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Effect of a physiotherapy program in women with primary dysmenorrhea
European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 24–29
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Effect of a physiotherapy program in women with primary dysmenorrhea Mario I. Ortiz a,b,*, Sandra Kristal Corte´s-Ma´rquez c, Luis C. Romero-Quezada a, Gabriela Murguı´a-Ca´novas b, Alfonso P. Jaramillo-Dı´az c A´rea Acade´mica de Medicina del Instituto de Ciencias de la Salud, Universidad Auto´noma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico Universidad del Futbol y Ciencias del Deporte, San Agustı´n Tlaxiaca, Hidalgo, Mexico c Universidad Polite´cnica de Pachuca, Zempoala, Hidalgo, Mexico a
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 May 2015 Received in revised form 17 July 2015 Accepted 6 August 2015
Objective: To evaluate the efficacy of a physiotherapy program for relieving symptoms of primary dysmenorrhea among Mexican women. Study design: This was a single-center, prospective, experimental, parallel group, randomized controlled trial. This cross-sectional study was performed at the Universidad Polite´cnica de Pachuca, Hidalgo, Mexico. Female patients with primary dysmenorrhea, age of 18–22 years; pain intensity from 4 to 10 cm on a Visual Analogue Scale (VAS); and sedentary lifestyle were included. The patients were then randomized to receive a physiotherapy program for three months or to no intervention program. The physiotherapy program consisted of overall stretching, specific stretches, Kegel exercises, jogging, and relaxation exercises. Patient evaluations of symptomatology and pain intensity were recorded basally and throughout for three menstrual periods. The data were entered into a computerized database for descriptive and inferential statistical analyses. Results: A per-protocol population of eighty three women with a mean age of 20.2 1.8 years underwent the physiotherapy program, and seventy seven participants with a mean age of 20.4 1.2 years received no treatment. The participant assessments of pain on the VAS during the second and the third menstrual cycles demonstrated a significant reduction in the treatment group (p < 0.05) compared with the control group. Conclusions: The results showed that strengthening, stretching and muscle relaxation techniques, in addition to jogging, are effective for reducing dysmenorrheic symptoms when they are regularly performed. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Physiotherapy program Physical exercise Primary dysmenorrhea Mexican women
Introduction Dysmenorrhea is chronic, cyclic pelvic pain associated with menstruation and may be associated with nausea, vomiting, diarrhea, headache, fatigue, back pain, and dizziness. The prevalence of dysmenorrhea ranges from 20% to 90% [1–3]. Dysmenorrhea is thought to be caused by the release of prostaglandins into the uterine tissue [1–5]. Therefore, non-steroidal anti-inflammatory drugs (NSAIDs) are the established initial therapy for dysmenorrhea [1–5]. Other treatments have been suggested, including oral contraceptives, acupuncture, acupressure, yoga, and vitamin B1, among others [3–6].
* Corresponding author at: A´rea Acade´mica de Medicina del Instituto de Ciencias de la Salud, Universidad Auto´noma Del Estado de Hidalgo, Eliseo Ramı´rez Ulloa 400, Col. Doctores, Pachuca, Hgo. 42090, Mexico. Tel.: +52 77 1717 2000x2361; fax: +52 77 1717 2000x2361. E-mail address: [email protected] (M.I. Ortiz). http://dx.doi.org/10.1016/j.ejogrb.2015.08.008 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Exercise has been claimed to be beneficial for dysmenorrhea. Several authors have reported that physical exercise is indicated as medical treatment for the care of dysmenorrhea and its symptoms [7–10]. Billig [8] was one of the first supporters of exercise for dysmenorrhea; he created a series of stretching exercises and observed a relief of the dysmenorrheic symptoms [8,9]. An experimental study evaluated dysmenorrheic symptoms in women with physical training (30 min of running or jogging three days a week) versus a sedentary control group [10]. The authors found a significant decrease in symptoms in the training group during menstruation. Furthermore, non-experimental studies found that the performance of exercise in women significantly correlated with the reduction of negative mood and physical symptoms caused by dysmenorrhea [11,12]. In contrast, two studies found that physical activity was not associated with a decrease or change in the pain of dysmenorrhea [13,14]. There is limited evidence regarding the benefits or effectiveness that physical activity could have on the symptoms that occur in women
M.I. Ortiz et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 24–29
with dysmenorrhea. Therefore, the objective of the present study was to evaluate the efficacy of a physiotherapy program on primary dysmenorrhea in Mexican students. Material and methods Participants The study protocol was approved by the Ethics Committee from the UFCD, Hidalgo, Mexico, and the study was conducted in accordance with the Declaration of Helsinki. Recruitment was performed from students of the Universidad Polite´cnica de Pachuca, Hidalgo, Mexico. The inclusion criteria were agreement to participate in the investigation and signed informed consent; age of 18–22 years; sedentary lifestyle (Defined as a type of lifestyle where an individual does invest less than 25 min/day in perform physical activity three times a week) [15]; primary dysmenorrhea screened by a physician, who obtained a medical history and performed a physical examination. Each woman had a history of primary dysmenorrhea, reporting as painful menstruation in the last four previous months with pain intensity greater than 40 mm on a Visual Analogue Scale (VAS). The exclusion criteria