Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

RESEARCH ARTICLE

The Effect of Psychomotor Physical Therapy on Subjective Health Complaints and Psychological SymptomsMonica H. Breitve1*, Minna J. Hynninen2 & Alice Kvåle3

1Haugesund Hospital, Department of Psychological Health Care, Haugesund, Norway2Faculty of Psychology, University of Bergen, Norway3Section for Physiotherapy Science, Department of Public Health and Primary Health Care, University of Bergen, Norway

Abstract

Background and Purpose. The objective of this study was to examine the effect of Norwegian psychomotor physi-

cal therapy on subjective health complaints and psychological symptoms. Method. A non-randomized waiting list

controlled design was used. Physiotherapists in Norway recruited patients for a treatment group (n = 40) and

waiting list control group (n = 22). Patients on the waiting list could only be included for 6 months, as they then

started treatment. Symptoms registration was obtained from both groups at baseline and 6 months, and only for

the treatment group also at 12 months. The following self-report forms were used; Subjective Health Complaints

Inventory (SCH); Beck Depression Inventory-II (BDI-II); Spielberger State-Trait Anxiety Inventory-Trait (STAI-

T); Bergen Insomnia Scale (BIS); Fatigue Questionnaire (FQ); Quality of Life Inventory (QOLI); The Client Satis-

faction Questionnaire (CSQ). Results. The patients had had widespread and clinically signifi cant health problems

for an average of 9 years upon entrance to the study. After 6 months in psychomotor physical therapy, all the

measured symptoms in the treatment group were signifi cantly reduced, but only quality of life was signifi cantly

reduced when compared to the waiting list control group. After 12 months in therapy, the patients in the treatment

group had continued to improve on all measured variables. The symptoms of anxiety and depression, as well as

quality of life, were improved from clinical to non-clinical level. Conclusions. Norwegian psychomotor physical

therapy seems to have potential for reducing symptoms of subjective health complaints, depression, anxiety, insom-

nia, fatigue and improving quality of life, although the process takes time. Further research is needed to gain more

rigorous data, and randomized controlled studies are highly welcomed. Copyright © 2010 John Wiley & Sons, Ltd.

Received 19 June 2009; Revised 13 October 2009; Accepted 5 January 2010

Keywords

Body awareness; Mental health; Musculoskeletal disorders; Quantitative research; Outcome measurement

*Correspondence

Monica H Breitve, Haugesund Hospital, Department of Psychological Health Care, Pb 2170, Haugesund, Norway, 5504.

Email: monica.breitve@helse-fonna.no

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pri.462

most frequent reasons for repeated visits to a general

practitioner (Karlsson et al., 1997; Khan et al., 2003).

Medical examination, tests and referrals to specialists

reveal an organic basis for less than 20% of cases

(Kroenke and Mangelsdorff, 1989). Not surprisingly,

Introduction

Vague, diffi cult-to-diagnose complaints, such as

chronic muscular pain, sleep problems, fatigue, head-

ache, and unspecifi c gastrointestinal problems, are the

Effect of psychomotor physical therapy M. H. Breitve et al.

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

health workers tend to think that patients with such

unexplained and long-lasting symptoms are diffi cult to

help (Sharpe et al., 1994). Patients are often dissatisfi ed

with the care (Deyo, 1998) and many have suffered

for several years without adequate treatment. As a

consequence, they may seek assistance from non-

professionals in the fl ourishing health market (Eriksen

and Ursin, 2004).

Eriksen and Ursin (2002) have suggested using the

term ‘subjective health complaints’ (SHC) rather than

‘unexplained symptoms’, as the term is neutral, does

not offer any diagnosis or clues to causality, and avoids

the assumption of disease. Although the complaints are

not accompanied by what is traditionally considered as

objective fi ndings (generally defi ned as radiological

fi ndings or aberrations in laboratory analyses), they are,

however, a real phenomenon and concern for the

patient, with major impacts on both an individual’s

quality of life and health care costs for the society.

