration of Components into Structured Sessions -\u003c/b\u003e Sessions begin with landing attention into the body, a brief exercise (~\u0026thinsp;3 minutes) guiding participants to focus on physical sensations, such as contact with support surfaces, body weight, and volume. This transition helps participants shift from their previous tasks to a state of body-centered awareness. Participants are then guided through deep breathing exercises (~\u0026thinsp;5 minutes), followed by a transition into the core of the session, which consists of movement-based exercises intertwined with postural stillness (~\u0026thinsp;25 minutes).\u003c/p\u003e \u003cp\u003eMovement exercises progress from small, localized motions to broader, whole-body exercises, involving approximately 5\u0026ndash;8 repetitions of 3\u0026ndash;4 regional movements and 3\u0026ndash;4 whole-body movements (engaging multiple body parts). Most movement exercises are integrated with deep breathing. However, for exercises involving a very large range of motion, coordination with deep breathing is not emphasized to prevent discomfort from increased respiratory effort [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Movement exercises integrated with deep breathing aim to promote coordination and facilitate interoceptive awareness that encourages a positive emotional experience [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThree postural stillness exercises are interwoven throughout each session, involving stretch-based or neutral postures (e.g., sitting or upright positions without active stretch). During these exercises, participants are encouraged to adopt a natural breath with minimal effort. Alternating movement and stillness aim to facilitate awareness of distinct bodily qualities and associated reactions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The session concludes similarly to how it begins, with a brief seated exercise (~\u0026thinsp;3 minutes) guiding participants to focus on physical sensations, such as contact with support surfaces, body weight, and volume. However, this concluding exercise emphasizes releasing any residual effort in the body and breath, inviting participants to extend this sense of ease into a psychological attitude of non-striving\u0026mdash;accepting their current state without the need to change or control it [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. The entire session lasts approximately 35\u0026ndash;40 minutes. A random transcription of three sessions is available in the supplementary material, providing examples that illustrate how the core components are integrated into each session.\u003c/p\u003e \u003cp\u003eWhile the components of this intervention overlap with elements found in mindfulness, somatic education, yoga, and tai chi, these approaches are typically embedded within broader philosophical systems (e.g., Yoga and Tai Chi) and incorporate complex bodily and psychological practices [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. In research settings, many intervention protocols adopt an implicit guidance style common to these traditions, where key elements\u0026mdash;such as movement fluidity, effort regulation, embodied attention, and stillness\u0026mdash;are not explicitly instructed but are instead expected to develop naturally through practice. This implicit structure makes it difficult to delineate which specific components contribute to therapeutic effects.\u003c/p\u003e \u003cp\u003eTo avoid the imprecision of equating distinct interventions under the broad label of \"Mindful Movement,\" we deliberately refrain from using this term. Unlike mindfulness-based practices, which do not emphasize explicit movement training or breath manipulation, our intervention incorporates structured guidance for movement characteristics and breath regulation. Additionally, mindfulness protocols typically include components such as inquiry and psychoeducation, which are not part of the present intervention [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This distinction helps refine the hypothesized therapeutic pathway, ensuring that the specific mechanisms underlying intervention effects can be more precisely examined or inferred.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eVariability in the number of attended sessions and the different points at which participants begin their assessments lead to differences in both the total number of completed sessions and the specific session numbers at which assessments are conducted (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The primary analysis employs a weighted fixed-effects regression model for both continuous and categorical outcomes to ensure that participants with more observations do not disproportionately influence the results, accounting for this variability [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. For continuous outcomes, multiple linear regression models will examine pre-post session changes in pain intensity, arousal, valence, positive affect, and negative affect, with each outcome analyzed separately. For categorical outcomes, fixed-effects logistic regression will be used to assess the likelihood of improvement per session, applying inverse probability weighting to balance contributions from individuals with varying numbers of attended sessions while preserving within-subject effects. Proportions of improvement, worsening (defined as a one-point change in the scales), or stability (no change) will be reported as descriptive statistics, and chi-square tests will supplement the analysis by exploring categorical response distributions across sessions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo examine factors influencing session-by-session changes, both session-related and participant-related predictors will be included in the models. Session-related predictors include \"Environment\" (ordinal, capturing the quality of internet, audio, and physical setting), \"Instructions Comprehension\" (ordinal, reflecting participants\u0026rsquo; understanding of session instructions), and \"Number of Previous Sessions\" attended. Baseline clinical characteristics include Baseline Depression Level, Baseline Anxiety Level (both continuous), and Previous Standard Treatment Failure (categorized as hormonal, surgical, combined treatment, or no prior treatment). Commonly used sociodemographic covariates (e.g., age, education, socioeconomic status) will not be included in the models, as the study focuses on immediate within-subject changes, minimizing the influence of stable individual differences.