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A more global approach to musculoskeletal pain: Expressive writing as an effective adjunct to physiotherapy a
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Luisa Pepe , Roberta Milani , Michela Di Trani , Gianluca Di b
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Folco , Vittorio Lanna & Luigi Solano
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Department of Dynamic and Clinical Psychology, University of Rome “Sapienza”, Rome, Italy b
Department of Physical Medicine and Rehabilitation, “Luigi Di Liegro” Hospital, Rome, Italy Published online: 20 Nov 2013.
To cite this article: Luisa Pepe, Roberta Milani, Michela Di Trani, Gianluca Di Folco, Vittorio Lanna & Luigi Solano (2014) A more global approach to musculoskeletal pain: Expressive writing as an effective adjunct to physiotherapy, Psychology, Health & Medicine, 19:6, 687-697, DOI: 10.1080/13548506.2013.859712 To link to this article: http://dx.doi.org/10.1080/13548506.2013.859712
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Psychology, Health & Medicine, 2014 Vol. 19, No. 6, 687–697, http://dx.doi.org/10.1080/13548506.2013.859712
A more global approach to musculoskeletal pain: Expressive writing as an effective adjunct to physiotherapy
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Luisa Pepea*, Roberta Milanib, Michela Di Trania, Gianluca Di Folcob, Vittorio Lannab and Luigi Solanoa Department of Dynamic and Clinical Psychology, University of Rome “Sapienza”, Rome, Italy; Department of Physical Medicine and Rehabilitation, “Luigi Di Liegro” Hospital, Rome, Italy
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(Received 5 March 2013; accepted 21 October 2013) The aim of this study was to investigate the effects of written emotional disclosure as an adjunct to physiotherapy. Forty outpatients with musculoskeletal pain were treated with Mézières physiotherapy for 10 sessions. Half of the subjects also wrote about difficult life experiences immediately after four of these sessions. Data analysis showed that although both the writing and non-writing groups displayed lower pain scores after physiotherapy, the difference was stronger in the writing group. Pain scores continued to decrease six months after physiotherapy in the writing group alone. The postural evaluation revealed a greater improvement in the writing group than in the non-writing group, while the TAS-20 and SCL-90 scores decreased in the writing group alone. These results indicate that written emotional disclosure is an effective adjunct to physiotherapy insofar as it promotes further health improvements at both the physical and psychological levels. Keywords: written disclosure; emotion; physiotherapy; low back pain and neck pain; alexithymia
Introduction Authors with different theoretical views (Bucci, 1997; Ferro, 2002; Fonagy, 2001; Modell, 1990; Pennebaker & Beall, 1986) have advocated the beneficial value of storytelling, in that it allows people to give new meaning to past experiences and to process-related emotions. Pennebaker has empirically shown how subjects writing about traumatic events for 15–20 min a day for three or four days could obtain both psychological and physical benefits on various parameters, such as immune function (Esterling, Antoni, Fletcher, Margulies, & Schneiderman, 1994; Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Petrie, Booth, Pennebaker, Davison, & Thomas, 1995), coping ability in college students (Pennebaker, Colder, & Sharp, 1990), increased ability to find work (Antonelli, Pecci, & Solano, 2000; Spera, Buhrfeind, & Pennebaker, 1994), decrease in sick leave and in the number of medical visits in public employees (Pepe, Nicolardi, Bucci, & Solano, 2009). Research on clinical samples showed symptom improvement in patients with: asthma and rheumatoid arthritis (Smyth, Stone, Hurewitz, & Kaell, 1999; Warner et al., 2006); breast cancer (Stanton et al., 2002); HIV infection (Petrie, Fontanilla, Thomas, Booth, & Pennebaker, 2004). Other research revealed reduced post-surgery hospital stay *Corresponding author. Email: [email protected] © 2013 Taylor & Francis
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(Solano, Donati, Pecci, Persichetti, & Colaci, 2003; Solano et al., 2007), better control of glycaemia in diabetes (Pastena, Tabasso, Pepe, Maida, & Solano, 2007), less pain at delivery and lower post-natal depression (Bucci, Solano, Donati, & San Martini, 2005). The effects of this procedure appear to be related to “re-transcribing” emotionally relevant events, so processing hitherto “undigestible” emotions (Bion, 1962), which may become thinkable and communicable, thereby preventing their potential negative effects at a sub-symbolic (i.e. bodily) level (Bucci, 1997; Taylor, Bagby, & Parker, 1997). Construction of a significant story allows connection of experience and related emotions with the verbal level (Smyth & Pennebaker, 2008); more, the narrative obtained in writing offers the possibility of multiplying the perspectives of the narrated event (Fonagy, 1991; Pennebaker & Francis, 1996). A further, not alternative, explanation, is that, besides favouring a more adaptive re-transcription of specific events, writing may enhance and/or develop a mental function named by different authors: translation from an analogue to a digital format (Pennebaker & Chung, 2007); transformation from beta to alfa elements (Bion, 1962); capacity of connecting the sub-symbolic with symbolic systems (Bucci, 1997; Solano, 2010). This enhanced function may then be applied by individuals to all subsequent life situations, with positive effects on physical and mental health (Pennebaker & Chung, 2007). Expressive writing appeared particularly useful as an intervention in subjects with physical illness, since these rarely recognize psychological distress or formulate a request for psychological treatment. Writing may in fact be presented to subjects as a research instrument or as a tool for promoting capacities to cope with their illness. Its field of application is therefore considerably broader than any known formal psychotherapeutic treatment, provided that the intervention is integrated in a pre-existing context that is significant for the individual, therefore not requiring specific effort and motivation. For all these reasons, we decided to propose the writing disclosure to patients suffering from neck and back pain, in the context of their physiotherapeutic treatment. Neck and back pain affect as many as 60–80% of the adult population in developed countries (Carey, Garrett, Jackman, & Hadler, 1999), causing a substantial burden on society (Dagenais, Caro, & Haldeman, 2008). Back pain is defined as a localized pain in the lumbar/sacral region, while neck pain is defined as a localized pain in the cervical spinal region (Coppola & Masiero, 2005). Back pain is related to incorrect posture and to other factors (traumas, disc hernias, surgical operations, etc.), which may in turn worsen incorrect posture; psychological and emotional factors also often underlie postural behaviour (Scoppa, 2000). Patients with fibromyalgia and low back pain show high alexithymia scores Verissimo (2007, 2008), suggesting that identification and regulation of emotions is a determinant factor in pain modulation. Françoise Mézières’ Global Postural Rehabilitation, the method utilized in our study, is based on a global view of the body (Mézières, 1949, 1984): regaining balance and improved flexibility in a rehabilitative sense does not simply mean achieving an objective (biomechanical and neurological) readjustment of the imbalance, but also helping the individual patient to explore his/her posture and the emotional components that led to the imbalance itself, in that particular moment in his/her life. We chose to investigate the effect of written emotional disclosure as an adjunct to Mézières’s physiotherapy on the assumption that it would improve the participants’ capacity to deal with their life events and ensuing emotions and that this would be reflected in both their physical and psychological well-being. We therefore expected the writing group subjects, compared with non-writing group subjects, to display: (1) A greater reduction in pain; (2) a greater improvement in postural evaluation scores;
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(3) a greater increase in perceived psychophysical well-being and (4) a greater improvement in contact and processing of emotion, as expressed by a greater reduction in alexithymia scores.