were motor disability or limitation of any grade; regular use of non-steroidal anti-inflammatory drugs (NSAIDs) or drugs indicated for dysmenorrhea; chronic degenerative diseases; and secondary dysmenorrhea. Study design This was a single-center, prospective, experimental, parallel group, randomized controlled trial. The sample size was determined using a computerized software package. A sample size of 174 participants was estimated to provide 80% power calculation to detect a difference of 10 mm (VAS scale of 100 mm) between experimental and control groups in women’ assessment of pain relief, assuming a 0.05 significance level. With a projected dropout rate of 10%, a minimum of 192 participants (96 per group) were estimated to be required. Randomization and blinding Participants were randomly divided and enrolled into 2 groups: an experimental group (96 participants identified by letter A) and a control group (96 participants identified by letter B). The allocation sequence was concealed and it was generated using a table of random numbers. The allocation was blinded for the statistician and clinical evaluators. The physiotherapeutic program was led and monitored by independent trained researchers. Intervention program Once included the participants, the current intensity of pain was evaluated at the end of the baseline menstrual period with a VAS. Likewise, the presence and magnitude of dysmenorrheic symptoms were evaluated using a Likert scale (none = 0; mild = 1; moderate = 2; and severe = 3) at the end of the baseline menstrual period in the 2 groups. Both assessments were made within 5 days after the last day of the baseline menstruation with the application of a demographic questionnaire, which included a detailed description of menstruation. The experimental group underwent the physiotherapy program at the training facilities at the school. The program (each session) consisted of five phases (see below) performed consecutively for a total duration of 50 min per session, three times a week (Monday, Wednesday and Friday) at specific times in the morning.
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The program was led and monitored by three trained researchers and completed by the participants for at least three menstrual cycles. The majority of exercises were performed in 5–10 repetitions. The physiotherapeutic program (non-pharmacological and non-invasive physiotherapeutic interventions) was prepared through literature review and validated by expert physiotherapists. The control group performed no overall stretching, specific stretches, Kegel exercises, jogging or relaxation exercises. The control group remained in the courtyard of the School (patients remained standing, talking and walking without a set schedule). The intensity of pain and the presence and magnitude of dysmenorrheic symptoms were evaluated with the VAS and the Likert scale mentioned above at the end of each menstrual period during 3 periods in the 2 groups. At the end of the study, the effectiveness of the program was evaluated using another Likert scale (no = 0; weak = 1; moderate = 2; and complete = 3). Phases of the physiotherapy program Phase 1. Overall stretching. Time: 10 min. Some of the benefits of muscle stretching are to prevent muscle spasms, improve range of motion, prevent muscle injuries, and improve the level of physical activity [16]. Nine stretching exercises were proposed (Table 1). Phase 2. Specific stretches. Time: 10 min. Billig [8] proposed a program of stretching the connective tissue around the pelvis, hip flexors and muscles in the inner thigh. Three types of specific stretches similar to those of Billig were proposed (Table 1). Phase 3. Jogging. Time: 10 min. The Jogging was realized to an intensity from 60 to 70% of maximal heart rate. The American College of Sports Medicine recommends physical activity such as jogging for 10–30 min three times a week to improve aerobic capacity and to promote health [17]. Phase 4. Kegel exercises. Time: 10 min. Kegel exercises involve contraction of the perineal muscles. In addition to relieving dysmenorrheic discomfort, these exercises are useful for labor and for preventing urinary incontinence [16]. We proposed five exercises (Table 1). Phase 5. Relaxation exercises. Time: 10 min. There is evidence that behavioral interventions such as muscle relaxation may be effective for dysmenorrhea [18]. In our study, participants in the supine position took a deep breath through the nose slowly (while slowly counting to five); then, the participants let the air escape through the mouth for a count of seven. Statistical analysis Analysis of efficacy data was accomplished on the intention-totreat population defined as all randomized patients who fulfilled the inclusion criteria, had completed the physiotherapy program for at least one menstrual cycle and had at least one evaluable cycle. Per-protocol population was defined as a subset of the intention-to-treat population who did not incur serious violations of the protocol and had completed the physiotherapy program during the second and third menstrual cycles. The data were entered into a computerized database. The software package for Windows SigmaStat Version 2.03, was used for the descriptive and inferential statistical analyses. Continuous quantitative variables were analyzed by the t test. Categorical variables were analyzed by the Pearson X2 test. Also, an analysis of variance (ANOVA) for repeated measures followed by the Student–Newman–Keuls test to compare differences between scores of the level of pain at different times in the 2 groups was used. p < 0.05 was considered significant.
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M.I. Ortiz et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 24–29
Table 1 Physiotherapeutic program performed by the participants three times a week for 50 min.