\u003c/p\u003e \u003cp\u003eMissing data within a session (e.g., missing pre- or post-session scores) will initially result in session exclusion, but sensitivity analyses using a mixed-effects model will assess the robustness of results under different missing data assumptions. Effect sizes will be reported using standardized beta coefficients [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. Adjusted R-squared values will be used to assess model fit. Continuous variables will be summarized using means and standard deviations or medians and interquartile ranges, depending on distribution, while categorical variables will be reported as frequencies and percentages\u003c/p\u003e \u003cp\u003eA logistic regression model will assess the likelihood of participation based on baseline characteristics to evaluate whether systematic differences exist between participants who complete assessments and those who do not [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The model will include anxiety, depression, number of endometriosis-related pain symptoms, comorbidities, education level, and income as predictors. To further explore potential biases, interaction terms will be incorporated (e.g., anxiety \u0026times; depression) to test whether combined psychosocial factors impact participation likelihood. Odds ratios (ORs) with 95% confidence intervals will quantify the relative risk of non-participation for each predictor. Model discrimination will be evaluated using the area under the ROC curve (AUC), with values\u0026thinsp;\u0026ge;\u0026thinsp;0.70 indicating acceptable classification performance.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eSample Size Calculation\u003c/h2\u003e \u003cp\u003eSample size calculations were performed in R using the pwr.f2.test function from the pwr package [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. The design assumes each pre-post pair represents an independent change outcome. The calculation accounts for three predictors included in the model. Assuming a medium effect size (f\u0026sup2; = 0.15), a significance level (α\u0026thinsp;=\u0026thinsp;0.05), and a power of 0.80, the required sample size is 77 participants. This ensures sufficient power to detect a change of at least one point on the outcome scales.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity Analyses\u003c/h2\u003e \u003cp\u003eMixed-effects models will complement the primary analysis by incorporating all pre-post session assessments to examine individual variability and session effect consistency [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. These models will account for both within-subject (session-to-session) and between-subject differences, allowing for a more precise estimation of intervention effects while preserving individual trajectories. Fixed effects will include session-related predictors (e.g., environment quality, instruction comprehension, number of previous sessions) and baseline clinical characteristics (e.g., baseline depression and anxiety levels, prior treatment failure).\u003c/p\u003e \u003cp\u003eRandom intercepts will be used to account for baseline differences across participants, ensuring that each individual has a personalized starting level for outcomes of interest (e.g., pain, affect). This adjustment controls for pre-session variability that might influence session effects. Random slopes will model individual deviations in the relationship between predictors and outcomes, allowing session-related factors (e.g., number of previous sessions) to exert differential effects across participants. Cross-level interactions between baseline clinical characteristics and session-related predictors will be explored to assess individual susceptibility to session effects. All available pre-post session assessments will be included under the assumption that data are missing at random, leveraging the ability of mixed models to handle incomplete datasets without requiring imputation. Given the hierarchical structure of the data, sessions will be modeled as repeated measures nested within participants, allowing for the estimation of both within-person and between-person effects.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eMediator Analysis\u003c/h2\u003e \u003cp\u003eThe mediating roles of nonreactivity (FFMQ) and acceptance (MPFI) in the relationship between the intervention and changes in outcomes (e.g., pain, arousal, valence, positive affect, and negative affect) will be analyzed using a multilevel mediation approach that reflects the structure of the data [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. The primary focus is on within-session mediation, examining how session-related levels of nonreactivity and acceptance\u0026mdash;assessed immediately after each session\u0026mdash;account for intervention effects on pre-to-post changes in outcomes. Specifically, the model will estimate: (1) the effect of the intervention on nonreactivity and acceptance as experienced during the session, and (2) the extent to which these session-related mediator levels predict pre-to-post session changes in outcomes. Indirect effects will be calculated as the product of these pathways.