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Method Participants Forty patients affected by neck pain and low back pain who attending the “Luigi di Liegro” hospital in Rome for physiotherapy. The inclusion criteria were: age between 25 and 65, a minimum level of education corresponding to a junior high school diploma, the absence of other significant pathologies, no analgesic intake, not undergoing psychotherapy. No compensation was offered. The final group consisted of 12 men and 28 women, mean age 44.75 years, mean education 13.57 years, mean duration of 6.11 years from the onset of pain to treatment. 85% of patients were working. Measures General questionnaire Social and demographic data (age, education, occupation, marital status) and information on alcohol, cigarette and drug use, level of physical exercise, years of pain. Visual Analogue Scale (VAS) It is used for the assessment of pain in the cervical and/or lumbar spine. It is a 10 cm long line that visually represents the magnitude of pain perceived by a patient. The patient is asked to mark a spot on the line corresponding to the level of pain felt. The distance, measured in millimetres starting from the end which indicates the absence of pain, represents the measurement of perceived pain. Postural evaluation It was performed by the physiotherapist. Posture is assessed by observing the position and alterations of the feet, knees, hips, spine, scapula, neck and head. Points from 0 to 2, assigned for alterations in each joint, are added to yield a final score. Symptom Check List (SCL-90) A 90-item self-report scale, each item representing a physical or psychic symptom with a score from 0 to 4 assigned depending on its presence and frequency in the previous week (Derogatis, 1977; Italian version Magni, Messina, De Leo, Mosconi, & Carli, 1983). The Global Score Index (GSI) was used as a measure of perceived psychophysical well-being. Twenty-Item Toronto Alexithymia Scale (TAS-20) A 20-item self-report scale, each item scored from one to five. It yields a total alexithymia score, plus a score for each of three factors: difficulty identifying feelings (DIF); difficulty describing feelings (DDF), externally orientated thinking (EOT) (Bagby, Parker, & Taylor, 1994a, 1994b; Italian version Bressi et al., 1996).
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Procedure All patients attending the physiatric clinic who met the inclusion criteria were asked by the physician involved to take part in a study designed to evaluate the psychological aspects connected with pain’ until a number of 40 was reached. Only four patients (9%) refused to take part in the study, while dropout was nought. Physical treatment consisted of 10 weekly physiotherapy sessions lasting one hour each. Patients were randomized in blocks of two to a writing group or a non-writing group. Informed consent was obtained from each patient during their first physiotherapy session. Then, they completed the general questionnaire and the VAS, TAS-20 and SCL-90 questionnaires. The postural evaluation was conducted by the physiotherapist. While the participants in both groups attended all 10 physiotherapy sessions, the written task was added to the physiotherapy in the writing group alone at the end of each of the first four sessions, in a separate room in the clinic. Both the questionnaires and the writing instructions were administered by a qualified psychologist. Instructions were the following: I’d like you to write down your deepest thoughts and feelings about the most difficult experience in your life, for about 20 min. In your writing, I’d like you to really let go and explore your very deepest emotions and thoughts. You can write about your relationships with others including your children, relatives and friends. You can write about your past, your present, or your future, or about who you have been, who you would like to be, or who you are now. You may write about the same general issues or experiences on every day of writing or on a different topic each day. All of your writing will be completely confidential.
The psychologist collected texts and checked that the writing task had in fact been accomplished. After the last physiotherapy session, patients from both groups were asked to complete the VAS, TAS-20 and SCL-90 questionnaires again. The physiotherapist (blind as to the writing condition of patients) conducted the postural evaluation once more. Six months after the beginning of treatment, all patients were asked to complete the VAS test again in a follow-up appointment. Statistical analyses To evaluate homogeneity, the writing and non-writing groups were compared on independent social, anagraphic, health variables and on dependent variables at baseline using χ2 for categorical variables and Analysis of Variance for continuous variables. To test hypotheses, we applied repeated measures ANCOVA, with group (writing/ non-writing) and time (before/after physiotherapy/six months after the end of physiotherapy) as independent variables; the VAS, postural evaluation, SCL-90 and TAS-20 scores as dependent variables and years of pain as covariate to control the effect of this variable on outcomes (since it appeared marginally different in the two groups). Results The writing and non-writing groups did not differ significantly on any independent variable, nor on any dependent variable at baseline (Tables 1 and 2). Years of pain wear marginally higher in the non-writing group. This variable was therefore introduced as a covariate in subsequent analyses. Group (writing/non-writing) × time (before/after physiotherapy/six months follow-up) interactions were significant for all the variables (except TAS-20 DIF), and differences were all in the expected directions. Means, standard deviations, F, p, effect size and observed power are reported in Table 3.
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Table 1. Sociodemographic and health features of the writing and non-writing groups – continuous variables.
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Variables Age Years of education Years of pain Cigarette (mean/day) Alcohol (mean/day) Physical activity (hours/week) Visual Analogue Scale (VAS) Postural evaluation GSI (SCL-90) TAS-20 TOT DIF DDF EOT
Table 2.
Writing group (N = 20) m (SD)
Non-writing group (N = 20) m (SD)
44.80 (11.53) 14.45 (2.66) 4.28 (4.19) 2.65 (6.52) .10 (.44) 1 (1.65) 8.30 (1.26) 32.50 (8.32) .73 (.53)
44.70 12.70 7.93 2.40 .25 .50 8.11 27.95 .56
(7.80) (2.81) (7.25) (5.37) (.63) (1.14) (1.38) (10.69) (.44)
.001 4.081 3.799 .017 .740 1.233 .206 2.255 1.153
.974 .051 .059 .895 .395 .274 .605 .141 .289
(n.s.) (n.s.) (n.s.) (n.s.) (n.s.) (n.s.) (n.s.) (n.s) (n.s.)
