Norwegian Psychomotor Physiotherapy: A scoping review

Tove Dragesund, fysioterapeut PhD, førsteamanuensis. Fakultet for Helse- og Sosialvitskap, Høgskulen på Vestlandet. tove.dragesund@hvl.no.

Aud Marie Øien, fysioterapeut PhD, førsteamanuensis. Fakultet for Helse- og Sosialvitskap, Høgskulen på Vestlandet.

Denne vitenskapelige artikkelen er fagfellevurdert etter Fysioterapeutens retningslinjer, og ble akseptert 5.desember 2022. Ingen interessekonflikter oppgitt.

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Abstract

Background: Norwegian Psychomotor Physiotherapy (NPMP) is an established treatment approach mainly applied to patients with long-lasting musculoskeletal pain. The research in the field of NPMP is gradually expanding. The aim of this study was therefore to conduct a systematic search of the published literature for empirical studies in the field, to chart the characteristics and methodologies used and uncover gaps in the research field.

Methods: A scoping review methodology was chosen.

Results: A total of 93 full text research articles were analysed. The analysis identified primarily articles with a quantitative approach concerning development and standardisation of the NPMP body examination into scales. The qualitative studies concerned different experiences from the body examination and the treatment approach from the patients’ and/or the physiotherapists’ perspectives.

Conclusion: The literature in the field is limited but has slowly expanded during the last 20 years. More research is generally needed to further develop and expand the treatment approach.

Keywords: Norwegian Psychomotor Physiotherapy, Scoping review, Quantitative methods, Qualitative methods

Norsk psykomotorisk fysioterapi. En scoping review studie

Sammendrag

Hensikt: Norsk psykomotorisk fysioterapi (NPMF) er en etablert behandling tilnærming primært for pasienter med langvarige muskel- og skjelett smerter og sammensatte lidelser. Forskning innen fagfeltet er i utvikling. Hensikten med denne studien var derfor å gjennomføre et systematisk søk av den publiserte litteraturen i fagfeltet for å kartlegge omfang, metodisk tilnærming og å bidra til å avdekke kunnskapshull.

Metode: Scoping review ble valgt som metode.

Resultater: I alt ble 93 artikler analysert. Analysen avdekket primært artikler med en kvantitativ tilnærming som omhandlet utvikling og standardisering av kroppsundersøkelsen i NPMF. De kvalitative studiene omhandlet ulike erfaringer fra kroppsundersøkelsen og behandlingstilnærmingen fra pasientenes og eller fysioterapeutenes perspektiv.

Konklusjon: Litteraturen i fagfeltet er begrenset, men har gradvis ekspandert de siste 20 årene. Mer forskning er generelt nødvendig for å videreutvikle behandlingstilnærmingen.

Nøkkelord: Norsk psykomotorisk fysioterapi, Scoping review, Kvantitative metoder, Kvalitative metoder.

Introduction

Long-lasting musculoskeletal pain is characterized by reduced physical function, often linked with anxiety and depression, and with increased risk of developing other health conditions, early retirement, reduced wealth, and social participation, and increased all-cause mortality (1).

Norwegian Psychomotor Physiotherapy (NPMP) is a physiotherapeutic approach applied to patients with long-lasting musculoskeletal pain and complex health complaints (2, 3). The approach emerged from the collaboration between the physiotherapist Aadel Bülow-Hansen and the psychiatrist Trygve Braatøy (1946-1951) (2, 3). Bülow-Hansen and Braatøy collaborated by treating the same patients and discussing experiences and theories. One major interest during their collaboration was how muscular tension, breathing and emotions interdepended and mutually influenced each other(2, 3). As such their approach conceptualized the reciprocal relationship between restrictions and regulations of muscular tension, breathing, movements and emotions (2,3).

Since 1952, the treatment approach has furthered developed being a specialization in physiotherapy. From 1994 the education was a post graduate education at Oslo University College of Applied Sciences, and from 2000 at the Artic University of Norway, Tromsø (UiT) (2). Further, the education was at a level of master’s degree at UiT since 2010, at the Western Norway University of Applied Sciences and the Oslo Metropolitan University since 2018 and 2021, respectively.