Genetics, biological sensitization and psychosocial

factors are likely to play a role in the etiopathogenesis

of SHC, and their degree of impact may differ between

individuals and within groups of people (Wilhelmsen,

2005). Furthermore, aberrations in posture, respira-

tion, movements and muscles, are common. Lack of

fl exibility, increased muscle tension and a restricted

respiration are found in these patients, signifi cantly dif-

ferent from fi ndings in healthy people (Kvåle et al.,

2005). Unexplained somatic symptoms have been

strongly and consistently linked to psychological dis-

tress, in particular anxiety and depression (Simon et al.,

1996). However, viewing such symptoms as ‘psychiat-

ric’ may complicate the interactions between health

workers and patients, as patients may resent ‘all in your

head’ assumptions (Bakal et al., 2006).

Norwegian Psychomotor Physical Therapy (NPPT)

belongs to the realm of so called ‘Body and Mind’ or

‘Body Awareness’ therapies (Kvåle and Ljunggren,

2007). In Norway, the NPPT has been an established

treatment form for almost 50 years, and is commonly

applied for patients with long-lasting pain and psycho-

logical symptoms. General practitioners refer patients

to NPPT for health complaints such as fi bromyalgia,

widespread pain, anxiety or depression, and patients

themselves typically present with more comprehensive

and diffuse complaints (Kamps and Arnesen, 2004).

The majority of patients are women, and their

health problems have often lasted over several years

(Aabakken et al., 1991; Breitve et al., 2008), which

seems to suggest that the approach commonly is uti-

lized as a ‘last resort’, for ‘diffi cult’ patients or when

nothing else seems to work.

In NPPT, as in other body awareness therapies,

patients’ symptom experiences are validated at the

physiological level, even when what is traditionally

defi ned as objective fi ndings are lacking (Kvåle and

Ljunggren, 2007). The body is emphasized as a source

of information and a mediator of previous experiences,

trauma, stress, personality and emotions, and the

patient is invited to a collaborative exploration of what

the bodily symptoms are trying to convey (Øien et al.,

2009). The NPPT is process-oriented and the aim of

treatment is to facilitate change of the affected func-

tions through movement exercises and massage. The

movement exercises generally consist of body aware-

ness through grounding exercises, as well as relaxation

training (Thornquist and Bunkan 1991; Øien et al.

2007). Case descriptions and qualitative studies of

NPPT support the plausibility of the approach for pro-

viding common ground and treatment rational for the

patient and therapist, and describe how creating order

out of chaos also contributes to patients’ ability to self-

soothing and symptom reduction (Ekerholt and

Bergland, 2004; Øien et al., 2009). However, outcome

studies utilizing established measures are lacking.

In the current study, we wanted to examine the effect

of NPPT on subjective health complaints and psycho-

logical symptoms in a heterogenic sample of patients.

In addition to pain, patients with diffuse complaints

also commonly report fatigue and sleep diffi culties

(Malmgren-Olsson and Armelius, 2003), and their

quality of life is likely to suffer (Råheim and Håland,

2006). Therefore, measures of fatigue, sleep and quality

of life were also included as outcome variables.

Method

Design

A non-randomized, non-blinded waiting list controlled

design was used.

Subjects

Participants were recruited by 26 physiotherapists spe-

cialized in NPPT, working in private practice or in a

hospital. To be eligible for inclusion, the participants

were to be 18 years or older, and referred to NPPT by

a general practitioner. For the waiting list group,

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

M. H. Breitve et al. Effect of psychomotor physical therapy

current psychomotor treatment was an exclusion

criterion.

Procedure

For treatment group, patients were recruited during the

fi rst treatment session. Those who agreed to participate

completed baseline assessments during or immediately

after the fi rst session. As long waiting lists for NPPT

are common, physiotherapists contacted waiting list

patients by mail or by telephone and invited them into

the study. These patients completed baseline assess-

ments and returned it by mail. Participants in the

waiting list did not receive any treatment within the

framework of the study. Both groups were followed at

6 months. The treatment group was also followed at 12

months, as NPPT is a process-oriented therapy that

generally is assumed to require longer than 6 months.

However, the waiting lists are seldom more than 6

months, and therefore, in the framework of our natu-

ralistic study, the waiting list patients could not be fol-

lowed as controls for longer. Both follow-up assessments

were conducted by mail.