44.65 15.30 11.70 17.75
(11.75) (6.60) (4.60) (4.78)
.939 .487 1.470 .203
.338 .489 .233 .654
(n.s.) (n.s.) (n.s.) (n.s.)
48.35 16.70 13.40 18.45
(12.38) (6.07) (4.26) (5.03)
F
p
Sociodemographic features of writing and non-writing group – categorical variables. Writing group
Sex Marital status
Women Men Married Divorced Widowed Single
15 5 12 2 0 6
Non-writing group 13 7 13 4 1 2
TOT
χ2
p
28 12 25 6 1 8
.48
.49
3.70
.29
The group × time interaction for the VAS scores was significant (F = 19.33, p = .000). Post hoc tests showed a significant difference in both groups from before to after physiotherapy, though the writing group showed greater improvement (writing group from m = 8.30 to m = 2.76, p = .000; non-writing group from m = 8.11 to m = 5.43, p = .000), whereas six months after the end of physiotherapy the difference from baseline was significant for the writing group alone (writing group from m = 8.30 to m = 2.33, p = .00; non-writing group from m = 8.11 to m = 6.04, p = .14). The difference between the writing group (m = 2.76) and the non-writing group (m = 5.43) was significant immediately after physiotherapy (p = .008) and six months after the end of physiotherapy (writing group m = 2.33, non-writing group m = 6.04, p = .0004) (Figure 1). The group × time interaction for the postural evaluation was significant (F = 10.42, p = .003). Post hoc comparisons showed improvements in both groups immediately after physiotherapy, though the writing group improved to a greater extent (from m = 32.50 to m = 18.45, p = .0000 for the writing group; from m = 27.95 to m = 21.65, p = .0001 for the non-writing). The group × time interaction was also significant for psychophysical well-being, as measured by the GSI of the SCL-90, (F = 7.17, p = .011). Post hoc analyses showed a significant decrease in the writing group (from m = .73 to m = .58, p = .02), while the non-writing group remained stable (from m = .56 to m = .59, p = .59).
TAS-20 F3 (EOT)
TAS-20 F2 (DDF)
TAS-20 F1 (DIF)
TAS-20 (Total score)
SCL-90 (GSI)
Before physiotherapy After physiotherapy 6-month follow-up Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy
8.30 2.76 2.33 32.50 18.45 .73 .58 48.35 40.95 16.70 14.05 13.40 11.05 18.45 15.85
(1.26) (2.03) (2.28) (8.32) (7.49) (.53) (.51) (12.38) (10.78) (6.07) (5.99) (4.26) (5.34) (5.03) (5.05)
Writing group m (SD) 8.11 (1.38) 5.43 (2.58) 6.04 (2.39) 27.95 (10.69) 21.65 (8.32) .56 (.44) .59 (.60) 44.65 (11.75) 44.25 (14.66) 15.30 (6.60) 13.70 (8.11) 11.70 (4.60) 11.95 (5.25) 17.75 (4.78) 18.70 (5.63)
Non-writing group m (SD)
8.14
5.49
.13
7.18
7.17
10.42
19.33
F
Interaction between group and time on all dependent variables with years of pain as covariate.
Postural evaluation
VAS
Table 3.
.007
.025
.72 (n.s.)
.011
.011
.003
.000
p
.18
.13
.00
.16
.16
.22
.34
Effect size η2
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.79
.63
.06
.74
.74
.88
.99
Observed power
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The overall TAS-20 score showed a significant group × time interaction (F = 7.18, p = .011). Post hoc analyses showed a significant decrease in the TAS-20 scores in the writing group (from m = 48.35 to m = 40.95, p = .0008), whereas those in the non-writing group remained unchanged (from m = 44.65 to m = 44.25, p = .84). The first TAS-20 factor (DIF) score did not reveal any significant group × time interaction (F = .13, p = .72). A significant main effect of time emerged (F = 4.69, p = .04), with both groups improving on this variable (writing group: from m = 16.70 to m = 14.05; non-writing group: from m = 15.30 to m = 13.70). The DDF and EOT TAS-20 factors showed a significant group × time interaction (F = 5.49, p = .025 for DDF; F = 8.14, p = .007 for EOT). DDF scores decreased significantly in the writing group (m = 13.40 before physiotherapy, m = 11.05 after physiotherapy, p = .009) though not in the non-writing group (from m = 11.70 to m = 11.95, p = .77). EOT scores also significantly decreased in the writing group (from m = 18.45 to m = 15.85, p = .03), though not in the non-writing group (from m = 17.75 to m = 18.70, p = .40). Discussion Overall, the results of our study support the hypothesis that the cognitive and emotional processing afforded by written emotional disclosure strengthens the effects of physiotherapy, promoting greater psychophysical improvement in individuals affected by low back pain and neck pain. Confirming our first hypothesis, the written processing of a traumatic event combined with physiotherapy more effectively reduced back and/or neck pain when compared with the control group who received physiotherapy alone (Table 3 and Figure 1). This result was apparent in the short and long term and is in agreement with literature showing the effects of psychological intervention on pain reduction (e.g. van Hooff et al., 2012).
10 8,3
9 8 7
8,11
6
VAS
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5,43
6,04
2,76
2,33
5 4 3 2 1 0 Before Physiotherapy
After Physiotherapy
Writing Group
Figure 1.
Writing effect on pain (VAS scores).