Results Sociodemographic and clinical characteristics of both groups A total of 192 patients were randomized into the study. Ninety six patients were randomly assigned to control group and ninety six patients were assigned to group undergoing physiotherapy. Nonetheless, 19 randomized participants could not be incorporated in the analysis of the intention-to-treat population, 10 due to loss prior to initiation, and 9 due to absence of efficacy data for at least one menstrual cycle (Fig. 1). Consequently, there were a total
of 173 participants (experimental group: n = 89 and control group: n = 84) included in the intention-to-treat population and 160 participants (experimental group: n = 83 and control group: n = 77) in the per-protocol population. The baseline demographic and clinical data of the participants are shown in Table 2. Effects of physiotherapy program on pain of dysmenorrhea The mean baseline dysmenorrheic pain intensity obtained with the VAS in the control group was 62.9 1.5; the mean baseline in the treatment group was 64.9 1.3 (p > 0.05). The intensity of
M.I. Ortiz et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 24–29
27
Table 2 Sociodemographic and clinical data of the 182 patients according to group.
Randomized n=192
Did not Receive Allocated Intervention 10
Available randomized Patients n = 182 Experimental group n= 92 Control Group n = 90
No Efficacy data Withdrawn n= 5 Protocol devi
Characteristic
Experimental group n = 92
Control group n = 90
p-Value
Age (mean SD) Weight (mean SD) Height (mean SD) Body mass index (mean SD) Maternal history of dysmenorrhea, n (%) Menarche (mean SD) Regular cycle, n (%)
20.1 1.2 56.5 9.1 1.58 0.07 22.5 3.3 21 (25.3)
20.4 1.2 58.5 9.6 1.59 0.06 23.0 3.5 17 (22.1)
0.207 0.139 0.308 0.298 0.764
12.4 1.4 47 (51.1)
12.4 1.7 49 (54.4)
0.857 0.764
Frequency of menstruation, d 20–25, n (%) 26–30, n (%) >30, n (%)
14 (15.2) 62 (67.4) 16 (17.4)
19 (21.1) 49 (54.4) 22 (24.4)
0.201
Duration of menstruation, d 1–5, n (%) More than 5, n (%)
63 (68.5) 29 (31.5)
69 (76.7) 21 (23.3)
0.284
Amount of flow Scant, n (%) Moderate, n (%) Heavy, n (%)
10 (10.9) 67 (72.8) 15 (16.3)
17 (18.9) 63 (70.0) 10 (11.1)
0.232
Response to physiotherapy treatment
Intention –To- Treat Population Analyzed n = 173 Experimental group n= 89 Control Group n = 84
The final response to physical therapy results obtained in the experimental group is shown in Table 4. The physiotherapy program produced a statistically significant response during the 2nd and 3rd menstrual cycles (per-protocol population; p < 0.001). This final result was not observed in the control group (p > 0.05) (data not shown). Comment
Other Losses Withdrawn n= 6
Per-Protocol Population n = 160 Experimental group n= 83 Control Group n = 77
Medications and alternative treatments are the main therapeutic strategies to alleviate the signs and symptoms caused by primary dysmenorrhea. Currently, NSAIDs are the drugs of first choice in the treatment of primary dysmenorrhea. The use of NSAIDs is supported by findings that have shown that prostaglandins (mainly Prostaglandins F2a and E2) are the main substances involved in the pathogenesis of primary dysmenorrhea [1–5]. Hormonal methods are second in line of effectiveness for the treatment of primary dysmenorrhea; these methods include the
70 60
dysmenorrheic pain during the first menstrual cycle in both groups (intention-to-treat population) showed no statistically significant difference (Fig. 2; p > 0.05). However, in the per-protocol population, a statistically significant decrease in pain in the physiotherapy group (p < 0.05, Fig. 2), but not in the control group, was found during the second and third menstrual cycles. Dysmenorrheic symptoms A statistically significant reduction of symptoms was found in the treatment group, mainly during the second and third cycles (per-protocol population; Table 3; p < 0.05). Moreover, a statistically significant reduction of symptoms was not found in the three menstrual cycles evaluated in the control group (data not shown).
VAS (mm)
Fig. 1. Flow diagram for randomized participants.
50 40
Control Group
30
*
Experimental Group
20
**
*p<0.05 vs control **p<0.005 vs control
10 0 0
1
2
3
Menstrual cycle Fig. 2. Dysmenorrheic pain scores in the control and experimental groups. The participants were evaluated 3 menstrual cycles. Baseline = zero menstrual cycle (control group: n = 90 and experimental group: n = 92). Intention-to-treat population (One menstrual cycle. Control group: n = 84 and experimental group: n = 89). Per-protocol population (Second and third menstrual cycles. Control group: n = 77 and experimental group: n = 83). VAS = Visual Analogue Scale.
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Table 3 Effect of a physiotherapy program on the severity of symptoms in women with primary dysmenorrhea. The participants were evaluated for three menstrual cycles.