The research in the field of NPMP is gradually expanding. Hence a review might provide an overview and bring together the research in the field (6). The aim was therefore to 1) conduct a systematic search of the published literature of empirical studies in the field of NPMP, 2) chart the characteristics and methodologies used in the identified studies, 3) and uncover gaps in the research field.

Methods

A scoping review methodology is well suited for mapping the size and scope of research on a topic, synthesizing findings, and identifying gaps in the literature (4). The approach is further appropriated given the expectation of finding papers with diverse methodology (4). We followed the framework for scoping reviews originally described by Arksey and O’Malley (5) and later advanced by Levac et al. (6) and Khalil et al. (7).

Identifying relevant studies

Relevant peer-reviewed articles were identified in the databases: The Cochrane Library, Epistemonikos, PEDro (The Physiotherapy Evidence Database), AMED, Cinahl, Scopus, Medline, Embase, Forskningsdatabasen.dk, Norart, Oria, Web of Science, SveMed+, Idunn, Google Scholar. The searches were conducted in March 2020 and in June 2021. The search terms used to identify the relevant studies were psychomotor physiotherapy, psychomotor physical therapy, Psykomotorisk fysioterapi [psychomotor] AND [physiotherapy] (appendix).

No restrictions were placed on the study search to ensure inclusion of the full breadth of the literature.

Study selection

To capture the breadth of the literature, articles were included if it: 1) was peer-reviewed, 2) contained NPMP treatment and or elements from the treatment approach, 3) contained the body-examination in NPMP or elements of the examination. No limitation was set for year of publication. Articles were excluded if they: 1) were not peer-reviewed, 2) not written in English or Scandinavian languages.

After the identification of the citations in the electronic database search, the first screening focused on the title and abstract (n=1066). Following this, the authors independently screened the possible articles to be included in the further analysis. A total of 106 articles were chosen to be studied further (Figure 1). The authors then considered these articles and excluded 13 articles because they were not peer-reviewed. Finally, this process ended in including 93 articles (Figure 1).

Charting extraction

Information about the studies is described in table 1.

Table 1

Data synthesis and analysis

The studies were further analysed to gain insight into the results presented in the studies. During this process, the identified studies were re-read to further extract the results. The methodology and perspectives in the studies varied. Consequently, we divided the studies in three groups: quantitative studies, qualitative studies, and studies including both qualitative and quantitative methods. The quantitative studies were thematic divided in, patients receiving NPMP, examination and outcome of the treatment. The qualitative studies were divided in empirical studies from the patients’ and the physiotherapists’ perspectives, and theoretical articles.

Results

Distribution of publications and methodology

The included 93 full text articles were from 1975 to 2021 and most of them were conducted in Norway (n=87) (Figure. 1, Table 1). Eighteen of the years had no publications, twenty-one of the years had either one, two or three publications and the years 2001, 2003, 2006, 2007, 2008, 2010, 2012, 2014, 2018, 2019, 2020 and 2021 had 4 or more publications (Figure 2).

A total of 68 studies were written in English and published in international journals. Most of the studies used quantitative approaches (n=51). Among these studies, 21 concerned development and evaluation of psychometric properties of different test scales emerged from the NPMP body examination (8-28). Three studies included development and evaluation of a body awareness questionnaire (29-31). There were five outcome studies of NPMP treatment, including three randomized controlled studies (RCT)(32-36). Among the other quantitative studies, 20 included the use of one of the scales, emerged from the NPMP body examination or elements from the NPMP treatment approach (36,39-57).

One study included both a quantitative and a qualitative approach (58).

Among the qualitative studies, 15 studies (59-73) explored experiences from the physiotherapist’s perspective, 10 studies (74-83) from the patients’ perspectives and three studies (84-86) from both the physiotherapist and the patients’ perspectives. There were two case studies (87, 88) and seven theoretical studies (89-95). The theoretical perspectives in the qualitative studies were, in addition to NPMP, primarily Merleau-Ponty’s phenomenology of perception. However, different perspectives for example from social science, psychology and communication theories were also used.

The sample size in the studies varied from 1-416 participants, mainly being patients with musculoskeletal pain or mental health problems. The physiotherapists were specialized in NPMP. Most of the studies were conducted in primary health care or mental health clinics.