6-month follow-up
Non-Writing Group
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One possible explanation is that writing allows patients to come into contact with their emotions (as shown by the reduction in alexithymia scores) and to explore emotionally relevant past events, which in turn leads to an assimilation and resolution of the events themselves. Another possible explanation (see introduction) is that an enhanced capacity for processing emotionally meaningful events was applied by subjects to subsequent life situations, with positive effects on physical and mental health. This mechanism could be particularly relevant for long-term results, apparently the most important from a clinical and economic viewpoint. Confirming our second hypothesis, though postural evaluation values improved in both groups, writing subjects achieved a more balanced posture than non-writing subjects, possibly thanks to the contribution of emotional processing on body perception. The patient’s subjective evaluation of pain and the physiotherapist’s objective evaluation of posture converge to demonstrate the effectiveness of combined treatment. As predicted in our third hypothesis, writing subjects reported fewer symptoms of various origins at the SCL-90, so displaying a greater improvement in psychophysical well-being than non-writing subjects. As predicted in the fourth hypothesis, only the writing group obtained lower global TAS-20 scores after physiotherapy. This result appears particularly significant for patients with musculoskeletal pain, who show higher alexithymia levels than healthy subjects (Verissimo 2007, 2008). As to individual factors, DIF showed an improvement in both groups, whereas DDF and EOT improved in the writing group alone. This suggests that the Mézières treatment did improve patients’ perception of their own bodies, entailing improved identification of bodily sensations, possibly leading to improved perception and discrimination of feelings. By contrast, only patients who wrote additionally improved in the DDF and EOT factors, which may be ascribed to the cognitive/emotional processing that occurred as a result of writing. One possible explanation is that the writing group was able to process emotions that had been helped to surface by the Mézières treatment at a non-symbolic level: in this regard, it is noteworthy that some patients cried after a Mézières physiotherapy session, possibly expressing a hitherto unknown psychological suffering, which found the time and space for adequate processing in writing. Multidisciplinary intervention, as achieved in our study by the joint utilization of physiotherapy and writing, appears to obtain a global, integrative effect on all systems of the organism, verbal and non-verbal, symbolic and non symbolic (Bucci, 1997), cognitive/experiential and physiological (Taylor et al., 1997). Important aspects of our results are the very low rate of refusal (9%, four patients) and 0% rate of dropout, showing that the technique may be easily and extensively applied in this population, and the importance of its implementation in a significant pre-existing context, in this case immediately after the physiotherapy sessions, and not as a separate intervention. Limitations and perspectives One limitation of this study may be the relatively small size of the sample. Another limitation might be the initial, marginally significant differences between the writing and non-writing groups as regards the years of pain: this problem was dealt with by considering this variable as a covariate. Another aspect that could be considered a limitation is that the control subjects did not write at all while in the original procedure they generally wrote about neutral topics.
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We believe that it would be very difficult to write about neutral topics in a hospital context: writing about “the room they were in” or “what they were wearing” would possibly lead patients to write about their being in hospital or their illness in general, which are in themselves very emotional issues not so different from those addressed in the writing group. A solution for future research could be the implementation in the control group of some intervention different from writing, such as viewing films on theoretical issues. Comparison of the effects of written disclosure with other kinds of psychological intervention as an adjunct to physiotherapy could be considered an important future development. As stated in the introduction, however, the rate of refusal of formal psychological intervention in subjects with somatic illness might make comparison very problematic. References Antonelli, F., Pecci, F. & Solano, L. (2000). L’elaborazione scritta dell’esperienza di licenziamento di un campione di 40 disoccupati [Written processing of the redundancy experience in a sample of 40 subjects in search of employment]. IV Congresso Italiano di Psicologia della Salute, Orvieto, 21–23 settembre 2000. Bagby, R.M., Parker, J.D.A., & Taylor, G.J. (1994a). The Twenty-Item Toronto Alexithymia Scale – I. Item selection and cross-validation of the factor structure. Journal of Psychosomatic Research, 38, 23–32. Bagby, R.M., Parker, J.D.A., & Taylor, G.J. (1994b). The Twenty-Item Toronto Alexithymia Scale – II. Convergent discriminant, and concurrent validity. Journal of Psychosomatic Research, 38, 33–40. Bion, W.R. (1962). Learning from experience. London: Heinemann. Bressi, C., Taylor, G.J., Parker, J.D.A., Bressi, S., Brambilla, V., Aguglia, E., … Invernizzi, G. (1996). Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: An Italian multicenter study. Journal of Psychosomatic Research, 41, 551–559. Bucci, W. (1997). Psicoanalisi e scienza cognitiva, 2000, Roma: Fioriti [Psychoanalysis and cognitive science. A multiple code theory]. New York, NY: Guilford Press. Bucci, F., Solano, L., Donati, V., & San Martini, P. (2005). Regolazione affettiva e salute in gravidanza e nel puerperio: Effetti di un intervento di scrittura in 39 gestanti primipare [Affect regulation and health in pregnancy and post-partum: Effects of expressive writing in 39 pregnant women]. Infanzia e Adolescenza, 4, 114–128. Carey, T.S., Garrett, J.M., Jackman, A., & Hadler, N. (1999). Recurrence and care seeking after acute back pain: Results of a long-term follow up study. North Carolina Back Pain Project Medical Care, 37, 157–164. Coppola, L. & Masiero, S. (2005). Riabilitazione in ortopedia [Rehabilitation in orthopedics]. Padova: Piccin Nuova Libreria. Dagenais, S., Caro, J., & Haldeman, S. (2008). A systematic review of low back pain cost of illness studies in the United States and internationally. Spine Journal, 8, 8–20. Derogatis, L.R. (1977). The SCL-90 manual I: Scoring, administration and procedures for the SCL90. Baltimore, MD: John Hopkins University School of Medicine, Clinical psychometrics Unit. Esterling, B.A., Antoni, M.H., Fletcher, M.A., Margulies, S., & Schneiderman, N. (1994). Emotional disclosure through writing or speaking modulates latent Epstein-Barr virus antibody titers. Journal of Consulting and Clinical Psychology, 62, 130–140. Ferro, A. (2002). Fattori di Malattia, fattori di guarigione. Milano: Raffaello Cortina Editore. (Engl. Transl., Seeds of Illness, seeds of recovery, 2004, London: Routledge). Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. International Journal of Psychoanalysis, 72, 639–656. Fonagy, P. (2001). Attachment theory and psychoanalysis. New York, NY: Other Press. (Italian Transl., Psicoanalisi e teoria dell’attaccamento, 2002, Milano: Raffaello Cortina Editore). Magni, G., Messina, C., De Leo, D., Mosconi, A., & Carli, M. (1983). Psychological distress in parents of children with acute lymphatic leukemia. Acta Psychiatrica Scandinavica, 68, 297–300. Mézières, F. (1949). La révolution en gymnastique orthopédique [A revolution in orthopedic gym]. Paris: Vuibert.