\u003c/p\u003e \u003cp\u003eAdditionally, session-to-session variations in these mediators will be modeled to capture within-person indirect effects across repeated sessions. Between-person differences in mediation effects will also be explored but are not the primary focus. Given the shared underlying construct of nonreactivity and acceptance, a composite score integrating both variables will be explored as an additional mediator to expand variability and strengthen statistical power, addressing the limited range of the individual scales. This composite will be computed using standardized averages or factor scores based on shared variance between the two measures. Bayesian mediation modeling or rank-based methods will also be explored to further enhance the robustness of parameter estimation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eAnalysis of Qualitative Data from the Self-Reflective Report\u003c/h2\u003e \u003cp\u003e The qualitative data obtained from the Self-Reflective Report will undergo thematic analysis to explore how participants subjectively experience their bodies and emotions before the session, describe perceived shifts post-session, and engage with discomfort during the exercises. The coding process will follow an inductive-deductive approach, incorporating both emerging themes from the data and concepts from self-regulation frameworks [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePre-session responses will be analyzed to identify bodily sensations (e.g., tension, fatigue, discomfort, ease), emotional states (e.g., anxiety, frustration, calmness), and cognitive-affective framing (e.g., resistance, openness, anticipation). Post-session responses will be examined individually and comparatively to assess subjective accounts of both positive and negative experiences, such as relief, relaxation, vitality, safety, emotional clarity, lingering discomfort, increased distress, frustration, or fatigue. In-session reflections will be analyzed to capture participants' attitudes toward challenges, including avoidance, acceptance, engagement, or frustration, as well as strategies used to manage discomfort, such as breath regulation, attentional shifts, withdrawal, or suppression. These examples illustrate potential themes but do not limit the scope of analysis, allowing for additional emergent themes to be identified.\u003c/p\u003e \u003cp\u003eBecause participants may struggle to maintain present-moment awareness in their reports\u0026mdash;often shifting toward interpretations, explanations, or descriptions of past or future concerns and situations\u0026mdash;the analysis will assess the extent to which responses remain confined to immediate bodily and emotional sensations as an indicator of present-centered awareness. Additionally, themes related to cognitive shifts away from the present moment will be examined separately, capturing the types of interpretations, anticipated concerns, or past experiences participants bring into their reflections. This will provide insight into the content of these interpretations and concerns and how frequently participants spontaneously move away from describing present experiences.\u003c/p\u003e \u003cp\u003eQualitative data will be organized into a structured dataset to track thematic patterns over time, with individual case summaries as a basic method for examining consistency or variability across sessions. Each participant's responses will be compiled chronologically, with pre-, post-, and in-session reflections categorized per session. Themes will be coded at both the session level (capturing intra-session experiences) and the participant level (assessing patterns over multiple sessions). The frequency and variability of key themes will be analyzed to ensure the consistency of the participants' experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eIntegration of Qualitative and Quantitative Data\u003c/h2\u003e \u003cp\u003eTo triangulate qualitative findings with quantitative measures, a mixed-methods approach will be used to compare thematic categories with pre-post changes in pain intensity, affect, and arousal scores. A convergent design will be applied, in which qualitative and quantitative data are analyzed separately and then integrated for comparison [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Qualitative themes emerging from post-session reflections will be systematically compared with session-level changes in quantitative measures to identify meaningful patterns of correspondence or divergence. For example, qualitative reports of reduced discomfort, emotional relief, or positive expectation may correspond with decreased pain intensity or positive affect increases. Likewise, reports of exacerbated distress, frustration, or difficulty engaging with the exercises may be examined concerning increases in pain intensity, negative affect, or arousal levels. These represent potential patterns of alignment, but the analysis will remain open to additional, emergent relationships between subjective reports and quantitative outcomes.\u003c/p\u003e \u003cp\u003eA quantitative coding approach will be applied to selected qualitative categories, such as \"change in bodily perception,\" \"emotional relief,\" or \"difficulty maintaining present-moment awareness,\" transforming them into categorical or ordinal variables. These converted variables will then be incorporated into statistical analyses (e.g., mixed-effects models) to assess their association with session-level quantitative changes [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. Patterns of correspondence and divergence will be examined. Cases where qualitative descriptions of bodily and emotional shifts align with quantitative changes will be analyzed for consistency across participants and sessions. Conversely, cases where subjective reports indicate improvement despite stable or worsening quantitative scores (or vice versa) will be examined to explore potential discrepancies between experiential and measured changes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe observational study outlined in this protocol aims to evaluate the immediate effects of an online self-regulation intervention on pain, affect, and arousal in women with symptomatic endometriosis. The study addresses critical gaps in endometriosis pain management by exploring underdeveloped therapeutic pathways beyond lesion-focused frameworks within a middle-income public health setting [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. By targeting psychological attitudes (e.g., attentional flexibility, nonreactivity, and acceptance) [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and