Colic pain in the lower abdomen Bloating Irritability Depression Pain or tenderness of breasts Back pain Gastrointestinal disorders Headache Leg edema (swelling)
Baseline
Menstrual cycle
Mean (MSD) n = 92
1st Mean (MSD) n = 89
1.62 1.50 0.72 0.67 0.75 1.46 0.57 0.95 0.43
1.35 1.25 0.51 0.52 0.55 1.30 0.40 0.77 0.22
(0.05) (0.05) (0.05) (0.05) (0.04) (0.06) (0.05) (0.05) (0.04)
(0.05)a (0.05) (0.05) (0.04) (0.04) (0.07) (0.04) (0.06) (0.03)a
2nd Mean (MSD) n = 83 0.95 0.88 0.31 0.20 0.37 0.71 0.34 0.41 0.12
(0.04)a,b (0.04)a,b (0.03)a (0.03)a,b (0.03)a,b (0.04)a,b (0.04)a (0.04)a,b (0.02)a
3rd Mean (MSD) n = 83 0.48 0.43 0.16 0.06 0.30 0.33 0.18 0.22 0.06
(0.03)a,b,c (0.03)a,b,c (0.02)a,b,c (0.01)a,b,c (0.03)a,b (0.03)a,b,c (0.03)a,b (0.03)a,b,c (0.03)a,b
a
p < 0.05 significantly different from baseline. p < 0.05 significantly different from 1st cycle. p < 0.05 significantly different from 2nd cycle. Data are represented as the mean of each symptom according to a Likert scale (zero to 4). b c
administration of estrogens and/or progestins or oral contraceptives [3–5]. Other treatments for dysmenorrhea, for which there are not enough data on effectiveness, include the administration of nitroglycerin, fish oil supplements, vitamin supplements, nifedipine, terbutaline, antispasmodics, acupuncture, surgical section of pelvic nerves, thermotherapy, physiotherapy, vegetarian diet, herbs, and others [3–6,16]. Patients suffering from primary dysmenorrhea usually do not go to the physician for care. Instead, they resort to non-drug remedies and self-medication. Several studies have found an important therapeutic failure or a small analgesic effect of NSAIDs [1,2]. Therefore, it is necessary to resort to other therapeutic measures to eliminate or ameliorate the symptoms that women experience with dysmenorrhea and to obtain clinical benefits in women as well as better school and/or work attendance. In our study, the application of a physiotherapy program for 3 menstrual cycles produced a statistically significant improvement in the symptoms of students with dysmenorrhea. The program included general stretching, jogging, specific exercises, exercises to strengthen the pelvic floor, and relaxation exercises for 50 min three days a week. The women showed improvement mainly during the second and third menstrual cycle. Our results are consistent with the results observed in four clinical studies, which found that physical exercise of different modalities and intensities performed by women was significantly correlated with reduced menstrual symptoms [11,12]. However, none of the four previous studies were experimental. The four studies were of a descriptive correlation design, and only surveys or questionnaires were applied to determine the symptoms of dysmenorrhea and its probable relationship with risk factors (which increase the symptoms) and protective factors (which reduce the symptoms). For example, significant effects of exercise on negative mood and physical symptoms caused by dysmenorrhea were demonstrated through a questionnaire applied to women attending sports clubs and gyms (women performed at least 5 h a week of exercise) [11]. Table 4 Response to physiotherapy. Menstrual cycle
No response to treatment (null) Low response to treatment Moderate response to treatment Satisfactory response to treatment (complete)
1st n (%) n = 89
2nd n (%) n = 83
3rd n (%) n = 83
25 29 35 0
0 4 58 21
0 0 11 72
(27.7) (32.6) (39.3) (0.0)
(0.0) (4.8) (69.9) (25.3)
(0.0) (0.0) (13.3) (86.7)
This type of study might have errors or biases due to inadequate recording and control of the risk factors and protective factors. Our prospective experimental study might be better compared with the experimental study by Israel et al. [10], which demonstrated that the performance of walking or jogging for 30 min three times a week for three menstrual cycles significantly reduced the symptoms caused by dysmenorrhea. However, our exercise program was very different than the program in the study by Israel et al. [10] because our program included general and specific stretching exercises, jogging, exercises to strengthen the pelvic floor, and relaxation exercises for 50 min three days a week [7,8,16]. In this sense, our proposal of a physiotherapy intervention program included first performing overall stretching exercises for 10 min 3 times a week. The purpose of these exercises is to prevent, or reduce as much as possible, the pain radiating to the lumbar zone and to the adductor muscles of the lower extremities; this pain is common in women with dysmenorrhea [16]. In the early 1940s, Billig [8] suggested that dysmenorrheic pain is due to contractions of ligamentous bands in the abdomen of the women. He suggested a series of exercises to reduce menstrual cramps, which consisted of stretching exercises of the connective tissue around the pelvis, hip flexors and muscles in the medial thigh [7,8,16]. In the present study, exercises similar to those of Billig were included for 10 min 3 times a week. The purpose of these exercises was to achieve a reduction of pain radiating mainly in the lumbar muscles and adductors of the lower limbs [7,8,16]. ‘‘Physical activity’’ is considered as any bodily movement produced by skeletal muscles that require energy expenditure. Physical inactivity is the fourth most important risk factor for mortality worldwide [19]. Physical inactivity is widespread in many developing and developed countries and is considered to be a risk factor for hypertension, hyperglycemia, overweight and obesity. Therefore, it is estimated that physical inactivity is among the leading causes of different types of cancers, diabetes, and ischemic heart disease [19,20]. It has been widely demonstrated that regular physical activity might reduce the risk of diabetes, hypertension, colon cancer, breast cancer and coronary heart disease and stroke. There is also a relationship between physical activity and decreased anxiety and depression, increased selfesteem, academic performance, decreased use of some substances of abuse, and appreciation of a more satisfying life [19–21]. Likewise, physical activity is a conclusive energy utilization factor and is therefore critical for achieving energy balance and adequately controlling the weight of the person [19,20]. In the present study, we included 10 min of jogging three times a week as the third phase in our program [7,10,16]. Among the recommendations for physical activity that the WHO gives for adults 18–64