Quantitative studies

Patients receiving NPMF

Characteristics of the patients referred to NPMP treatment were described in two studies (32,96). The patients (80-82%) were primarily women, with a mean aged at 42 years. Their main symptoms were long-lasting, local, or general musculoskeletal pain and tension. Two third of the sample presented mixed symptoms, mainly with depression, anxiety, and musculoskeletal pain.

Examination

Based on the body examination of NPMP, a clinical examination tool was developed (89) to evaluate short-term dynamic psychotherapy (37). The findings indicated that 53.3 % of the patients improved on the scores on the body examination tool. A positive change on the scores were also strongly correlated with psychological improvement. A similar examination tool was used to examine dental, psychological and bodily ailments in a group of female patients with myofascial pain-dysfunction. The examination revealed that the patients had increased muscular tension and an inadequate respiratory function (38).

Furthermore, two different, test scales: the Global Physiotherapy Examination-52 (GPE-52) and the Comprehensive Body Examination (CBE) are developed. The GPE-52 is developed from Sundsvold’s (8, 9) assessment method, and further psychometric evaluated (13, 14, 18-20, 22). The scale includes 52 single tests distributed in the 5 body domains; body posture, respiration, movement, muscle, and skin quality and was found to be reliable and valid for assessing localisation and degree of physical aberrations in patients with long-lasting musculoskeletal pain. The CBE are based on the clinical body examination called Resource Oriented Body Examination (ROBE) and further developed and evaluated in several studies (10-12, 15-17). The CBE also revealed physical aberration in the 5 body domains described above. Later, the two scales, GPE-52 and CBE, are further merged into one scale: the Global Body Examination (GBE) (23-28).

The ROBE is also merged into a shorter scale, the ROBE II, that distinguished bodily characteristics between patients with psychosomatic, musculoskeletal, and schizophrenic disorders (21).

A self-reported questionnaire reflecting the phenomenon of body awareness; the Body Awareness Rating Questionnaire (BARQ) is developed for evaluative purposes (29, 30) and further revised (35). The revised BARQ-R being a unidimensional and feasible measurement for assessing the phenomenon of body awareness in the context of body-mind approaches for patients with musculoskeletal pain problems (31).

The scales of the ROBE (39), the ROBE II (42, 43), the GPE-52 (36, 42, 44, 48, 49, 55,57), the CBE (40,41) and the GBE (50), are used to assess and characterise body ailments of participants in different studies or to evaluate the outcome of a treatment (36,46, 47).

Outcome

Outcomes of NPMP treatment are evaluated in two different one-group studies (32, 46) and one study with a compared group on a waiting-list (33). The studies showed that NPMP has the potential for reducing symptoms like health complaints, depression, anxiety, insomnia, fatigue and improving quality of life.

One randomized controlled study of long-term NPMP in groups, indicated additional improvement of symptoms and a higher rate of return to work (34).

Two studies evaluated individual NPMP treatment, one with a control group on waiting-list (35) and another with a control group receiving Cognitive Patient Education combined with active individualized physiotherapy (COPE-PT) (36, 49). The results from the first study showed that 6-month NPMP increased the patients’ experiences of quality of life and self-esteem, and reduced pain. The second study showed that NPMP contributed to improve pain and physical function. However, COPE-PT, targeted towards pain-coping and increasing activity, contributed to somewhat more improvements on some of the outcome measures than NPMP at 6- and 12-month follow-up.

Elements from NPMP approach are also included in different studies including patients suffering from dizziness (54), chronic pain (51) and patients with migration experiences (53, 56).

Qualitative studies

Patients’ perspective

Studies from the patients’ perspectives included experiences of the NPMP examination (74), and experiences of NPMP massage (75) and of breathing (78,79) after completed NPMP treatment. The body examination had a great impact on the patients’ understanding of their own ailments. The NPMP massage enhanced relaxation as well as perception and reflection on own body, while experiences of breathing enabled the patients to better understand the interaction between breathing and well-being.

The patients’ embodied experiences of change after NPMP treatment are described to enhance self-perception and self-knowledge. Examples like; being more in touch with and familiar with their body and self, to be better acquainted with bodily reactions and to better interpret bodily symptoms and to connect these reactions to relational dimensions and habitual ways of acting. The relation to and the interaction (verbal and nonverbal) with the physiotherapists during the treatment seemed crucial. The patients valued the physiotherapists’ sensitivity, their ability to be trusted and adjust the treatment to their needs. They also appreciated to be given enough time and space to explore how to become more in contact with their bodies. The experiences described above seemed to be prerequisites for the patients’ changing process during the treatment (75- 83, 85, 87).