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Mézières, F. (1984). Originalité de la méthode Mézières [Original aspects of the Mezière method]. Paris: Maloine. Modell, A.H. (1990). Other times, other realities toward a theory of psychoanalytic treatment. Harvard University Press. (Italian Transl., Per una teoria del trattamento psicoanalitico, 1994, Milano: Raffaello Cortina Editore). Pastena, R., Tabasso, C., Pepe, L., Maida, P., & Solano, L. (2007). Effetti della tecnica della scrittura sul benessere e il controllo glicemico in soggetti diabetici con diversi livelli di alessitimia [Effects of expressive writing on wellbeing and glycemic control in diabetic subjects with different alexithymia levels]. Psicologia della Salute, 1, 127–145. Pennebaker, J.W., & Beall, S.K. (1986). Confronting a traumatic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281. Pennebaker, J.W., & Chung, C.K. (2007). Expressive writing, emotional upheavals, and health. In H.S. Friedman & R.C. Silver (Eds.), Foundations of health psychology (pp. 263–284). New York, NY: Oxford University Press. Pennebaker, J.W., Colder, M., & Sharp, L.K. (1990). Accelerating the coping process. Journal of Personality and Social Psychology, 58, 528–537. Pennebaker, J.W., & Francis, M. (1996). Cognitive, emotional, and language processes in disclosure. Cognition and Emotion, 10, 601–626. Pennebaker, J.W., Kiecolt-Glaser, J., & Glaser, R. (1988). Disclosure of traumas and immune function: Health implications for psychotherapy. Journal of Consulting and Clinical Psychology, 56, 239–245. Pepe, L., Nicolardi, F., Bucci, F., & Solano, L. (2009). Salute ed elaborazione scritta di eventi emotivamente rilevanti in ambito lavorativo [Health and written processing of emotionally relevant events in a professional domain]. Psicologia della Salute, 3, 113–137. Petrie, K.J., Booth, R., Pennebaker, J.W., Davison, K.P., & Thomas, M. (1995). Disclosure of trauma and immune response to Hepatitis B vaccination program. Journal of Consulting and Clinical Psychology, 63, 787–792. Petrie, K.J., Fontanilla, I., Thomas, M.G., Booth, R.J., & Pennebaker, J.W. (2004). Effects of written emotional expression on immune function in patients with human immunodeficiency virus infection: A randomized trial. Psychosomatic Medicine, 66, 272–275. Scoppa, F. (2000). Un approccio globale allo studio della postura [A global approach to posture]. Il Fisioterapista, 4, 61–66. Smyth, J.M., & Pennebaker, J.W. (2008). Exploring the boundary conditions of expressive writing: In search of the right recipe. British Journal of Health Psychology, 13, 1–7. Smyth, J.M., Stone, A.A., Hurewitz, A., & Kaell, A. (1999). Effect of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: A randomized trial. JAMA, 281, 1304–1309. Solano, L. (2010). Some thoughts between body and mind in the light of Wilma Bucci’s multiple code theory. International Journal of Psychoanalysis, 91, 1445–1464. Solano, L., Donati, V., Pecci, F., Persichetti, S., & Colaci, A. (2003). Post-operative course after papilloma resection: Effects of written disclosure of the experience in subjects with different alexithymia levels. Psychosomatic Medicine, 65, 477–484. Solano, L., Pepe, L., Donati, V., Persichetti, S., Laudani, G., & Colaci, A. (2007). Differential health effects of written processing of the experience of a surgical operation in high and low risk conditions. Journal of Clinical Psychology, 63, 357–369. Spera, S.P., Buhrfeind, E.D., & Pennebaker, J.W. (1994). Expressive writing and coping with job loss. Academy of Management Journal, 37, 722–733. Stanton, A.L., Danoff-Burg, S., Sworowski, L.A., Collins, C.A., Branstetter, A.D., RodriguezHanley, A., … Austenfeld, J.L. (2002). Randomized, Controlled trial of written emotional expression and benefit finding in breast cancer patients. Journal of Clinical Oncology, 20, 4160–4168. Taylor, G.J., Bagby, R.M., & Parker, J.D.A. (1997). Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge: Cambridge University Press. van Hooff, M.L., ter Avest, W., Horsting, P.P., O’Dowd, J., de Kleuver, M., van Lankveld, W., & van Limbeek, J. (2012). A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain. European Spine Journal, 21, 1257–1264. Verissimo, R. (2007). Alexithymia and health impact in fibromyalgia. Arquivos de Psiquiatria, 4, 29–36.
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Verissimo, R. (2008). Alexithymia, psychopathology and pain among patients with lumbago. Journal of Psychosomatic Research, 64, 679. Warner, L.J., Lumley, M.A., Csasey, R.J., Pierantoni, W., Salazar, R., Zoratti, E.M., … Simon, M.R. (2006). Health effects of written emotional disclosure in adolescents with asthma: A randomized, controlled trial. Journal of Pediatric Psychology, 31, 557–568.
Psychology, Health & Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cphm20
A more global approach to musculoskeletal pain: Expressive writing as an effective adjunct to physiotherapy a
b
a
Luisa Pepe , Roberta Milani , Michela Di Trani , Gianluca Di b
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Folco , Vittorio Lanna & Luigi Solano
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Department of Dynamic and Clinical Psychology, University of Rome “Sapienza”, Rome, Italy b
Department of Physical Medicine and Rehabilitation, “Luigi Di Liegro” Hospital, Rome, Italy Published online: 20 Nov 2013.