M.I. Ortiz et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 194 (2015) 24–29
years of age, aerobic activity should be performed in 10-min sessions. A sensation of euphoria and satisfaction after a sports effort are accompanied by the release of endogenous opioids and by the production and release of other hormones and catecholamines [22,23]. This effect might help reduce sensitivity to pain and other symptoms experienced by women with primary dysmenorrhea. In the early 1940s, the gynecologist Kegel created a series of exercises of the perineal musculature [16,24,25]. In the case of dysmenorrhea in women, these exercises are intended to increase local blood supply, which apparently favors more rapid elimination of prostaglandins, which has been suggested to decrease the duration and intensity of menstrual pain [16,24,25]. In the present study, as the fourth phase in our physiotherapy program, these exercises were included for 10 min 3 times a week. Finally, in the fifth phase in our program, we included 10 min three times a week of relaxation exercises. The result of the relaxation is decreased activity of the sympathetic nervous system and reduction of pain. Relaxation also serves to distract the attention away from pain and provides a tool for controlling pain and reducing negative emotions accompanying pain or injury [3,16,17]. It is likely that the therapeutic effect observed in the present study is due to a synergism of the five phases of the program. The observed final effect was greater than the sum of the effects that the exercises could produce individually. Conclusion The physiotherapy program was more effective in reducing dysmenorrheic pain and symptoms than was no intervention. The results demonstrated that strengthening, stretching and muscle relaxation techniques plus jogging are effective in reducing the symptoms caused by primary dysmenorrhea when these exercises are performed regularly. Conflict of interest The authors state that no conflicts of interest exist. References [1] Ortiz MI, Rangel-Flores E, Carrillo-Alarco´n C, Veras-Godoy HA. Prevalence and impact of primary dysmenorrhea among Mexican high school students. Int J Gynecol Obstet 2009;107:240–3.
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[2] Ortiz MI. Primary dysmenorrhea among Mexican university students: prevalence, impact and treatment. Eur J Obstet Gynecol Reprod Biol 2010;152:73–7. [3] Latthe PM, Champaneria R, Khan KS. Dysmenorrhoea. Clin Evid (Online) 2011. pii: 0813. [4] French L. Dysmenorrhea. Am Fam Physician 2005;71:285–95. [5] Zahradnik HP, Hanjalic-Beck A, Groth K. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: a review. Contraception 2010;81:185–96. [6] Morgan PJ, Kung R, Tarshis J. Nitroglycerin as a uterine relaxant: a systematic review. J Obstet Gynaecol Can 2002;24:403–9. [7] Brown J, Brown S. Exercise for dysmenorrhoea. Cochrane Database Syst Rev 2011;17:CD004142. [8] Billig HE. Dysmenorrhoea, the result of a postural defect. Arch Surg 1943;46: 611–3. [9] Prior JC, Vigna Y. Conditioning exercise and premenstrual symptoms. J Reprod Med 1987;32:423–8. [10] Israel RG, Sutton M, O’Brien KF. Effects of aerobic training on primary dysmenorrhea symptomatology in college females. J Am Coll Health 1985;33:241–4. [11] Aganoff JA, Boyle GJ. Aerobic exercise, mood states and menstrual cycle symptoms. J Psychosom Res 1994;38:183–92. [12] Choi PYL, Salmon P. Symptom changes across the menstrual cycle in competitive sportswomen, exercisers and sedentary women. Br J Clin Psychol 1995;34:447. [13] Harlow SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obst Gynaecol 1996;103:1134. [14] Sandoval J, Madrid A, Sandoval S, et al. Factors affecting dysmenorrhea in adolescents, according to socioeconomic. Rev Per Ginecol Obstet 2013;59:95. [15] Cabrera de Leo´n A, Rodrı´guez-Pe´rez M del C, Rodrı´guez-Benjumeda LM, et al. Sedentary lifestyle: physical activity duration versus percentage of energy expenditure. Rev Esp Cardiol 2007;60:244. [16] Garcı´a B, Chillo´n R, Rebollo J, et al. Primary dysmenorrhea and physiotherapy. Fisioterapia 2005;27:327. [17] Escamilla R, Wickham R. Fitness and rehabilitation through exercise. In: Kolt G, Zinder-Mackler L, editors. Sports physical therapy and exercise. Elsevier; 2004. p. 145–63. [18] Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM. Behavioural interventions for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2007;3:CD002248. [19] World Health Organization (WHO). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva; 2009, http://www. who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf [accessed 25.01.14]. [20] Madden KM. Evidence for the benefit of exercise therapy in patients with type 2 diabetes. Diabetes Metab Syndr Obes 2013;6:233. [21] Valois RF, Zullig KJ, Huebner ES, et al. Physical activity behaviors and perceived life satisfaction among public high school adolescents. J Sch Health 2004;74:59. [22] Gallo R. Physiological changes in female athletes. Educ Fı´sica Deporte 1995; 17:103. [23] Weinstein A, Weinstein Y. Exercise addiction – diagnosis, bio-psychological mechanisms and treatment issues. Curr Pharm Des 2014;20:4062. [24] Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can 2003;25:487. [25] Beales D, Hope JB, Hoff TS, et al. Current practice in management of pelvic girdle pain amongst physiotherapists in Norway and Australia. Man Ther 2015;20:109.
