Pelvic floor muscle exercises and mindfulness for women with endometriosis-associated pelvic pain

The primary aim of this study is to evaluate the feasibility and acceptability of conducting a randomised controlled study that includes pelvic floor muscle (PFM) exercise and mindfulness delivered in a hybrid mode (face-to-face sessions and remote sessions) for women with endometriosis-associated pelvic pain. The sessions will be conducted one-on-one. The research team will randomise participants to one of two PFM exercise protocols: Arm1: PFM contraction plus relaxation exercise + mindfulness. Arm 2: PFM relaxation exercise + mindfulness. Arm1: women will receive eight weeks of PFM contraction plus relaxation exercises and mindfulness. Women will be asked to attend four face-to-face sessions at Monash University over a period of 8 weeks of supervised PFM exercise and four Zoom video- consultations to practise PFM exercises and mindfulness under the physiotherapist’s supervision and guidance. PFM exercises and mindfulness will be taught by the physiotherapy researcher (PhD student with training in PFM contraction and relaxation exercises and mindfulness) using a standardised protocol. Women will be asked to perform fast PFM contraction, PFM maximal contraction, and PFM endurance exercises. Each PFM contraction exercise will be followed by a PFM relaxation exercise. Therefore, the anticipated ratio of contraction to relaxation exercises is one contraction exercise to one relaxation exercise. The PFM exercise protocol will be progressed gradually through the addition of repetitions and alterations in exercise positions (supine, sitting, and standing). The progression will be based on a set time-based program (everybody does the same thing at the same time-point). However, individual rate of progression and response (i.e. individual ability to contract and hold PFM and the number of repetitions) will determine exact progression for each individual. Mindfulness exercises will include breath awareness and body scan practice. During the face-to-face treatment sessions, women will use a single-patient intravaginal probe connected to a surface electromyography (sEMG) biofeedback unit. The sEMG biofeedback unit will be used in clinic to educate participants in performing the correct PFM exercises (at weeks 1, 2, 5, and 8). At home, women will be asked to keep a diary to record PFM contraction plus relaxation exercises and the frequency of practice of mindfulness sessions throughout the eight weeks. The estimated time for each supervised treatment session is 45 mins. The frequency of the sessions is 1x 45 mins session per week for 8 weeks. All participants will be asked to perform the PFM contraction plus relaxation exercise + mindfulness protocol at home for the same frequency and duration as the in-clinic protocol. Participants will be asked to keep a diary to record PFM contraction plus relaxation exercises + mindfulness practice frequency throughout the eight weeks. The diary will be reviewed weekly by the physiotherapist. The exercise diary and session attendance checklists will be used as strategies to assess or monitor adherence to the intervention.