Vulvodynia or chronic vulvar pain is a highly prevalent and debilitating condition affecting up to 16% of women and provoked vestibulodynia (PVD) is the most common subtype. Physiotherapy (PT) is recognized as a first-line treatment for PVD and is effective for reducing pain and improving sexual function. It has been shown in different fields of medicine that the therapist himself, beyond the treatment provided, plays a significant role in treatment efficacy [1-2]. For instance, in psychology, the relationship with the patient, including support given by the therapist, is a predominant factor in treatment response [1]. In surgical treatments, it was shown that the surgeon’s experience influences treatment success [2]. However, no studies thus far have investigated the role of the physiotherapist in PT treatment response in women with PVD. Given that PT requires both interpersonal and technical skills, it could be hypothesized that both the physiotherapist’s support and experience will affect treatment response. This is the first study to evaluate the moderating role of the physiotherapist by investigating the associations between (1) the physiotherapist’s support, as perceived by the patient during treatment and (2) the physiotherapist’s experience, and the improvement in pain and sexual function in women with PVD.

This study is embedded in a randomized clinical trial treating women with PVD with either pelvic floor physical therapy or topical lidocaine. Data of the 105 women allocated to the physical therapy group were considered in the analyses. Women were included in the study after having their diagnosis of PVD confirmed by one of our collaborating gynecologists following a standardized protocol. They had to report a mean pain intensity of ≥5 (at the numerical scale from 0 to 10), for at least 90% of sexual intercourse attempts and for a ≥6 month duration.
PT treatment response was assessed at baseline, post-treatment and at 6-months follow-up by an assessor blinded to group assignation using the following validated and recommended outcomes [3]: pain intensity during intercourse (numerical rating scale 0-10), pain quality (McGill Pain Questionnaire) and sexual function (Female Sexual Function Index).

The physiotherapist’s support as perceived by the patient during treatment was assessed with the Interpersonal Behavior Scale-short form (IBS-SF). The questionnaire total score, ranging from 10 to 70, was calculated to assess behaviors pertaining to relatedness (or sense of care), competence and autonomy support with higher score being associated with higher support.
The physiotherapist’s clinical experience was assessed for each professional at the time they were conducting the treatment of each participant. It was calculated as the total number of days worked per week was converted into years of experience as a general physiotherapist, pelvic floor physiotherapist, and pelvic pain physiotherapist, by considering the number of working days after deducting weekends, holidays and work leave.
Multilevel modeling analyses were used to assess the moderating effect of physiotherapist’s experience and support on changes from baseline to post-treatment and from baseline to 6-months follow-up. Data was analyzed using the software SPSS® 25.0 (Statistical Package for the Social Sciences, IBM) and significance level considered p<0.05.

Of 105 patients enrolled in the study, 99 completed post treatment and 94 returned for the 6-months follow-up. A total of 15 female physiotherapists were involved in treatments. As for the physiotherapist’s support as perceived by the patients, the average score was 6.2 (±0.8 SD; range 3.3 to 7.0). The physiotherapist’s support perceived by the patient was associated with greater improvements in pain quality (B -4.924; SE 1.890; 95%CI -8.675; -1.175) and sexual function (B 1.749; SE 0.838; 95%CI 0.081; 3.416) from baseline to post-treatment. The moderating role of the physiotherapist’s support was not significant for changes in pain intensity and for all three outcomes at 6-month follow-up (p>0.05). Physiotherapists had an averaged total experience of 5.2 years (±3.9 SD) of which 2.6 years (2.4 SD) of experience was specifically on treating pelvic floor muscles and 0.9 years (±1.2 SD) on treating pelvic pain. Results showed that the physiotherapist’s experience (general or specific to pelvic floor/pelvic pain) was not associated with treatment response outcomes (p>0.05).

This study presents original data regarding the role of the physiotherapist in PT treatment response in women with pain. Our results showed that higher physiotherapist’ support was associated with greater improvement of pain quality and sexual function from baseline to post-treatment. Our findings emphasize the importance of the supportive behaviors from the physiotherapist to enhance patient’s response to PT during the active phase of treatment. These significant outcomes were however not sustained at 6-month follow-up which could be anticipated given that the interrupted contact with the physiotherapist during this period.
In regards to clinical experience, our results showed a non-significant moderating effect on treatment response. However, it is important to highlight that the present study was carried out in a clinical research trial setting where the physiotherapists received an intensive training in order to provide standardized treatment.

Findings of this study reveal that the physiotherapist’s support as perceived by the patient was identified as an important factor related to improvement in pain quality and sexual function immediately after treatment in women with PVD. In the context of our randomized controlled trial where the physiotherapists are following a standardized protocol and are highly trained in pelvic floor rehabilitation, the physiotherapist’s clinical experience was not related to treatment response. Future clinical research and practitioners should focus on the quality of the support given to patients with PVD in order to improve the effectiveness of their intervention.

Anderson, T., et al., A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome. J Consult Clin Psychol, 2016. 84(1): p. 57-66.
Cahill, P.J., et al., The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis. J Bone Joint Surg Am, 2014. 96(16): p. 1333-9.
Pukall, C.F., et al., Recommendations for Self-Report Outcome Measures in Vulvodynia Clinical Trials. Clin J Pain, 2017. 33(8): p. 756-765.