adaptive physiological states (e.g., movement practices, postural stillness, and breath regulation) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e], the intervention seeks to mitigate maladaptive cognitive-affective responses, reframe pain-related behaviors, and enhance patients' ability of self-regulation [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConventional care strategies for endometriosis predominantly emphasize etiology-focused approaches, such as hormonal therapies and surgical interventions. While these treatments address certain biological aspects of the disease, they often neglect the complicated interplay between pain mechanisms and psychosocial factors, leaving many patients underserved [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. This protocol highlights the importance of integrating self-regulation as a transdiagnostic therapeutic mechanism, addressing interconnected emotional, physiological, and behavioral contributors to pain in a comprehensive manner [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Such an intervention's unified framework creates opportunities for synergistic effects, amplifying its potential impact on participants' well-being.\u003c/p\u003e \u003cp\u003eWhile much of the existing research in endometriosis pain management focuses on long-term outcomes, this study prioritizes the consistency and relevance of acute effects. In the context of endometriosis, where women often experience sudden and severe pain flares, understanding immediate intervention effects is critical [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. These findings will provide valuable insights into the intervention's capacity to offer real-time symptom relief and equip patients with strategies to manage fluctuating pain and emotional distress effectively.\u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eMethodological Strengths\u003c/h2\u003e \u003cp\u003eThis study demonstrates several methodological strengths that support its aim of evaluating immediate intervention effects in a resource-constrained public health setting. The repeated-measures within-group design captures acute changes effectively and enhances causal inference by observing temporal relationships between the intervention and outcomes [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. By minimizing between-subject variability and focusing on immediate pre- to post-session changes, this approach reduces the influence of natural symptom fluctuations and provides a nuanced understanding of how the intervention addresses pain and emotional distress during critical moments, such as pain flares.\u003c/p\u003e \u003cp\u003eAdopting an online format represents another significant strength, improving accessibility for participants who may face geographical, logistical, or financial barriers to in-person sessions [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. This format is particularly relevant in middle-income countries, where public health systems are often strained, and regular travel to treatment centers may be prohibitive [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, the intervention's adaptability to accommodate a high patient influx without requiring increased session complexity is an important feature. By maintaining consistent session content, the protocol enables participants to join groups with lower delay, minimizing wait times and making the intervention more feasible within public health contexts [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These methodological elements contribute to advancing the understanding and implementation of scalable interventions for chronic pain conditions in resource-limited settings.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLimitations and Future Directions\u003c/h3\u003e\n\u003cp\u003eWhile the study protocol demonstrates a robust methodological foundation, several limitations should be considered. The absence of a traditional control group limits the ability to definitively attribute observed changes exclusively to the intervention, as placebo effects, desirability bias or other uncontrolled factors cannot be entirely excluded [\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. While the within-group repeated-measures design reduces between-subject variability and enhances temporal inference [\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e], its capacity to rule out external influences is inherently limited.\u003c/p\u003e \u003cp\u003eParticipants with high baseline levels of anxiety, depression, or pain sensitivity may exhibit variable responses, including occasional worsening of outcomes [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. These variations emphasize the need for adaptive intervention strategies that accommodate diverse participant needs, such as tailored session adjustments or additional support for more vulnerable individuals [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Additionally, the intervention is structured to integrate participants immediately after physician assessments, avoiding long waitlists. While this ensures broad accessibility and aligns with public health system constraints, it lacks the opportunity to progressively increase the complexity of exercises, which may limit the long-term development of the self-regulation skills being trained [\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, the protocol does not include structured evaluations of adherence to self-management strategies outside the intervention sessions, leaving a critical gap in understanding how well participants sustain these practices in their daily lives. Future research should explore the intervention's long-term impact by monitoring participants over extended periods, providing insights into the sustainability of outcomes and the potential for reducing recurrent pain flares, associated emotional distress and well-being improvement.