Action research aiming to improving professional practice for counsellors in social work are studied (98, 99) emphasizing that the supervision based on NPMP movements, opened access to personal learning and contributed to increased self-knowledge in professional social work practices.

The patients’ experiences from a self-management intervention program including principles and element from NPMP treatment are also explored (52).

Physiotherapists’ perspective

From the physiotherapists’ perspective, the implicit verbal and non-verbal communication during the NPMP examination are studied (59, 60), as well as the physiotherapists’ clinical reasoning process during the examination (61-64,100). The studies showed how practice, and way of thinking could differ among the physiotherapists in different clinical contexts; a NPMP therapist, a manual therapist, and a district physiotherapist. The relationship, context, and actual basis of cooperation were influenced by how the physiotherapists related to the patients’ bodies.

The physiotherapists‘ experiences from demanding treatment processes (68) and the impact of own embodied knowledge in clinical practice (69) underscored the value of being sensitive and self-aware during the treatment. The physiotherapists searched to adjust their therapeutic approaches, depending on the individual patient’s specific problems and degree of emotional and bodily strain. They experienced the importance of creating a common ground with the patients, inviting them to involve themselves in the treatment.

In treatment of torture survivors and patients with adverse child abuse, the physiotherapists experienced that tailoring both the examination and the treatment to the individual patient were crucial (67, 88). In an outpatient clinic for mental health, the bodily approach in NPMP seemed to contribute with something different from and complementary to the verbally approaches in the interdisciplinary team treating patients with eating disorders (66). The physiotherapists experienced that the use of touch in treatment of patients with anorexia neurosis were challenging. However, being aware of and adjust the touch to the patient’s bodily reactions contributed to give the patients comfort and security (73).

The professional development in the field of NPMP was described as a gradual process, integrating theory and experiences from practice. Clinical experiences and contact with colleagues were the most significant sources of development (65). Reflections about the approach from the perspective of highly experienced NPMP physiotherapists concluded that a complex understanding of body knowledge to meet each patient's compound problems is needed (70).

The closing down during the Covid-19 pandemic impacted the practicing of NPMP (72). The approach was performed in new ways, illuminating how video-consultation in contrast to hands - on, could be offered to the patients.

The communication process during long-term treatment, explored from both the patients’ and the physiotherapists’ perspective, emphasised that demanding episodes generated a potential for development and improvement of the treatment outcomes. Understanding such episodes as open and dynamic, in contrast to defining the patient as demanding, suggested to be a useful perspective during the treatment (84, 86).

Experiences from a long-term collaboration between a physiotherapist and a psychologist treating the same patients described how reduced body awareness seemed to correspond with fragmented memories of their own life history and how enhanced body awareness became a vital aspect in the therapeutic processes (101).

Theoretical studies

Theoretical aspects of Braatøy’s thinking, underpinning the NPMP treatment, were analysed considering Løgstrup’s philosophy (90-92). The approach was presented as a bodily-existential process (90). Embodied awareness was discussed with the distinction between awareness in the senses and awareness in understanding (9)1. The everyday language rooted in sensation, might have possibilities to overcome the gap between body and mind (92).

A theoretical article concerning anorexia nervosa underscored the value of addressing bodily restraints in the treatment approach (93). Another article describing contribution factors and treatment implications of exercised induced laryngeal obstruction (EILO) in athletes, emphasized the physiotherapist skills and competence regarding examining breathing patterns and postural de-alignments in the treatment process (94).

Exploring a narrative approach to long-term NPMP treatment indicated that emergent narratives point to potential moments of change and seem to be a useful supplement in the treatment (95).

Qualitative and quantitative study

One study focused on evaluating the effect of NPMP treatment on exercise-induced laryngeal obstruction in elite athletes (58). The study underscored how a diaphragmatic breathing pattern, a more balanced tension in respiratory muscles, and sound cervical alignment and stability might help to reduce adverse stress on the respiratory system and optimise the function of the larynx during high-intensity exercise.