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Effect of a physiotherapy program in women with primary dysmenorrhea Mario I. Ortiz a,b,*, Sandra Kristal Corte´s-Ma´rquez c, Luis C. Romero-Quezada a, Gabriela Murguı´a-Ca´novas b, Alfonso P. Jaramillo-Dı´az c A´rea Acade´mica de Medicina del Instituto de Ciencias de la Salud, Universidad Auto´noma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico Universidad del Futbol y Ciencias del Deporte, San Agustı´n Tlaxiaca, Hidalgo, Mexico c Universidad Polite´cnica de Pachuca, Zempoala, Hidalgo, Mexico a
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 May 2015 Received in revised form 17 July 2015 Accepted 6 August 2015
Objective: To evaluate the efficacy of a physiotherapy program for relieving symptoms of primary dysmenorrhea among Mexican women. Study design: This was a single-center, prospective, experimental, parallel group, randomized controlled trial. This cross-sectional study was performed at the Universidad Polite´cnica de Pachuca, Hidalgo, Mexico. Female patients with primary dysmenorrhea, age of 18–22 years; pain intensity from 4 to 10 cm on a Visual Analogue Scale (VAS); and sedentary lifestyle were included. The patients were then randomized to receive a physiotherapy program for three months or to no intervention program. The physiotherapy program consisted of overall stretching, specific stretches, Kegel exercises, jogging, and relaxation exercises. Patient evaluations of symptomatology and pain intensity were recorded basally and throughout for three menstrual periods. The data were entered into a computerized database for descriptive and inferential statistical analyses. Results: A per-protocol population of eighty three women with a mean age of 20.2 1.8 years underwent the physiotherapy program, and seventy seven participants with a mean age of 20.4 1.2 years received no treatment. The participant assessments of pain on the VAS during the second and the third menstrual cycles demonstrated a significant reduction in the treatment group (p < 0.05) compared with the control group. Conclusions: The results showed that strengthening, stretching and muscle relaxation techniques, in addition to jogging, are effective for reducing dysmenorrheic symptoms when they are regularly performed. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Physiotherapy program Physical exercise Primary dysmenorrhea Mexican women
Introduction Dysmenorrhea is chronic, cyclic pelvic pain associated with menstruation and may be associated with nausea, vomiting, diarrhea, headache, fatigue, back pain, and dizziness. The prevalence of dysmenorrhea ranges from 20% to 90% [1–3]. Dysmenorrhea is thought to be caused by the release of prostaglandins into the uterine tissue [1–5]. Therefore, non-steroidal anti-inflammatory drugs (NSAIDs) are the established initial therapy for dysmenorrhea [1–5]. Other treatments have been suggested, including oral contraceptives, acupuncture, acupressure, yoga, and vitamin B1, among others [3–6].