\u003c/p\u003e \u003cp\u003eFuture studies should incorporate randomized controlled trials or innovative approaches, such as cross-over or N-of-1 trials, to complement the current findings. These designs could provide additional insights into the intervention's efficacy while balancing the strengths of within-person approaches for understanding individual variability. Expanding the application of this intervention to diverse settings, including low-resource environments, and examining its scalability and feasibility in these contexts would also provide critical data for broader implementation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAvailability of data and materials: The datasets used and/or analyzed during this study will be publicly available on ZENODO upon acceptance of the primary study.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding sources: This study received no funding\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: This study was conducted in accordance with the Declaration of Helsinki and approved by the Committee on Human Research at Rio de Janeiro State University (Pedro Ernesto University Hospital, approval number [Approval Number]). The requirement for written informed consent was waived by the Committee following ethical review and approval, as the study is observational, involves minimal risk, and all procedures and data collection were conducted as part of routine clinical care.\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eWe state that all listed authors contributed to the preparation of the manuscript as follows:\u003c/p\u003e\n\u003cp\u003eMarcelo de França Moreira - Conceptualization, Investigation, Writing-Original draft preparation.\u003c/p\u003e\n\u003cp\u003eMarco Aurelio Pinho Oliveira - Conceptualization, Writing-Original draft preparation.\u003c/p\u003e\n\u003cp\u003eAll authors commented on the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ede C Williams AC, McGrigor H. A thematic synthesis of qualitative studies and surveys of the psychological experience of painful endometriosis. BMC Womens Health. 2024;24:50.\u003c/li\u003e\n\u003cli\u003eAs-Sanie S, Black R, Giudice LC, Gray Valbrun T, Gupta J, Jones B, et al. Assessing research gaps and unmet needs in endometriosis. Am J Obstet Gynecol. 2019;221:86\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eMoreira MF, Oliveira MAP. Exploring the interplay between catastrophizing and endometriosis pain through two-wave and intensive longitudinal data. Pain Med. 2024. https://doi.org/10.1093/pm/pnae132.\u003c/li\u003e\n\u003cli\u003eMoreira M de F, Gamboa OL, Pinho Oliveira MA. Cognitive-affective changes mediate the mindfulness-based intervention effect on endometriosis-related pain and mental health: A path analysis approach. Eur J Pain. 2023. https://doi.org/10.1002/ejp.2149.\u003c/li\u003e\n\u003cli\u003eMoreira M de F, Oliveira MAP. Bringing endometriosis to the road of contemporary pain science. BJOG. 2025. https://doi.org/10.1111/1471-0528.18096.\u003c/li\u003e\n\u003cli\u003eZarbo C, Brugnera A, Frigerio L, Malandrino C, Rabboni M, Bondi E, et al. Behavioral, cognitive, and emotional coping strategies of women with endometriosis: a critical narrative review. Arch Womens Ment Health. 2018;21:1\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eTodd J, Pickup B, Coutts-Bain D. Fear of progression, imagery, interpretation bias, and their relationship with endometriosis pain. Pain. 2023;164:2839\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eDe Ruddere L, Craig KD. Understanding stigma and chronic pain: a-state-of-the-art review. Pain. 2016;157:1607\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eBorders AEB, Grobman WA, Amsden LB, McDade TW, Sharp LK, Holl JL. The relationship between self-report and biomarkers of stress in low-income reproductive-age women. Am J Obstet Gynecol. 2010;203:577.e1\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSyed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38:976\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003eGBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eBailey T, Shahabi L, Tarvainen M, Shapiro D, Ottaviani C. Moderating effects of the valence of social interaction on the dysfunctional consequences of perseverative cognition: an ecological study in major depression and social anxiety disorder. Anxiety Stress Coping. 2019;32:179\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eWeber CS, Thayer JF, Rudat M, Wirtz PH, Zimmermann-Viehoff F, Thomas A, et al. Low vagal tone is associated with impaired post stress recovery of cardiovascular, endocrine, and immune markers. Eur J Appl Physiol. 2010;109:201\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eLischke A, Jacksteit R, Mau-Moeller A, Pahnke R, Hamm AO, Weippert M. Heart rate variability is associated with psychosocial stress in distinct social domains. J Psychosom Res. 2018;106:56\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eWilliams DP, Joseph N, Hill LK, Sollers JJ 3rd, Vasey MW, Way BM, et al. Stereotype threat, trait perseveration, and vagal activity: evidence for mechanisms underpinning health disparities in Black Americans. Ethn Health. 2019;24:909\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eSimpson P, Holopainen R, Sch\u0026uuml;tze R, O\u0026rsquo;Sullivan P, Smith A, Linton SJ, et al. Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review. Phys Ther. 2021;101.\u003c/li\u003e\n\u003cli\u003eMalfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, et al. Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial. JAMA Neurol. 2018;75:808\u0026ndash;17.\u003c/li\u003e\n\u003cli\u003eMcHugh RK, Murray HW, Barlow DH. Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions. Behav Res Ther. 2009;47:946\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eJohnson S, Bradshaw A, Bresnahan R, Evans E, Herron K, Hapangama DK. Biopsychosocial approaches for the management of female chronic pelvic pain: A systematic review. BJOG. 2024. https://doi.org/10.1111/1471-0528.17987.\u003c/li\u003e\n\u003cli\u003eAs-Sanie S, Till SR, Schrepf AD, Griffith KC, Tsodikov A, Missmer SA, et al. Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain. Am J Obstet Gynecol. 2021;225:568.e1\u0026ndash;568.e11.