Genito-Pelvic Pain/Penetration Disorder (GPPPD) is a common condition characterized by persistent or recurrent pain during intercourse for more than six months, categorized as a sexual dysfunction in the Diagnostic and Statistical Manual of Mental Disorders. As GPPPD shares similarities with other persistent pain conditions like phantom limb pain or complex regional pain syndrome, it should be treated as persistent pain. Neuroplastic changes in the peripheral and central nervous systems have been observed in women with GPPPD. Graded Motor Imagery (GMI) has shown promise in managing similar pain states but has not been studied in GPPPD. This study aimed to assess the efficacy of an online GMI program on pain intensity and sexual function in women with GPPPD.

A randomized controlled trial was conducted to compare the effects of a GMI program with a control group in women with GPPPD. Participants were recruited following the ethical principles outlined in the Declaration of Helsinki. After providing written consent, participants completed baseline characteristics and outcome assessments via an online form, along with a brief explanatory video and written procedure information. Participants were randomized into intervention or control groups using sealed opaque envelopes in a 1:1 ratio. The intervention group received an online GMI program for six weeks, divided into three phases: left/right laterality discrimination judgment task, guided imagery exercises, and gradual exposure to painful activities. The control group completed outcome assessments every two weeks but received no intervention initially. Post-intervention, the control group gained access to the full GMI program.

Pain intensity was assessed using the Visual Analogue Scale (VAS) before and after the intervention and between each phase of the program. Sexual function was evaluated using the short version of the Female Sexual Function Index (FSFI-6). Statistical analysis involved mixed model two-way repeated measures ANOVA to assess within-subject and between-subject differences.
The determination of the required sample size indicated that each group should consist of a minimum of 40 participants. This configuration would provide 80% statistical power to identify a clinically meaningful reduction of 1.4 points in pain intensity (VAS), standard deviation of 1.3 points, derived from our previous research, while maintaining an α-error level of 0.05.

Of the 96 recruited participants, 9 did not meet inclusion criteria, and 4 refused to continue with the intervention, leaving 83 women for analysis. Significant improvements in pain intensity were observed over time within the GMI group (p<0.05), with a mean reduction from 6.9 to 4.7 on the VAS and an effect size of 0.339. Between-group analysis showed a significant difference between the GMI group and the control group (p<0.05), with an effect size of 0.239. Sexual function showed non-significant improvement in the GMI group, while the control group exhibited worsening. No significant differences were found between the groups regarding sexual function.

This study represents the first investigation of a GMI program in women with GPPPD. The GMI program produced significant improvements in pain intensity but non-significant improvements in sexual function. This aligns with the focus of GMI on desensitizing the central nervous system without directly addressing sexual function. The online delivery of the program enhances accessibility for women hesitant about face-to-face therapy.

Graded Motor Imagery emerges as an effective treatment option for women with GPPPD, significantly reducing pain intensity. Future research should explore complementary interventions targeting sexual function to provide comprehensive care for women with this persistent pain condition, ensuring accessibility to all affected individuals.