Discussion

This scoping review identified an informative number of articles, primarily conducted in Norway and with a quantitative approach concerning development and standardisation of the NPMP body examination into test scales. The qualitative studies concerned different experiences from the body examination and the treatment approach from the patients’ and/or the physiotherapists’ perspectives.

The number of studies concerning development and evaluation of the measurement properties of GPE-52, CBE and GBE were surprising. The scales include examination of the body through 5 body domains. Scores on the different domains are summarized into sub-scores and further into a sum score, reflecting body ailment and resources (10-20,22-28,36,39-50,55,57). Hence the scales seem to have the possibility to reveal in which domain(s) the ailments are localized and how the whole body are functionally influenced by the ailments.

One strength with NPMP is the individually tailoring of the approach according to each patients need (2,3). Using the phenomenological perspective of the body (103), as theoretical perspectives in the included qualitative studies in this review, has contributed to improve the understanding of the phenomenon of long-lasting musculoskeletal pain, as well as the NPMP approach for patients with such pain problems. The patients included in the studies, described their experiences of the verbal and nonverbal interaction with the physiotherapists both during the NPMP examination and treatment. The NPMP examination impacted the patients’ understanding of their own ailments. The patients further described how enough time and space to explore and reflect upon body sensations, new ways of moving and acting during the treatment were valuable. Gradually, they described that the

treatment process increased body contact and made them more aware how history and life influenced their symptoms and ailments with a need to take better care of themselves during daily life (74-83, 84, 86). As such the treatment seem to contribute to an enhanced self-perception and -understanding. Earlier studies have described how patients with long-tasting musculoskeletal pain for years consult specialists for help to make sense of their illness and to confirm the reality of symptoms (104-106). Thus, living with long-lasting musculoskeletal pain is described as a long and lonely struggle for health care (106). As such NPMP seem to meet requires and needs patients with such pain problem might have.

From the physiotherapists’ perspectives, the NPMP treatment of patients with complex health problems, were experienced as challenging with the need to be anchored in themselves and adjust the treatment approach according to the patients’ response. These findings seem to correspond with studies from similar therapeutic settings, where the therapist’s own body awareness, empathy, trust, and acceptance as well as direction and advances in the therapeutic process are emphasized (107-109).

Within treatment of patients with long-lasting and complex health complaints, a dilemma still exists between experience-based and evidence-based knowledge (110). NPMP is a flexible approach focusing on tuning in to meet the different patients’ needs. Hence the approach is difficult to standardize and to find measurements grasping the important changes experienced from the patients’ perspectives, as described above. This might be explanations for why there are few quantitative studies evaluating outcome of the treatment approach.

This scoping review identified 93 studies spanned the years 1975 to 2021. Given the 46- year publication span, the number of studies might look sparce. However, the history, development, and academic positioning of the NPMP approach must then be taken into consideration. First, the treatment approach is developed and established in Norway (3). Secondly, the approach was organized to a specialisation within physiotherapy. Consequently, a limited group of physiotherapists are specialists in the approach. Finally, there are few specialists with an academic competence. The education has recently reached the level of clinical master at three Universities. Over time this might have a significant influence on further research in the field which in turn might further develop the treatment approach.

Research gap and further direction

This scoping review revealed that more research is generally required. There is, however, a gap in the following fields:

· None of the included studies included experiences from children and youngsters, and patients in mental health clinics

· None of the studies included gender perspectives

· None of the studies explored negative experiences from the treatment

· Few studies included immigrant and refugees

· Few studies explored preventive perspectives

· Few studies explored professional education and development

· Few studies evaluated the outcome of the treatment

Strengths and Limitations

To our knowledge, this is the first study identifying the breadth of literature in the field of NPMP. A rigorous methodological approach has been applied and results are presented systematically to give a transparent review of the literature. Since the research in the field is limited with a long publication span, especially the quality of the oldest literature might vary. However, we found it important to include all the chosen studies to get a good picture of the state of the art.

Conclusion

This scoping review examined a total of 93 studies to map the current state of the research in the field of NPMP treatment. The number of studies is limited but has slowly expanded during the last 20 years. Research gap are revealed concerning children and youngsters, men, immigrants, refugees, and patients in mental health clinics. However, research exploring negative experiences from the treatment, preventive perspectives of the approach as well as examination of the professional education and development are also needed.

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