\u003c/li\u003e\n\u003cli\u003eZajec V, Miku\u0026scaron; M, Vitale SG, D\u0026rsquo;alterio MN, Gregov M, \u0026Scaron;arić MJ, et al. Current status and challenges of drug development for hormonal treatment of endometriosis: a systematic review of randomized control trials. Gynecol Endocrinol. 2022;38:713\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003ede Fran\u0026ccedil;a Moreira M, Gamboa OL, Pinho Oliveira MA. Association between severity of pain, perceived stress and vagally-mediated heart rate variability in women with endometriosis. Women Health. 2021;61:937\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eVercellini P, Barbara G, Abbiati A, Somigliana E, Vigan\u0026ograve; P, Fedele L. Repetitive surgery for recurrent symptomatic endometriosis: what to do? Eur J Obstet Gynecol Reprod Biol. 2009;146:15\u0026ndash;21.\u003c/li\u003e\n\u003cli\u003eLamvu G, Soliman AM, Manthena SR, Gordon K, Knight J, Taylor HS. Patterns of prescription opioid use in women with endometriosis: Evaluating prolonged use, daily dose, and concomitant use with benzodiazepines. Obstet Gynecol. 2019;133:1120\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eLinton SJ. A Transdiagnostic Approach to Pain and Emotion. J Appl Biobehav Res. 2013;18:82\u0026ndash;103.\u003c/li\u003e\n\u003cli\u003eWilliams PG. Self-regulation, executive functioning, and neurovisceral integration. Pain. 2010;151:5\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eSauer-Zavala S, Gutner CA, Farchione TJ, Boettcher HT, Bullis JR, Barlow DH. Current Definitions of \u0026ldquo;Transdiagnostic\u0026rdquo; in Treatment Development: A Search for Consensus. Behav Ther. 2017;48:128\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eTaylor AG, Goehler LE, Galper DI, Innes KE, Bourguignon C. Top-down and bottom-up mechanisms in mind-body medicine: development of an integrative framework for psychophysiological research. Explore . 2010;6:29\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eTang Y-Y, Ma Y, Fan Y, Feng H, Wang J, Feng S, et al. Central and autonomic nervous system interaction is altered by short-term meditation. Proc Natl Acad Sci U S A. 2009;106:8865\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eZheng Y-L, Wang D-X, Zhang Y-R, Tang Y-Y. Enhancing Attention by Synchronizing Respiration and Fingertip Pressure: A Pilot Study Using Functional Near-Infrared Spectroscopy. Front Neurosci. 2019;13:1209.\u003c/li\u003e\n\u003cli\u003eRussell TA, Arcuri SM. A Neurophysiological and Neuropsychological Consideration of Mindful Movement: Clinical and Research Implications. Front Hum Neurosci. 2015;9:282.\u003c/li\u003e\n\u003cli\u003eZautra AJ, Fasman R, Davis MC, Craig ADB. The effects of slow breathing on affective responses to pain stimuli: an experimental study. Pain. 2010;149:12\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eFranklin AR, Mathersul DC, Raine A, Ruscio AM. Restlessness in generalized anxiety disorder: Using actigraphy to measure physiological reactions to threat. Behav Ther. 2021;52:734\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eVan Damme S, Van Ryckeghem DML, Wyffels F, Van Hulle L, Crombez G. No pain no gain? Pursuing a competing goal inhibits avoidance behavior. Pain. 2012;153:800\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eJafari H, Gholamrezaei A, Franssen M, Van Oudenhove L, Aziz Q, Van den Bergh O, et al. Can slow deep breathing reduce pain? An experimental study exploring mechanisms. J Pain. 2020;21:1018\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eKerr CE, Sacchet MD, Lazar SW, Moore CI, Jones SR. Mindfulness starts with the body: somatosensory attention and top-down modulation of cortical alpha rhythms in mindfulness meditation. Front Hum Neurosci. 2013;7:12.\u003c/li\u003e\n\u003cli\u003eKhalsa SS, Adolphs R, Cameron OG, Critchley HD, Davenport PW, Feinstein JS, et al. Interoception and Mental Health: A Roadmap. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging. 2018;3:501\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eSchmalzl L, Kerr CE, editors. Neural mechanisms underlying movement-based embodied contemplative practices. Frontiers Media SA; 2016.\u003c/li\u003e\n\u003cli\u003eBourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M. Systematic review of endometriosis pain assessment: how to choose a scale? Hum Reprod Update. 2015;21:136\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eNnoaham KE, Hummelshoj L, Kennedy SH, Jenkinson C, Zondervan KT, World Endometriosis Research Foundation Women\u0026rsquo;s Health Symptom Survey Consortium. Developing symptom-based predictive models of endometriosis as a clinical screening tool: results from a multicenter study. Fertil Steril. 2012;98:692\u0026ndash;701.e5.\u003c/li\u003e\n\u003cli\u003eCastro MMC, Quarantini L, Batista-Neves S, Kraychete DC, Daltro C, Miranda-Scippa \u0026Acirc;. Validade da escala hospitalar de ansiedade e depress\u0026atilde;o em pacientes com dor cr\u0026ocirc;nica. Rev Bras Anestesiol. 2006;56:470\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eGalinha IC, Pereira CR, Esteves F. Vers\u0026atilde;o reduzida da escala portuguesa de afeto positivo e negativo - PANAS-VRP: An\u0026aacute;lise fatorial confirmat\u0026oacute;ria e invari\u0026acirc;ncia temporal. PSICOLOGIA. 2014;28:53\u0026ndash;65.\u003c/li\u003e\n\u003cli\u003eRussell JA. A circumplex model of affect. J Pers Soc Psychol. 1980;39:1161\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003ePosner J, Russell JA, Peterson BS. The circumplex model of affect: an integrative approach to affective neuroscience, cognitive development, and psychopathology. Dev Psychopathol. 2005;17:715\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eRemington NA, Fabrigar LR, Visser PS. Reexamining the circumplex model of affect. J Pers Soc Psychol. 2000;79:286\u0026ndash;300.\u003c/li\u003e\n\u003cli\u003eAnvari F, Lakens D. Using anchor-based methods to determine the smallest effect size of interest. J Exp Soc Psychol. 2021;96:104159.\u003c/li\u003e\n\u003cli\u003e\u0026Aring;kerblom S, Perrin S, Rivano Fischer M, McCracken LM. Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: the contributions of psychological flexibility. J Behav Med. 2021;44:111\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eTeper R, Inzlicht M. Meditation, mindfulness and executive control: the importance of emotional acceptance and brain-based performance monitoring. Soc Cogn Affect Neurosci. 2013;8:85\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eBarros VV de, Kozasa EH, Souza ICW de, Ronzani TM. Validity evidence of the brazilian version of the five facet mindfulness questionnaire (FFMQ). Psic: Teor e Pesq. 2014;30:317\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eFl\u0026oacute;rido S, Cunha M, Carreiras D, Galhardo A. Adapta\u0026ccedil;\u0026atilde;o da Vers\u0026atilde;o Portuguesa do Multidimensional Psychological Flexibility Inventory para Adolescentes: Estrutura Fatorial e Propriedades Psicom\u0026eacute;tricas. Rev Iberoam Diagn Eval - Aval Psicol. 2024;72:55.\u003c/li\u003e\n\u003cli\u003eMohr DC, Schueller SM, Montague E, Burns MN, Rashidi P. The behavioral intervention technology model: an integrated conceptual and technological framework for eHealth and mHealth interventions. J Med Internet Res. 2014;16:e146.\u003c/li\u003e\n\u003cli\u003eSun JC-Y, Rueda R. Situational interest, computer self-efficacy and self-regulation: Their impact on student engagement in distance education. Br J Educ Technol. 2012;43:191\u0026ndash;204.\u003c/li\u003e\n\u003cli\u003eMehling WE, Wrubel J, Daubenmier JJ, Price CJ, Kerr CE, Silow T, et al. Body Awareness: a phenomenological inquiry into the common ground of mind-body therapies. Philos Ethics Humanit Med. 2011;6:6.\u003c/li\u003e\n\u003cli\u003eCrane RS, Brewer J, Feldman C, Kabat-Zinn J, Santorelli S, Williams JMG, et al. What defines mindfulness-based programs? The warp and the weft. Psychol Med. 2017;47:990\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKerr CE, Agrawal U, Nayak S. The Effects of Tai Chi Practice on Intermuscular Beta Coherence and the Rubber Hand Illusion. Front Hum Neurosci. 2016;10:37.\u003c/li\u003e\n\u003cli\u003eSchmalzl L, Crane-Godreau MA, Payne P. Movement-based embodied contemplative practices: definitions and paradigms. Front Hum Neurosci. 2014;8:205.\u003c/li\u003e\n\u003cli\u003eTang Y-Y, Ma Y, Wang J, Fan Y, Feng S, Lu Q, et al. Short-term meditation training improves attention and self-regulation. Proc Natl Acad Sci U S A. 2007;104:17152\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGarcia-Toro M, Aguilar-Latorre A, Garcia A, Navarro-Guzm\u0026aacute;n C, Gervilla E, Segu\u0026iacute; A, et al. Mindfulness skills and experiential avoidance as therapeutic mechanisms for treatment-resistant depression through mindfulness-based cognitive therapy and lifestyle modification. Front Psychol. 2023;14:1008891.\u003c/li\u003e\n\u003cli\u003eJensen MP, Ehde DM, Day MA. The Behavioral Activation and Inhibition Systems: Implications for Understanding and Treating Chronic Pain. J Pain. 2016;17:529.e1\u0026ndash;529.e18.\u003c/li\u003e\n\u003cli\u003eSullivan MB, Erb M, Schmalzl L, Moonaz S, Noggle Taylor J, Porges SW. Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience for Self-Regulation and Resilience. Front Hum Neurosci. 2018;12:67.\u003c/li\u003e\n\u003cli\u003eMa X, Yue Z-Q, Gong Z-Q, Zhang H, Duan N-Y, Shi Y-T, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Front Psychol. 2017;8:874.\u003c/li\u003e\n\u003cli\u003eWeng HY, Feldman JL, Leggio L, Napadow V, Park J, Price CJ. Interventions and Manipulations of Interoception. Trends Neurosci. 2021;44:52\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eHalbert JD, Baban B, vanTuyll D, Barnes V, Thayer J, Kapuku GK. BREATH ATTENTION MEDITATION ENHANCES PARASYMPATHETIC ACTIVITY AND INCREASES ANTI-INFLAMMATION MARKERS. In: PSYCHOSOMATIC MEDICINE. LIPPINCOTT WILLIAMS \u0026amp; WILKINS TWO COMMERCE SQ, 2001 MARKET ST, PHILADELPHIA \u0026hellip;; 2019. p. A99\u0026ndash;A99.\u003c/li\u003e\n\u003cli\u003eKabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J Behav Med. 1985;8:163\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eWan L, Van Diest I, De Peuter S, Bogaerts K, Oyen N, Hombroux N, et al. Repeated experiences of air hunger and ventilatory behavior in response to hypercapnia in the standardized rebreathing test: effects of anxiety. Biol Psychol. 2008;77:223\u0026ndash;32.\u003c/li\u003e\n\u003cli\u003eLindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and Acceptance Theory (MAT). Clin Psychol Rev. 2017;51:48\u0026ndash;59.\u003c/li\u003e\n\u003cli\u003eRobins JM, Hern\u0026aacute;n MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology. 2000;11:550\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eNieminen P, Lehtiniemi H, V\u0026auml;h\u0026auml;kangas K, Huusko A, Rautio A. Standardised regression coefficient as an effect size index in summarising findings in epidemiological studies. ebph. 2013;10.\u003c/li\u003e\n\u003cli\u003eMaldonado G, Greenland S. Simulation study of confounder-selection strategies. Am J Epidemiol. 1993;138:923\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003ePWR.\u003c/li\u003e\n\u003cli\u003eBaayen RH, Davidson DJ, Bates DM. Mixed-effects modeling with crossed random effects for subjects and items. J Mem Lang. 2008;59:390\u0026ndash;412.\u003c/li\u003e\n\u003cli\u003ePreacher KJ, Zyphur MJ, Zhang Z. A general multilevel SEM framework for assessing multilevel mediation. Psychol Methods. 2010;15:209\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic analysis: A practical guide. bpsqmip. 2022;1:46\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eRobinson P. Designing and conducting mixed methods research. Aust N Z J Public Health. 2007;31:388.\u003c/li\u003e\n\u003cli\u003evan Grootel L, Balachandran Nair L, Klugkist I, van Wesel F. Quantitizing findings from qualitative studies for integration in mixed methods reviewing. Res Synth Methods. 2020;11:413\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003ede Fran\u0026ccedil;a Moreira M, Oliveira MAP. Endometriosis pain or its \u0026ldquo;phantom\u0026rdquo; pain? The elephant in the room of research. BJOG. 2024. https://doi.org/10.1111/1471-0528.17927.