Norwegian psychomotor physical therapy (NPPT)

The NPPT is based on the assumption that patients

with long-lasting problems, physical and/or psycho-

logical, may react with general aberrations related to

posture, respiration, and movements, as well as with

muscular tension and skin changes (Kvåle and

Ljunggren, 2007). Breathing and feelings are looked

upon as interdependent factors, and the primary differ-

ence between the psychomotor examination and that

of so-called traditional physiotherapy is the emphasis

on respiration and body awareness (Ekerholt and Ber-

gland, 2004). There is no standardized procedure for

the treatment, and thus, the NPPT therapist utilize

various treatment components within the theoretical

framework of the approach, based on their clinical

understanding of the patient. During the treatment,

techniques such as relaxation, massage and active exer-

cises are used for normalizing respiration and muscular

control and helping the patient to become aware of how

the body and mind interact (Bunkan, 2001).

Instruments

Based on fi ndings from previous qualitative studies and

studies using non-validated questionnaires, we chose

established and validated assessment instruments

with sound psychometric properties, covering a wide

spectrum of health complaints. All participants in the

treatment group were asked to fi ll out the self-report

measures at baseline, and at 6- and 12-month follow-

ups. All participants in the waiting list group were asked

to complete the assessment measures at baseline and at

the 6-month follow-up.

Subjective health complaints inventory (SHC) (Eriksen et al., 1999)

SHC measures duration and severity of 29 subjective

somatic and psychological complaints. In addition to a

total score, SHC has fi ve subscales; musculoskeletal

pain, pseudoneurology, gastrointestinal problems,

allergy and fl u.

Beck depression inventory-II (BDI-II) (Beck et al., 1996)

Depression was measured with the BDI-II, which

comprises 21 items. A cut-off score for clinically signifi -

cant depression has been defi ned as 14 or higher (Seggar

et al., 2002).

Spielberger state-trait anxiety inventory-trait (STAI-T) (Spielberger et al., 1983)

The STAI-T was used to measure the tendency for

anxiety. An empirically based cut-off score of 46 has

been defi ned to differentiate between functional and

dysfunctional populations (Fisher and Durham, 1999).

The scale is one of the most frequently used measures

of anxiety in applied clinical research.

Bergen insomnia scale (BIS) (Pallesen et al., 2008)

Sleep disturbances were measured with the BIS,

which contains six items that correspond to the diag-

nostic criteria for insomnia in DSM-IV-TR (American

Psychiatric Association, 2000). BIS provides a total

score on a continuous scale and a categorical score

for the presence of insomnia.

Fatigue questionnaire (FQ) (Chalder et al., 1993)

Fatigue was measured with the FQ. On the basis of

a validation study (Chalder et al., 1993), a categorical

score can be calculated that indicates the presence of

Effect of psychomotor physical therapy M. H. Breitve et al.

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

clinically signifi cant fatigue (sum of dichotomized item

scores >4 and duration >6 months).

Quality of life inventory (QOLI) (Frisch, 1994)

QOLI measures quality of life and satisfaction in 16

domains. Satisfaction in different domains is weighted

by their relative importance for the individual. A score

below 1.6 is estimated to indicate low quality of life.

The client satisfaction questionnaire (CSQ)(Larsen et al., 1979)

Satisfaction with the NPPT treatment was measured

with the CSQ. The scale comprises eight items, and

higher scores indicate more satisfaction.

Statistical analysis

Data were analyzed using SPSS version 14.0 (SPSS Inc,

Chicago, III). Independent samples t-tests and

Pearson’s X2 tests were used to examine demographic

and clinical variables at baseline. A 2 × 2 (time × group)

analysis of covariance was used to investigate differ-

ences between the groups in terms of change from base-

line to 6-month follow-up on the outcome variables,

adjusting for pre-test values. Paired-samples t-tests

were used to compare baseline values with 6-month

follow-up levels, and 6-month values with 12-month

follow-up levels in the treatment group. Within-group

effect sizes were calculated with the Cohen d formula

(Cohen, 1988). An effect size of 0.2 is considered small,

0.5 medium, and 0.8 represent a large effect size.