To cite this article: Luisa Pepe, Roberta Milani, Michela Di Trani, Gianluca Di Folco, Vittorio Lanna & Luigi Solano (2014) A more global approach to musculoskeletal pain: Expressive writing as an effective adjunct to physiotherapy, Psychology, Health & Medicine, 19:6, 687-697, DOI: 10.1080/13548506.2013.859712 To link to this article: http://dx.doi.org/10.1080/13548506.2013.859712
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Psychology, Health & Medicine, 2014 Vol. 19, No. 6, 687–697, http://dx.doi.org/10.1080/13548506.2013.859712
A more global approach to musculoskeletal pain: Expressive writing as an effective adjunct to physiotherapy
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Luisa Pepea*, Roberta Milanib, Michela Di Trania, Gianluca Di Folcob, Vittorio Lannab and Luigi Solanoa Department of Dynamic and Clinical Psychology, University of Rome “Sapienza”, Rome, Italy; Department of Physical Medicine and Rehabilitation, “Luigi Di Liegro” Hospital, Rome, Italy
a b
(Received 5 March 2013; accepted 21 October 2013) The aim of this study was to investigate the effects of written emotional disclosure as an adjunct to physiotherapy. Forty outpatients with musculoskeletal pain were treated with Mézières physiotherapy for 10 sessions. Half of the subjects also wrote about difficult life experiences immediately after four of these sessions. Data analysis showed that although both the writing and non-writing groups displayed lower pain scores after physiotherapy, the difference was stronger in the writing group. Pain scores continued to decrease six months after physiotherapy in the writing group alone. The postural evaluation revealed a greater improvement in the writing group than in the non-writing group, while the TAS-20 and SCL-90 scores decreased in the writing group alone. These results indicate that written emotional disclosure is an effective adjunct to physiotherapy insofar as it promotes further health improvements at both the physical and psychological levels. Keywords: written disclosure; emotion; physiotherapy; low back pain and neck pain; alexithymia
Introduction Authors with different theoretical views (Bucci, 1997; Ferro, 2002; Fonagy, 2001; Modell, 1990; Pennebaker & Beall, 1986) have advocated the beneficial value of storytelling, in that it allows people to give new meaning to past experiences and to process-related emotions. Pennebaker has empirically shown how subjects writing about traumatic events for 15–20 min a day for three or four days could obtain both psychological and physical benefits on various parameters, such as immune function (Esterling, Antoni, Fletcher, Margulies, & Schneiderman, 1994; Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Petrie, Booth, Pennebaker, Davison, & Thomas, 1995), coping ability in college students (Pennebaker, Colder, & Sharp, 1990), increased ability to find work (Antonelli, Pecci, & Solano, 2000; Spera, Buhrfeind, & Pennebaker, 1994), decrease in sick leave and in the number of medical visits in public employees (Pepe, Nicolardi, Bucci, & Solano, 2009). Research on clinical samples showed symptom improvement in patients with: asthma and rheumatoid arthritis (Smyth, Stone, Hurewitz, & Kaell, 1999; Warner et al., 2006); breast cancer (Stanton et al., 2002); HIV infection (Petrie, Fontanilla, Thomas, Booth, & Pennebaker, 2004). Other research revealed reduced post-surgery hospital stay *Corresponding author. Email: [email protected] © 2013 Taylor & Francis
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(Solano, Donati, Pecci, Persichetti, & Colaci, 2003; Solano et al., 2007), better control of glycaemia in diabetes (Pastena, Tabasso, Pepe, Maida, & Solano, 2007), less pain at delivery and lower post-natal depression (Bucci, Solano, Donati, & San Martini, 2005). The effects of this procedure appear to be related to “re-transcribing” emotionally relevant events, so processing hitherto “undigestible” emotions (Bion, 1962), which may become thinkable and communicable, thereby preventing their potential negative effects at a sub-symbolic (i.e. bodily) level (Bucci, 1997; Taylor, Bagby, & Parker, 1997). Construction of a significant story allows connection of experience and related emotions with the verbal level (Smyth & Pennebaker, 2008); more, the narrative obtained in writing offers the possibility of multiplying the perspectives of the narrated event (Fonagy, 1991; Pennebaker & Francis, 1996). A further, not alternative, explanation, is that, besides favouring a more adaptive re-transcription of specific events, writing may enhance and/or develop a mental function named by different authors: translation from an analogue to a digital format (Pennebaker & Chung, 2007); transformation from beta to alfa elements (Bion, 1962); capacity of connecting the sub-symbolic with symbolic systems (Bucci, 1997; Solano, 2010). This enhanced function may then be applied by individuals to all subsequent life situations, with positive effects on physical and mental health (Pennebaker & Chung, 2007). Expressive writing appeared particularly useful as an intervention in subjects with physical illness, since these rarely recognize psychological distress or formulate a request for psychological treatment. Writing may in fact be presented to subjects as a research instrument or as a tool for promoting capacities to cope with their illness. Its field of application is therefore considerably broader than any known formal psychotherapeutic treatment, provided that the intervention is integrated in a pre-existing context that is significant for the individual, therefore not requiring specific effort and motivation. For all these reasons, we decided to propose the writing disclosure to patients suffering from neck and back pain, in the context of their physiotherapeutic treatment. Neck and back pain affect as many as 60–80% of the adult population in developed countries (Carey, Garrett, Jackman, & Hadler, 1999), causing a substantial burden on society (Dagenais, Caro, & Haldeman, 2008). Back pain is defined as a localized pain in the lumbar/sacral region, while neck pain is defined as a localized pain in the cervical spinal region (Coppola & Masiero, 2005). Back pain is related to incorrect posture and to other factors (traumas, disc hernias, surgical operations, etc.), which may in turn worsen incorrect posture; psychological and emotional factors also often underlie postural behaviour (Scoppa, 2000). Patients with fibromyalgia and low back pain show high alexithymia scores Verissimo (2007, 2008), suggesting that identification and regulation of emotions is a determinant factor in pain modulation. Françoise Mézières’ Global Postural Rehabilitation, the method utilized in our study, is based on a global view of the body (Mézières, 1949, 1984): regaining balance and improved flexibility in a rehabilitative sense does not simply mean achieving an objective (biomechanical and neurological) readjustment of the imbalance, but also helping the individual patient to explore his/her posture and the emotional components that led to the imbalance itself, in that particular moment in his/her life. We chose to investigate the effect of written emotional disclosure as an adjunct to Mézières’s physiotherapy on the assumption that it would improve the participants’ capacity to deal with their life events and ensuing emotions and that this would be reflected in both their physical and psychological well-being. We therefore expected the writing group subjects, compared with non-writing group subjects, to display: (1) A greater reduction in pain; (2) a greater improvement in postural evaluation scores;
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(3) a greater increase in perceived psychophysical well-being and (4) a greater improvement in contact and processing of emotion, as expressed by a greater reduction in alexithymia scores.
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Method Participants Forty patients affected by neck pain and low back pain who attending the “Luigi di Liegro” hospital in Rome for physiotherapy. The inclusion criteria were: age between 25 and 65, a minimum level of education corresponding to a junior high school diploma, the absence of other significant pathologies, no analgesic intake, not undergoing psychotherapy. No compensation was offered. The final group consisted of 12 men and 28 women, mean age 44.75 years, mean education 13.57 years, mean duration of 6.11 years from the onset of pain to treatment. 85% of patients were working. Measures General questionnaire Social and demographic data (age, education, occupation, marital status) and information on alcohol, cigarette and drug use, level of physical exercise, years of pain. Visual Analogue Scale (VAS) It is used for the assessment of pain in the cervical and/or lumbar spine. It is a 10 cm long line that visually represents the magnitude of pain perceived by a patient. The patient is asked to mark a spot on the line corresponding to the level of pain felt. The distance, measured in millimetres starting from the end which indicates the absence of pain, represents the measurement of perceived pain. Postural evaluation It was performed by the physiotherapist. Posture is assessed by observing the position and alterations of the feet, knees, hips, spine, scapula, neck and head. Points from 0 to 2, assigned for alterations in each joint, are added to yield a final score. Symptom Check List (SCL-90) A 90-item self-report scale, each item representing a physical or psychic symptom with a score from 0 to 4 assigned depending on its presence and frequency in the previous week (Derogatis, 1977; Italian version Magni, Messina, De Leo, Mosconi, & Carli, 1983). The Global Score Index (GSI) was used as a measure of perceived psychophysical well-being. Twenty-Item Toronto Alexithymia Scale (TAS-20) A 20-item self-report scale, each item scored from one to five. It yields a total alexithymia score, plus a score for each of three factors: difficulty identifying feelings (DIF); difficulty describing feelings (DDF), externally orientated thinking (EOT) (Bagby, Parker, & Taylor, 1994a, 1994b; Italian version Bressi et al., 1996).