\u003c/li\u003e\n\u003cli\u003eThayer JF, Hansen AL, Saus-Rose E, Johnsen BH. Heart rate variability, prefrontal neural function, and cognitive performance: the neurovisceral integration perspective on self-regulation, adaptation, and health. Ann Behav Med. 2009;37:141\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eCoxon L, Lugt C, Horne AW, Evans E, Abreu-Mendes P, Arendt-Nielsen L, et al. Symptom flares in women with chronic pelvic pain: Questionnaire study within a cohort study (translational research in pelvic pain (TRiPP)). BJOG. 2024. https://doi.org/10.1111/1471-0528.17915.\u003c/li\u003e\n\u003cli\u003eHoward MC, Hoffman ME. Variable-centered, person-centered, and person-specific approaches: Where theory meets the method. Organ Res Methods. 2018;21:846\u0026ndash;76.\u003c/li\u003e\n\u003cli\u003eHamaker EL. Why researchers should think \u0026ldquo;within-person\u0026rdquo;: A paradigmatic rationale. In: Mehl MR, editor. Handbook of research methods for studying daily life (pp. New York, NY, US: The Guilford Press, xxvii; 2012. p. 43\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eSullivan MB, Hill K, Ballengee LA, Knoblach D, Fowler C, Haun J, et al. Remotely delivered psychologically informed Mindful Movement physical therapy for pain care: A framework for operationalization. Glob Adv Integr Med Health. 2023;12:27536130231209751.\u003c/li\u003e\n\u003cli\u003eSohl SJ, Tooze JA, Wheeler A, Zeidan F, Wagner LI, Evans S, et al. Iterative adaptation process for eHealth Mindful Movement and Breathing to improve gynecologic cancer surgery outcomes. Psychooncology. 2019;28:1774\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eMurray LK, Metz K, Callaway K. Transdiagnostic therapeutic approaches: A global perspective. Global Mental Health and Psychotherapy. 2019;:25\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eHo AMH, Phelan R, Mizubuti GB, Murdoch JAC, Wickett S, Ho AK, et al. Bias in Before-After Studies: Narrative Overview for Anesthesiologists. Anesth Analg. 2018;126:1755\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003ede Fran\u0026ccedil;a Moreira M, Gamboa OL, Oliveira MAP. Daily interaction between meditation and endometriosis pain and the mindfulness effect on pain interference in activities throughout a brief mindfulness-based intervention. Mindfulness . 2024. https://doi.org/10.1007/s12671-024-02381-y.\u003c/li\u003e\n\u003cli\u003eMilbocker KA, Smith IF, Klintsova AY. Maintaining a dynamic brain: A review of empirical findings describing the roles of exercise, learning, and environmental enrichment in neuroplasticity from 2017-2023. Brain Plast. 2024;9:75\u0026ndash;95.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5969427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5969427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEndometriosis is a chronic condition that affects millions of women worldwide, causing significant pain, emotional distress, and impaired quality of life. Despite advances in biomedical treatments, many patients continue to experience persistent symptoms due to the complex interplay between biopsychosocial factors, shaped by the lived experience of endometriosis and further exacerbated by socioeconomic adversities common in middle- and low-income countries. Self-regulation, the ability to modulate physiological and psychological responses, addresses core mechanisms underlying emotional challenges and pain, potentially benefiting interconnected difficulties. This study aims to evaluate the immediate effects of an online self-regulation intervention that integrates smooth whole-body movements, postural stillness, and deep breathing, explicitly guiding participants to train adaptive psychological attitudes such as present-centered awareness, nonreactivity, and acceptance through body exercises.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis observational study employs a within-subject, repeated-measures design to assess pre-to-post-session changes in pain intensity, affect, and arousal in women with symptomatic endometriosis. Assessments include self-reported measures of pain, affective states, and psychological attitudes before and after each session. Statistical analyses will use weighted fixed-effects regression models to estimate immediate changes, adjusting for session and clinical predictors. Mixed-effects models will explore individual variability, accounting for repeated measures within participants. Mediation analysis will examine whether nonreactivity and acceptance explain intervention effects on pain and affective outcomes. Additionally, qualitative analysis will be conducted using thematic content analysis of self-reflexive reports to capture participants' spontaneous narratives regarding their engagement with the intervention and its perceived impact beyond predefined quantitative outcomes. Data collection began in August 2024 at the Endometriosis Outpatient Clinic of Pedro Ernesto University Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy investigating the acute effects of a structured online self-regulation intervention, this study aims to provide insights into non-pharmacological strategies for managing endometriosis-related pain and emotional distress. Understanding the short-term impact of the intervention will help refine its delivery and inform future research on long-term effects. Given the limited accessibility of specialized pain management resources, particularly in low- and middle-income settings, this study may contribute to the development of scalable, low-cost therapeutic approaches.\u003c/p\u003e","manuscriptTitle":"Exploring the Immediate Effects of an Online Self-Regulation Intervention on Pain, Affect, and Arousal in Women with Endometriosis: An Observational Study Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-21 15:45:49","doi":"10.21203/rs.3.rs-5969427/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d513a9f5-8f6f-4b24-9df7-5cadc7ead259","owner":[],"postedDate":"February 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-21T15:45:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-21 15:45:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5969427","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5969427","identity":"rs-5969427","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}