P-value < 0.05 was regarded as statistically signifi cant.

Ethics

The study was approved by the Regional Committee for

Medical Research Ethics in western Norway (REK

Vest), and by the Norwegian Social Science Data Ser-

vices (NSD). Written informed consent was obtained

from all participants in this study. It was emphasized

that participation is voluntary, and a refusal to partici-

pate or a withdrawal from the study later on would not

have any consequences for treatment. Participation was

not economically rewarded.

Results

Baseline

Sixty-two of the 65 participants originally enrolled in

the study completed baseline assessments (Figure 1

shows participant fl ow in the study). At baseline, there

were no signifi cant differences between the treatment

Figure 1 Participant fl ow in the study

26 physiotherapists recruited patients

Treatment group41 agreed to participate40 completed baseline

assessments

Waiting list 24 agreed to participate22 completed baseline

assessments

Six months35 completed assessments

4 dropped out from treatment

1 could not be contacted

Six months17 completed assessments

4 had started in treatment1 dropped out from the

study due to illness

Twelve months23 completed assessments

8 dropped out from the study- 4 had finished treatment- 4 continued treatment

4 could not be contacted

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

M. H. Breitve et al. Effect of psychomotor physical therapy

group and the waiting list group on any of the sociode-

mographic characteristics, number of parallel treat-

ments (Table 1) or scores on the outcome measures.

Eighty-two percent of the total sample of 65 were

women, and mean age was 44.3 years (range 22-75, SD

12.2). Half of them (50%) were on sickness leave or on

disability pension. Their health problems had endured

for 9 years on average (105.0 months, range 6-371, SD

95.2), and during the previous month they had had 8.5

(range 0–20, SD 4.3) health complaints of clinical sig-

nifi cance, mostly in categories ‘musculoskeletal’ and

‘pseudoneurology’, measured with the SHC. Fifty-eight

percent had scores on the BDI-II above the cut-off for

clinically signifi cant depressive symptoms and 67% had

scores on the STAI-T above the cut-off for dysfunctional

populations. On the BIS, 85% had scores indicating the

presence of insomnia, and 54% suffered from clinically

signifi cant fatigue as indicated by scores on the FQ.

QOLI scores suggested low quality of life for 64%.

Longitudinal assessments

At 6 months, the mean number of treatment sessions

for the 35 participants in the NPPT treatment group

was 17.2 (range 4–28, SD 5.8). At 12 months, the mean

number of treatment sessions was 31.7 (range 7–130,

SD 25.2), and 16 participants were still continuing

treatment. Figure 2 shows error bars with the mean and

95% confi dence interval (CI) of the sum scores of all

outcome measures in both patient groups at baseline,

6, and 12 months. Except for sleep, as measured by the

BIS, at 6 months there was signifi cant improvement on

all outcome measures in the treatment group, with

small to moderate within-group effect sizes (0.2-0.5;

see Table 2).

In the waiting list group (n = 17), there was no sig-

nifi cant change over time on any of the measures. After

adjusting for baseline scores, one-way analysis of cova-

riance indicated that there were signifi cant between-

group differences on quality of life scores (QOLI) at the

6-month follow-up [F(1,48) = 4.23, p = 0.045, partial

eta squared = 0.08]. On the other outcome measures,

there were no signifi cant between-group differences.

From 6 to 12 months, participants in the treatment

group continued to improve signifi cantly on subjective

health complaints (SHC), depression (BDI-II), anxiety

(STAI-T), and sleep (BIS). The change from baseline to

12 months reached effect sizes ranging from 0.6 to 1.0.

Independent samples t-tests revealed that those who

did not complete the 12-month follow-up (n = 12) did

not differ signifi cantly from completers at baseline, but

had signifi cantly lower scores on depression (BDI-II)

[t(30.61) = 3.08, p = 0.004], insomnia (BIS) [t(31) =

2.34, p = 0.026], and satisfaction with treatment (CSQ)

[t(32) = 2.67, p = 0.012] at 6 months than those who

continued treatment.