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Procedure All patients attending the physiatric clinic who met the inclusion criteria were asked by the physician involved to take part in a study designed to evaluate the psychological aspects connected with pain’ until a number of 40 was reached. Only four patients (9%) refused to take part in the study, while dropout was nought. Physical treatment consisted of 10 weekly physiotherapy sessions lasting one hour each. Patients were randomized in blocks of two to a writing group or a non-writing group. Informed consent was obtained from each patient during their first physiotherapy session. Then, they completed the general questionnaire and the VAS, TAS-20 and SCL-90 questionnaires. The postural evaluation was conducted by the physiotherapist. While the participants in both groups attended all 10 physiotherapy sessions, the written task was added to the physiotherapy in the writing group alone at the end of each of the first four sessions, in a separate room in the clinic. Both the questionnaires and the writing instructions were administered by a qualified psychologist. Instructions were the following: I’d like you to write down your deepest thoughts and feelings about the most difficult experience in your life, for about 20 min. In your writing, I’d like you to really let go and explore your very deepest emotions and thoughts. You can write about your relationships with others including your children, relatives and friends. You can write about your past, your present, or your future, or about who you have been, who you would like to be, or who you are now. You may write about the same general issues or experiences on every day of writing or on a different topic each day. All of your writing will be completely confidential.
The psychologist collected texts and checked that the writing task had in fact been accomplished. After the last physiotherapy session, patients from both groups were asked to complete the VAS, TAS-20 and SCL-90 questionnaires again. The physiotherapist (blind as to the writing condition of patients) conducted the postural evaluation once more. Six months after the beginning of treatment, all patients were asked to complete the VAS test again in a follow-up appointment. Statistical analyses To evaluate homogeneity, the writing and non-writing groups were compared on independent social, anagraphic, health variables and on dependent variables at baseline using χ2 for categorical variables and Analysis of Variance for continuous variables. To test hypotheses, we applied repeated measures ANCOVA, with group (writing/ non-writing) and time (before/after physiotherapy/six months after the end of physiotherapy) as independent variables; the VAS, postural evaluation, SCL-90 and TAS-20 scores as dependent variables and years of pain as covariate to control the effect of this variable on outcomes (since it appeared marginally different in the two groups). Results The writing and non-writing groups did not differ significantly on any independent variable, nor on any dependent variable at baseline (Tables 1 and 2). Years of pain wear marginally higher in the non-writing group. This variable was therefore introduced as a covariate in subsequent analyses. Group (writing/non-writing) × time (before/after physiotherapy/six months follow-up) interactions were significant for all the variables (except TAS-20 DIF), and differences were all in the expected directions. Means, standard deviations, F, p, effect size and observed power are reported in Table 3.
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Table 1. Sociodemographic and health features of the writing and non-writing groups – continuous variables.
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Variables Age Years of education Years of pain Cigarette (mean/day) Alcohol (mean/day) Physical activity (hours/week) Visual Analogue Scale (VAS) Postural evaluation GSI (SCL-90) TAS-20 TOT DIF DDF EOT
Table 2.
Writing group (N = 20) m (SD)
Non-writing group (N = 20) m (SD)
44.80 (11.53) 14.45 (2.66) 4.28 (4.19) 2.65 (6.52) .10 (.44) 1 (1.65) 8.30 (1.26) 32.50 (8.32) .73 (.53)
44.70 12.70 7.93 2.40 .25 .50 8.11 27.95 .56
(7.80) (2.81) (7.25) (5.37) (.63) (1.14) (1.38) (10.69) (.44)
.001 4.081 3.799 .017 .740 1.233 .206 2.255 1.153
.974 .051 .059 .895 .395 .274 .605 .141 .289
(n.s.) (n.s.) (n.s.) (n.s.) (n.s.) (n.s.) (n.s.) (n.s) (n.s.)
44.65 15.30 11.70 17.75
(11.75) (6.60) (4.60) (4.78)
.939 .487 1.470 .203
.338 .489 .233 .654
(n.s.) (n.s.) (n.s.) (n.s.)
48.35 16.70 13.40 18.45
(12.38) (6.07) (4.26) (5.03)
F
p
Sociodemographic features of writing and non-writing group – categorical variables. Writing group
Sex Marital status
Women Men Married Divorced Widowed Single
15 5 12 2 0 6
Non-writing group 13 7 13 4 1 2
TOT
χ2
p
28 12 25 6 1 8
.48
.49
3.70
.29
The group × time interaction for the VAS scores was significant (F = 19.33, p = .000). Post hoc tests showed a significant difference in both groups from before to after physiotherapy, though the writing group showed greater improvement (writing group from m = 8.30 to m = 2.76, p = .000; non-writing group from m = 8.11 to m = 5.43, p = .000), whereas six months after the end of physiotherapy the difference from baseline was significant for the writing group alone (writing group from m = 8.30 to m = 2.33, p = .00; non-writing group from m = 8.11 to m = 6.04, p = .14). The difference between the writing group (m = 2.76) and the non-writing group (m = 5.43) was significant immediately after physiotherapy (p = .008) and six months after the end of physiotherapy (writing group m = 2.33, non-writing group m = 6.04, p = .0004) (Figure 1). The group × time interaction for the postural evaluation was significant (F = 10.42, p = .003). Post hoc comparisons showed improvements in both groups immediately after physiotherapy, though the writing group improved to a greater extent (from m = 32.50 to m = 18.45, p = .0000 for the writing group; from m = 27.95 to m = 21.65, p = .0001 for the non-writing). The group × time interaction was also significant for psychophysical well-being, as measured by the GSI of the SCL-90, (F = 7.17, p = .011). Post hoc analyses showed a significant decrease in the writing group (from m = .73 to m = .58, p = .02), while the non-writing group remained stable (from m = .56 to m = .59, p = .59).