* Corresponding author at: A´rea Acade´mica de Medicina del Instituto de Ciencias de la Salud, Universidad Auto´noma Del Estado de Hidalgo, Eliseo Ramı´rez Ulloa 400, Col. Doctores, Pachuca, Hgo. 42090, Mexico. Tel.: +52 77 1717 2000x2361; fax: +52 77 1717 2000x2361. E-mail address: [email protected] (M.I. Ortiz). http://dx.doi.org/10.1016/j.ejogrb.2015.08.008 0301-2115/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Exercise has been claimed to be beneficial for dysmenorrhea. Several authors have reported that physical exercise is indicated as medical treatment for the care of dysmenorrhea and its symptoms [7–10]. Billig [8] was one of the first supporters of exercise for dysmenorrhea; he created a series of stretching exercises and observed a relief of the dysmenorrheic symptoms [8,9]. An experimental study evaluated dysmenorrheic symptoms in women with physical training (30 min of running or jogging three days a week) versus a sedentary control group [10]. The authors found a significant decrease in symptoms in the training group during menstruation. Furthermore, non-experimental studies found that the performance of exercise in women significantly correlated with the reduction of negative mood and physical symptoms caused by dysmenorrhea [11,12]. In contrast, two studies found that physical activity was not associated with a decrease or change in the pain of dysmenorrhea [13,14]. There is limited evidence regarding the benefits or effectiveness that physical activity could have on the symptoms that occur in women
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with dysmenorrhea. Therefore, the objective of the present study was to evaluate the efficacy of a physiotherapy program on primary dysmenorrhea in Mexican students. Material and methods Participants The study protocol was approved by the Ethics Committee from the UFCD, Hidalgo, Mexico, and the study was conducted in accordance with the Declaration of Helsinki. Recruitment was performed from students of the Universidad Polite´cnica de Pachuca, Hidalgo, Mexico. The inclusion criteria were agreement to participate in the investigation and signed informed consent; age of 18–22 years; sedentary lifestyle (Defined as a type of lifestyle where an individual does invest less than 25 min/day in perform physical activity three times a week) [15]; primary dysmenorrhea screened by a physician, who obtained a medical history and performed a physical examination. Each woman had a history of primary dysmenorrhea, reporting as painful menstruation in the last four previous months with pain intensity greater than 40 mm on a Visual Analogue Scale (VAS). The exclusion criteria were motor disability or limitation of any grade; regular use of non-steroidal anti-inflammatory drugs (NSAIDs) or drugs indicated for dysmenorrhea; chronic degenerative diseases; and secondary dysmenorrhea. Study design This was a single-center, prospective, experimental, parallel group, randomized controlled trial. The sample size was determined using a computerized software package. A sample size of 174 participants was estimated to provide 80% power calculation to detect a difference of 10 mm (VAS scale of 100 mm) between experimental and control groups in women’ assessment of pain relief, assuming a 0.05 significance level. With a projected dropout rate of 10%, a minimum of 192 participants (96 per group) were estimated to be required. Randomization and blinding Participants were randomly divided and enrolled into 2 groups: an experimental group (96 participants identified by letter A) and a control group (96 participants identified by letter B). The allocation sequence was concealed and it was generated using a table of random numbers. The allocation was blinded for the statistician and clinical evaluators. The physiotherapeutic program was led and monitored by independent trained researchers. Intervention program Once included the participants, the current intensity of pain was evaluated at the end of the baseline menstrual period with a VAS. Likewise, the presence and magnitude of dysmenorrheic symptoms were evaluated using a Likert scale (none = 0; mild = 1; moderate = 2; and severe = 3) at the end of the baseline menstrual period in the 2 groups. Both assessments were made within 5 days after the last day of the baseline menstruation with the application of a demographic questionnaire, which included a detailed description of menstruation. The experimental group underwent the physiotherapy program at the training facilities at the school. The program (each session) consisted of five phases (see below) performed consecutively for a total duration of 50 min per session, three times a week (Monday, Wednesday and Friday) at specific times in the morning.
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The program was led and monitored by three trained researchers and completed by the participants for at least three menstrual cycles. The majority of exercises were performed in 5–10 repetitions. The physiotherapeutic program (non-pharmacological and non-invasive physiotherapeutic interventions) was prepared through literature review and validated by expert physiotherapists. The control group performed no overall stretching, specific stretches, Kegel exercises, jogging or relaxation exercises. The control group remained in the courtyard of the School (patients remained standing, talking and walking without a set schedule). The intensity of pain and the presence and magnitude of dysmenorrheic symptoms were evaluated with the VAS and the Likert scale mentioned above at the end of each menstrual period during 3 periods in the 2 groups. At the end of the study, the effectiveness of the program was evaluated using another Likert scale (no = 0; weak = 1; moderate = 2; and complete = 3). Phases of the physiotherapy program Phase 1. Overall stretching. Time: 10 min. Some of the benefits of muscle stretching are to prevent muscle spasms, improve range of motion, prevent muscle injuries, and improve the level of physical activity [16]. Nine stretching exercises were proposed (Table 1). Phase 2. Specific stretches. Time: 10 min. Billig [8] proposed a program of stretching the connective tissue around the pelvis, hip flexors and muscles in the inner thigh. Three types of specific stretches similar to those of Billig were proposed (Table 1). Phase 3. Jogging. Time: 10 min. The Jogging was realized to an intensity from 60 to 70% of maximal heart rate. The American College of Sports Medicine recommends physical activity such as jogging for 10–30 min three times a week to improve aerobic capacity and to promote health [17]. Phase 4. Kegel exercises. Time: 10 min. Kegel exercises involve contraction of the perineal muscles. In addition to relieving dysmenorrheic discomfort, these exercises are useful for labor and for preventing urinary incontinence [16]. We proposed five exercises (Table 1). Phase 5. Relaxation exercises. Time: 10 min. There is evidence that behavioral interventions such as muscle relaxation may be effective for dysmenorrhea [18]. In our study, participants in the supine position took a deep breath through the nose slowly (while slowly counting to five); then, the participants let the air escape through the mouth for a count of seven. Statistical analysis Analysis of efficacy data was accomplished on the intention-totreat population defined as all randomized patients who fulfilled the inclusion criteria, had completed the physiotherapy program for at least one menstrual cycle and had at least one evaluable cycle. Per-protocol population was defined as a subset of the intention-to-treat population who did not incur serious violations of the protocol and had completed the physiotherapy program during the second and third menstrual cycles. The data were entered into a computerized database. The software package for Windows SigmaStat Version 2.03, was used for the descriptive and inferential statistical analyses. Continuous quantitative variables were analyzed by the t test. Categorical variables were analyzed by the Pearson X2 test. Also, an analysis of variance (ANOVA) for repeated measures followed by the Student–Newman–Keuls test to compare differences between scores of the level of pain at different times in the 2 groups was used. p < 0.05 was considered significant.