At baseline, there were no signifi cant differences

between the groups in the working status. However, at

6 months a signifi cantly larger proportion of partici-

pants in the treatment group were on a sick leave or

disability pension. From 6 to 12 months, the percentage

of participants on a sick leave or disability pension in

the treatment group was reduced from 57.1 to 43.5

(Table 3).

Table 1. Participant characteristics at baseline

Treatment group

(N = 40)

Waiting list

(N = 22)

Women/men (%) 31 (77.5)/9 (22.5) 18 (81.8)/4 (18.2)

Age, mean (SD) 42.8 (12.1) 48.2 (12.8)

Higher education (>12 years) (%) 16 (40.0) 8 (36.4)

Married or live-in partner (%) 26 (65.0) 11 (50.0)

On sickness leave or disability pension (%) 21 (52.5) 10 (45.5)

Duration of health complaints, months 110.4 (82.1) 95.1 (117.0)

Parallel treatment

Medical (%) 25 (62.5) 9 (40.9)

Psychological (%) 11 (27.5) 2 (9.1)

Physical therapy (%) 6 (15.0) 5 (22.7)

Alternative (%) 3 (7.5) 5 (22.7)

Other (%) 3 (7.5) 3 (13.6)

Effect of psychomotor physical therapy M. H. Breitve et al.

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

At 6 months, the mean satisfaction with treatment

score (CSQ) was 26.6 (range 14–32, SD 4.9). At the

12-month follow-up, the mean satisfaction score had

increased to 28.5 (range 18-32, SD 3.5).

Discussion

After 6 months in NPPT, participants in the treatment

group reported a signifi cant reduction of subjective

II-IDB rof IC %59htiw rabrorrECHS rof IC %59htiw rabrorrE

Error bar with 95% CI for STAI-T Error bar with 95% CI for FQ

Error bar with 95% CI for BIS

Waiting list

35

30

25

20

15

Waiting list

25

20

15

10

5

Waiting list

55

50

45

40

35

Waiting list

25

20

15

10

5

Waiting list

30

25

20

15

10

Waiting list

2,5

2,0

1,5

1,0

0,5

0,0

Error bar with 95% CI for QOLI

Baseline (�), 6-months (�), and 12-months (×). Cut-off for clinically significant complaints is marked (- - - -) for BDI-II, STAI-T and QOLI.

Abbreviations: SHC – Subjective Health Complaints; BDI-II – Beck Depression Inventory –II; STAI-T – State-TraitAnxiety Inventory –Trait; FQ – Fatigue Questionnaire; BIS – Bergen Insomnia Scale; QOLI – Quality of Life Inventory; NPPT – Norwegian Psychomotor Physical Therapy.

_ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _

NPPT NPPT

NPPT NPPT

NPPT NPPT

Figure 2 The error bars show mean and 95% confi dence interval (CI) of the sum score for both groups at all measurement points

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

M. H. Breitve et al. Effect of psychomotor physical therapy

health complaints, depression, anxiety and fatigue, as

well as an increase in quality of life. In the waiting list

group, there was no signifi cant change over time. The

differences in the changes between the NPPT and the

waiting list were signifi cant for quality of life, but not

for the other outcome variables. However, the NPPT-

group continued to improve from 6 to 12 months on

all outcome variables. Patients in the treatment group

were generally satisfi ed with the treatment throughout

the follow-up period.

The design and certain limitations in our study may,

in part, explain the lack of signifi cant differences

between the groups on most outcome measures. The

sample size in the study was relatively small, and thus

it is possible that signifi cant differences between groups

were not detected when they truly existed. The waiting

list patients were also not followed after 6 months. As

the treatment group continued to improve from the

6- to the 12-month follow-up, statistically signifi cant

differences between the groups might have emerged

also on other outcome measures besides the quality of

life, if comparisons between the groups could have

been made at 12 months.

