Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC) is a chronic condition characterized by pain, pressure, or discomfort in the pelvic area accompanied by urinary symptoms such as urgency or frequency [1]. Some studies suggest that central sensitization may be an underlying mechanism of chronic pain in patients with PBS/IC [2,3]. However, biomedical treatments for PBS/IC have been found to be insufficiently effective. The guidelines emphasize the preference for holistic-focused multimodal physiotherapy approaches based on the biopsychosocial model in the treatment of PBS/IC. However, there is limited evidence supporting the effectiveness of biopsychosocial-based physiotherapy approaches in the management of PBS/IC. The objective of this study was to investigate the impact of biopsychosocial physiotherapy approaches on symptoms, pain intensity, disability, pain cognitions, and psychological symptoms in patients diagnosed with PBS/IC.

This is a single-arm experimental clinical trial. 15 patients with PBS/IC-related symptoms, such as pain, pressure, and discomfort for more than 6 months, were included in the study. Demographics, physical characteristics, and medical conditions of the patients were recorded. Primary outcome measures were the severity of symptoms (assessed using the Interstitial Cystitis Symptom and Problem Index) and pain intensity (assessed using the Visual Analogue Scale). Secondary outcome measures were determined as urinary symptoms, assessed by the 3-day Bladder Diary; disability, by the Pain Disability Index; pain cognitions, measured by the Pain Catastrophizing Scale (PCS) and the Pain Self-Efficacy Questionnaire; psychological symptoms, by the Hospital Anxiety and Depression Scale (HADS); and quality of life by the Short Form-36 (SF-36). Patients were evaluated at baseline and immediately after the completion of the interventions (i.e., at the end of week 6).
Patients were enrolled in a comprehensive physiotherapy programme that included patient education, pain neuroscience education, lumbopelvic stabilization exercises, and relaxation training. At the first treatment session, patients were informed about the anatomy and physiology of the urinary system, the function of the pelvic floor muscles, and the symptoms of PBS/IC and their risk factors. They were also given suggestions about implications for the behavioral changes that can help reduce symptoms. These suggestions emphasized stress management, staying away from bladder irritants, using the correct voiding and defecation posture, regulating fluid intake, and reducing or ceasing smoking or alcohol use.
During the first week of the study, patients underwent two Pain Neuroscience Education (PNE) sessions, each lasting approximately 30 minutes. Following the first session, a home education leaflet was provided to the patients. In this leaflet, the information from the first PNE session is summarized. Patients were encouraged to read the brochure several times and note down any questions before the second session. The research team tailored these materials specifically for patients with PBS/IC. For this reason, the investigators included appropriate visual materials, examples, and metaphors to adapt the PNE teaching material and home education leaflet.
The study involved strengthening and mobility exercises, which were performed twice a week for six weeks under the supervision of a trained physiotherapist. In accordance with functional, dynamic, and coordination principles, lumbopelvic strengthening exercises (with light and moderate intensity), stretching and flexibility exercises, and breathing exercises were gradually performed (by increasing the intensity and number of repetitions).
At the end of the physiotherapy session, relaxation training including visual imagery, meditation and breathing techniques was applied twice a week for six weeks in a comfortable and quiet environment. 
Numerical data was analyzed using the Wilcoxon test. The statistical significance level was determined as p<0.05.

A total of 15 women who had PBS/IC symptoms (age: 43,4±14,3 years, BMI: 25,6± 4,7 kg/m2) were included in this study. 
At the end of the 6th week, statistically significant improvements were observed in all outcome measures compared to the baseline, except for urinary symptoms and difficulties in the emotional and physical role sub-domains of quality of life (Table 1). A decrease in the pain intensity from 6,3 cm to 4,2 cm was observed at the end of the 6th week.

To the best of our knowledge, this study is the first to adopt pain neuroscience education and a biopsychosocial physiotherapy approach for patients diagnosed with PBS/IC. According to the results of this study, it seems that the biopsychosocial physiotherapy approach can improve pain intensity, pain-related beliefs, and psychological status in patients with PBS/IC at the short-term.
On the other hand, the biopsychosocial physiotherapy approach does not seem to be sufficient to improve the urinary symptoms of PBS/IC patients. In addition to the biopsychosocial physiotherapy approach, it would be useful to offer other interventions such as bladder training in these patients.

Multimodal biopsychosocial physiotherapy approaches may be a promising treatment modality in the first-line conservative management of PBS/IC to improve symptoms, disability, and pain related cognitions. In the management of PBS/IC, integrating this physiotherapy approach, which addresses the biological, psychological, and social aspects of pain, into the physiotherapy programs may be particularly beneficial for patients with maladaptive pain cognitions. Further randomized controlled trials should investigate the effect of the interventions based on the biopsychosocial model of pain in patients with PBS/IC.

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