TAS-20 F3 (EOT)
TAS-20 F2 (DDF)
TAS-20 F1 (DIF)
TAS-20 (Total score)
SCL-90 (GSI)
Before physiotherapy After physiotherapy 6-month follow-up Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy Before physiotherapy After physiotherapy
8.30 2.76 2.33 32.50 18.45 .73 .58 48.35 40.95 16.70 14.05 13.40 11.05 18.45 15.85
(1.26) (2.03) (2.28) (8.32) (7.49) (.53) (.51) (12.38) (10.78) (6.07) (5.99) (4.26) (5.34) (5.03) (5.05)
Writing group m (SD) 8.11 (1.38) 5.43 (2.58) 6.04 (2.39) 27.95 (10.69) 21.65 (8.32) .56 (.44) .59 (.60) 44.65 (11.75) 44.25 (14.66) 15.30 (6.60) 13.70 (8.11) 11.70 (4.60) 11.95 (5.25) 17.75 (4.78) 18.70 (5.63)
Non-writing group m (SD)
8.14
5.49
.13
7.18
7.17
10.42
19.33
F
Interaction between group and time on all dependent variables with years of pain as covariate.
Postural evaluation
VAS
Table 3.
.007
.025
.72 (n.s.)
.011
.011
.003
.000
p
.18
.13
.00
.16
.16
.22
.34
Effect size η2
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.79
.63
.06
.74
.74
.88
.99
Observed power
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The overall TAS-20 score showed a significant group × time interaction (F = 7.18, p = .011). Post hoc analyses showed a significant decrease in the TAS-20 scores in the writing group (from m = 48.35 to m = 40.95, p = .0008), whereas those in the non-writing group remained unchanged (from m = 44.65 to m = 44.25, p = .84). The first TAS-20 factor (DIF) score did not reveal any significant group × time interaction (F = .13, p = .72). A significant main effect of time emerged (F = 4.69, p = .04), with both groups improving on this variable (writing group: from m = 16.70 to m = 14.05; non-writing group: from m = 15.30 to m = 13.70). The DDF and EOT TAS-20 factors showed a significant group × time interaction (F = 5.49, p = .025 for DDF; F = 8.14, p = .007 for EOT). DDF scores decreased significantly in the writing group (m = 13.40 before physiotherapy, m = 11.05 after physiotherapy, p = .009) though not in the non-writing group (from m = 11.70 to m = 11.95, p = .77). EOT scores also significantly decreased in the writing group (from m = 18.45 to m = 15.85, p = .03), though not in the non-writing group (from m = 17.75 to m = 18.70, p = .40). Discussion Overall, the results of our study support the hypothesis that the cognitive and emotional processing afforded by written emotional disclosure strengthens the effects of physiotherapy, promoting greater psychophysical improvement in individuals affected by low back pain and neck pain. Confirming our first hypothesis, the written processing of a traumatic event combined with physiotherapy more effectively reduced back and/or neck pain when compared with the control group who received physiotherapy alone (Table 3 and Figure 1). This result was apparent in the short and long term and is in agreement with literature showing the effects of psychological intervention on pain reduction (e.g. van Hooff et al., 2012).
10 8,3
9 8 7
8,11
6
VAS
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5,43
6,04
2,76
2,33
5 4 3 2 1 0 Before Physiotherapy
After Physiotherapy
Writing Group
Figure 1.
Writing effect on pain (VAS scores).
6-month follow-up
Non-Writing Group
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One possible explanation is that writing allows patients to come into contact with their emotions (as shown by the reduction in alexithymia scores) and to explore emotionally relevant past events, which in turn leads to an assimilation and resolution of the events themselves. Another possible explanation (see introduction) is that an enhanced capacity for processing emotionally meaningful events was applied by subjects to subsequent life situations, with positive effects on physical and mental health. This mechanism could be particularly relevant for long-term results, apparently the most important from a clinical and economic viewpoint. Confirming our second hypothesis, though postural evaluation values improved in both groups, writing subjects achieved a more balanced posture than non-writing subjects, possibly thanks to the contribution of emotional processing on body perception. The patient’s subjective evaluation of pain and the physiotherapist’s objective evaluation of posture converge to demonstrate the effectiveness of combined treatment. As predicted in our third hypothesis, writing subjects reported fewer symptoms of various origins at the SCL-90, so displaying a greater improvement in psychophysical well-being than non-writing subjects. As predicted in the fourth hypothesis, only the writing group obtained lower global TAS-20 scores after physiotherapy. This result appears particularly significant for patients with musculoskeletal pain, who show higher alexithymia levels than healthy subjects (Verissimo 2007, 2008). As to individual factors, DIF showed an improvement in both groups, whereas DDF and EOT improved in the writing group alone. This suggests that the Mézières treatment did improve patients’ perception of their own bodies, entailing improved identification of bodily sensations, possibly leading to improved perception and discrimination of feelings. By contrast, only patients who wrote additionally improved in the DDF and EOT factors, which may be ascribed to the cognitive/emotional processing that occurred as a result of writing. One possible explanation is that the writing group was able to process emotions that had been helped to surface by the Mézières treatment at a non-symbolic level: in this regard, it is noteworthy that some patients cried after a Mézières physiotherapy session, possibly expressing a hitherto unknown psychological suffering, which found the time and space for adequate processing in writing. Multidisciplinary intervention, as achieved in our study by the joint utilization of physiotherapy and writing, appears to obtain a global, integrative effect on all systems of the organism, verbal and non-verbal, symbolic and non symbolic (Bucci, 1997), cognitive/experiential and physiological (Taylor et al., 1997). Important aspects of our results are the very low rate of refusal (9%, four patients) and 0% rate of dropout, showing that the technique may be easily and extensively applied in this population, and the importance of its implementation in a significant pre-existing context, in this case immediately after the physiotherapy sessions, and not as a separate intervention. Limitations and perspectives One limitation of this study may be the relatively small size of the sample. Another limitation might be the initial, marginally significant differences between the writing and non-writing groups as regards the years of pain: this problem was dealt with by considering this variable as a covariate. Another aspect that could be considered a limitation is that the control subjects did not write at all while in the original procedure they generally wrote about neutral topics.
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