Our design limits also the strength of conclusions

that can be drawn from the results, since it is not

possible to rule out certain sources of bias with a

Table 2. Mean values and mean change for all outcome measures

Measure Time Treatment group (n = 40) Waiting list (n = 22) Between-groups effects

Mean (SD) Within-group

ES

Mean (SD) Within-group

ES

F-value df P-value Partial Eta

squared

Subjective health

complaints

(SHC)

Baseline 26.5 (9.7) 25.6 (10.3)

6 months 23.3 (10.2)* 0.3 24.6 (12.5) 0.1 1.22 1,46 0.276 0.03

12 months 20.1 (8.3)* 0.7

Depression

(BDI-II)

Baseline 17.8 (10.6) 15.1 (9.3)

6 months 13.5 (9.8)*** 0.4 14.2 (11.0) 0.1 1.41 1,48 0.242 0.03

12 months 9.6 (7.9)** 0.9

Anxiety

(STAI-T)

Baseline 49.9 (9.2) 48.3 (11.6)

6 months 46.6 (9.6)** 0.4 47.9 (12.2) 0 1.02 1,46 0.318 0.02

12 months 42.4 (8.5)** 0.8

Fatigue (FQ) Baseline 18.8 (5.7) 18.5 (4.8)

6 months 15.9 (5.5)** 0.5 18.2 (5.0) 0.1 2.29 1,45 0.138 0.05

12 months 13.5 (5.3) 1.0

Sleep (BIS) Baseline 24.3 (8.0) 23.5 (10.5)

6 months 22.5 (7.2) 0.2 23.8 (11.0) 0 0.22 1,47 0.642 0.01

12 months 19.0 (7.9)*** 0.7

Quality of life

(QLI)

Baseline 1.1 (1.4) 1.5 (1.1)

6 months 1.5 (1.2)* 0.3 1.1 (1.7) −0.3 4.23 1,48 0.045 0.08

12 months 1.9 (1.3) 0.6

SD, standard deviation; ES, effect size; d.f., degree of freedom.

* P < 0.05, *** P < 0.001; P-value is based on paired-samples t tests to examine time effects in the treatment group.

Table 3. Differences in working status between patients in treatment (NPPT) versus waiting list control patients at baseline, 6, and 12 months

NPPT Waiting list

Baseline

(n = 40)

6 months

(n = 35)

12 months

(n = 23)

Baseline

(n = 22)

6 months

(n = 17)

Working 14 (35%) 13 (37.1%) 13 (56.5%) 11 (50%) 12 (70.6%)

Sick leave/disability 24 (60%) 20 (57.1%) 10 (43.5%) 10 (45.5%) 5 (29.4%)

No data 2 (5%) 1 (4.5%)

Effect of psychomotor physical therapy M. H. Breitve et al.

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

non-randomized, non-blinded study design. As the

physiotherapists who conducted the treatment were

not blind to patients’ study participation, it is possible

that they put a special effort on treating these patients.

This, in turn, may have infl uenced the generalizability

of the treatment effects. Also, as the participants were

not randomized to treatment and waiting list groups,

participant characteristics or factors other than the

NPPT treatment may have caused the observed differ-

ences in change between the groups. However, even

without randomization, the groups did not differ sig-

nifi cantly at baseline on any of the outcome measures

or on the major demographic variables.

Several participants dropped out from the study

during the follow-up period, which may have infl u-

enced the results. The 6-month data suggested that the

participants who did not complete the follow-up period

were less satisfi ed with the treatment, but their depres-

sive symptoms and sleep problems were also reduced

from baseline and, compared to the completers, signifi -

cantly lower (i.e. better) after 6 months in treatment.

The number of participants on sick leave or disability

pension was also reduced from 6 to 12 months but it is

uncertain to what degree this reduction was a conse-

quence of improvement due to treatment or an artifact

caused by the number of drop-outs from the study.

Finally, the choice of outcome measures may not

have been optimal for capturing the benefi cial effects of

NPPT as a holistic and non-symptom focused treat-

ment. Because our intention was to examine the poten-

tial of NPPT as a treatment for diffuse, somatic and

psychological health complaints, we chose instruments

assessing these symptoms as outcome measures.

However, it is uncertain to what degree the change that

can be measured with these instruments corresponds to

the treatment goals as formulated by the therapists, or

to patients’ expectations of treatment outcome.

