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Psychology, Health & Medicine

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A more global approach to

musculoskeletal pain: Expressive
writing as an effective adjunct to
physiotherapy
a

Luisa Pepe , Roberta Milani , Michela Di Trani , Gianluca Di

b

Folco , Vittorio Lanna & Luigi Solano

Department of Dynamic and Clinical Psychology, University of

Rome Sapienza, Rome, Italy
b

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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
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Psychology, Health & Medicine, 2014

Vol. 19, No. 6, 687697, http://dx.doi.org/10.1080/13548506.2013.859712

A more global approach to musculoskeletal pain: Expressive writing

as an effective adjunct to physiotherapy
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

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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 Mzires physiotherapy for 10 sessions. Half of the subjects also wrote
about difcult 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 benecial 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 1520 min a day for three or four days could obtain both psychological and physical benets 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 nd 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: luisa.pepe@virgilio.it
2013 Taylor & Francis

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L. Pepe et al.

(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 signicant 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 specic 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 eld 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
signicant for the individual, therefore not requiring specic 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 6080% 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 dened as a localized pain in the
lumbar/sacral region, while neck pain is dened 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 bromyalgia and low back pain show high
alexithymia scores Verissimo (2007, 2008), suggesting that identication and regulation
of emotions is a determinant factor in pain modulation.
Franoise Mzires Global Postural Rehabilitation, the method utilized in our study,
is based on a global view of the body (Mzires, 1949, 1984): regaining balance and
improved exibility 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
Mziress 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
reected 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;

Psychology, Health & Medicine

689

(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 signicant pathologies, no analgesic intake, not undergoing psychotherapy. No compensation was offered. The nal 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 nal 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 ve. It yields a total
alexithymia score, plus a score for each of three factors: difculty identifying feelings
(DIF); difculty describing feelings (DDF), externally orientated thinking (EOT)
(Bagby, Parker, & Taylor, 1994a, 1994b; Italian version Bressi et al., 1996).

690

L. Pepe et al.

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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 rst 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 rst four sessions, in a separate
room in the clinic. Both the questionnaires and the writing instructions were
administered by a qualied psychologist. Instructions were the following:
Id like you to write down your deepest thoughts and feelings about the most difcult experience in your life, for about 20 min. In your writing, Id 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 condential.

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 2 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 signicantly 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 signicant 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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691

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)

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

28
12
25
6
1
8

.48

.49

3.70

.29

The group time interaction for the VAS scores was signicant (F = 19.33,
p = .000). Post hoc tests showed a signicant 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 signicant 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 signicant 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 signicant (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 signicant for psychophysical well-being, as
measured by the GSI of the SCL-90, (F = 7.17, p = .011). Post hoc analyses showed a
signicant 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

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

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.18

.13

.00

.16

.16

.22

.34

Effect size 2

.79

.63

.06

.74

.74

.88

.99

Observed power

692
L. Pepe et al.

693

The overall TAS-20 score showed a signicant group time interaction (F = 7.18,
p = .011). Post hoc analyses showed a signicant 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 rst TAS-20 factor (DIF) score did not reveal any signicant group time
interaction (F = .13, p = .72). A signicant 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 signicant group time interaction
(F = 5.49, p = .025 for DDF; F = 8.14, p = .007 for EOT). DDF scores decreased signicantly 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 signicantly 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.
Conrming our rst 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

VAS

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Psychology, Health & Medicine

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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694

L. Pepe et al.

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.
Conrming 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 patients subjective evaluation of pain and the physiotherapists 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 signicant 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 Mzires treatment did improve patients perception of their own
bodies, entailing improved identication 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 Mzires treatment at a non-symbolic level: in this regard, it is
noteworthy that some patients cried after a Mzires 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 signicant
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 signicant 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.

Psychology, Health & Medicine

695

We believe that it would be very difcult 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 lms 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.

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