In spite of these limitations, the fi ndings suggests

that NPPT may have potential as a treatment for

persons with long-lasting and diffuse health com-

plaints: When using the cut-off scores for clinical sig-

nifi cance on depression (BDI-II; Seggar et al., 2002),

anxiety (STAI-T; Fisher and Durham 1999) and quality

of life (QOL; Frisch 1994), NPPT seems to reduce these

symptoms from a clinical to non-clinical level, as shown

in Figure 2. However, as in our study sample, the

patients seeking NPPT have typically suffered from a

heavy symptom burden over long periods of time, and

they may also have failed in different forms of therapies

before. Thus, it can be expected that treatment takes

time.

In the current study, participants who discontinued

treatment after 6 months were characterized by a more

rapid reduction of sleep problems and depressive

symptoms. For some patients, improved sleep might

reduce the need for further treatment and heighten the

tolerance level for pain and discomfort. For those who

completed the 12-month follow-up, the rate of change

appeared to be similar from baseline to 6 months, and

6 to 12 months on all outcome variables, except for

sleep, for which crucial improvement occurred after

6 months. In accordance with literature on NPPT

(Bunkan 2001; Øien et al., 2009), this may indicate that

the treatment will often require a process of up to 1 year

or even longer to reach its full potential.

Within treatment of long-lasting and diffuse pain

and health complaints, a dilemma still exists between

experience-based knowledge and so-called evidence-

based knowledge (Kvåle and Ljunggren, 2007). Psycho-

logical treatments such as CBT have been proven

effi cacious for many patients with long-lasting health

complaints (Sumathipala, 2007). The CBT model aims

at reducing symptoms by helping the patient modify

and change beliefs and behaviours that perpetuate or

maintain the health problems. However, psychological

treatments are not widely available (Sharpe and Carson,

2001) and it has been argued that they may not be

acceptable for all patients (Salmon et al., 1999). Also,

patients with pain and health complaints represent a

heterogeneous group, and a treatment that works for

one subgroup may not have an effect on another.

In contrast to shorter, symptom-focused treatment

forms, psychomotor physiotherapists claim that they

are pursuing a deeper change of the totality of the

person as an indivisible psychosomatic entity, as well as

addressing tension, movements and breathing patterns

(Bunkan 2001; Øien et al., 2009). Unfortunately, this

claim has not been accompanied by any documentation

so far. Previous research has demonstrated changes in

patients’ movement and breathing patterns following

treatment (Kvåle et al., 2005, 2008), and a former mul-

tidisciplinary treatment study including elements of

NPPT also showed that patients who return to work

signifi cantly improve their breathing pattern, more

than those who remained sick-listed (Kvåle et al., 2005).

However, it is yet unclear to what degree a change in

these variables is causative for benefi cial effects such as

symptom relief and increased quality of life.

Physiother. Res. Int. (2010) © 2010 John Wiley & Sons, Ltd.

M. H. Breitve et al. Effect of psychomotor physical therapy

Implications

Currently, most of the evidence for the effect and

mechanisms of NPPT comes from qualitative case

descriptions, interview studies and observational

studies. Even though such qualitative research has its

advantages, effect studies with reliable and validated

outcome measures are also needed. Using established

measures of outcome will facilitate comparisons

between studies as well as with other treatment forms.

Although NPPT may be a process-oriented and holistic

treatment form, it is not enough simply to state the

basic theoretical assumptions of the model; more docu-

mentation on both short- and long-term effects is

needed and the treatment should be compared with

evidence-based treatments, such as CBT. In addition

to examining the effect for patients’ symptom level

and/or quality of life, work-related disability and use of

health care services are important outcomes for such

studies. As different treatment forms may be more suit-

able for some subgroups of patients, investigating the

patient characteristics that moderate treatment effect

would be advantageous.

Although our fi ndings indicate that the NPPT con-

tributes to positive change in patients with long-lasting

and diffuse health complaints, the weaknesses in the

study design limit the strength of the fi ndings. High

quality studies examining the effi cacy of NPPT, as well

as the mechanisms that contribute to benefi cial effects,

are needed in order to document the effects of such

treatments and building a reliable evidence-base. In

order to provide guidelines for best possible care for the

patients, more research is needed to establish what

works and for whom, and what the patients’ want and

fi nd acceptable.

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