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Table 1 Physiotherapeutic program performed by the participants three times a week for 50 min.
Results Sociodemographic and clinical characteristics of both groups A total of 192 patients were randomized into the study. Ninety six patients were randomly assigned to control group and ninety six patients were assigned to group undergoing physiotherapy. Nonetheless, 19 randomized participants could not be incorporated in the analysis of the intention-to-treat population, 10 due to loss prior to initiation, and 9 due to absence of efficacy data for at least one menstrual cycle (Fig. 1). Consequently, there were a total
of 173 participants (experimental group: n = 89 and control group: n = 84) included in the intention-to-treat population and 160 participants (experimental group: n = 83 and control group: n = 77) in the per-protocol population. The baseline demographic and clinical data of the participants are shown in Table 2. Effects of physiotherapy program on pain of dysmenorrhea The mean baseline dysmenorrheic pain intensity obtained with the VAS in the control group was 62.9 1.5; the mean baseline in the treatment group was 64.9 1.3 (p > 0.05). The intensity of
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Table 2 Sociodemographic and clinical data of the 182 patients according to group.
Randomized n=192
Did not Receive Allocated Intervention 10
Available randomized Patients n = 182 Experimental group n= 92 Control Group n = 90
No Efficacy data Withdrawn n= 5 Protocol devi
Characteristic
Experimental group n = 92
Control group n = 90
p-Value
Age (mean SD) Weight (mean SD) Height (mean SD) Body mass index (mean SD) Maternal history of dysmenorrhea, n (%) Menarche (mean SD) Regular cycle, n (%)
20.1 1.2 56.5 9.1 1.58 0.07 22.5 3.3 21 (25.3)
20.4 1.2 58.5 9.6 1.59 0.06 23.0 3.5 17 (22.1)
0.207 0.139 0.308 0.298 0.764
12.4 1.4 47 (51.1)
12.4 1.7 49 (54.4)
0.857 0.764
Frequency of menstruation, d 20–25, n (%) 26–30, n (%) >30, n (%)
14 (15.2) 62 (67.4) 16 (17.4)
19 (21.1) 49 (54.4) 22 (24.4)
0.201
Duration of menstruation, d 1–5, n (%) More than 5, n (%)
63 (68.5) 29 (31.5)
69 (76.7) 21 (23.3)
0.284
Amount of flow Scant, n (%) Moderate, n (%) Heavy, n (%)
10 (10.9) 67 (72.8) 15 (16.3)
17 (18.9) 63 (70.0) 10 (11.1)
0.232
Response to physiotherapy treatment
Intention –To- Treat Population Analyzed n = 173 Experimental group n= 89 Control Group n = 84
The final response to physical therapy results obtained in the experimental group is shown in Table 4. The physiotherapy program produced a statistically significant response during the 2nd and 3rd menstrual cycles (per-protocol population; p < 0.001). This final result was not observed in the control group (p > 0.05) (data not shown). Comment
Other Losses Withdrawn n= 6
Per-Protocol Population n = 160 Experimental group n= 83 Control Group n = 77
Medications and alternative treatments are the main therapeutic strategies to alleviate the signs and symptoms caused by primary dysmenorrhea. Currently, NSAIDs are the drugs of first choice in the treatment of primary dysmenorrhea. The use of NSAIDs is supported by findings that have shown that prostaglandins (mainly Prostaglandins F2a and E2) are the main substances involved in the pathogenesis of primary dysmenorrhea [1–5]. Hormonal methods are second in line of effectiveness for the treatment of primary dysmenorrhea; these methods include the
70 60
dysmenorrheic pain during the first menstrual cycle in both groups (intention-to-treat population) showed no statistically significant difference (Fig. 2; p > 0.05). However, in the per-protocol population, a statistically significant decrease in pain in the physiotherapy group (p < 0.05, Fig. 2), but not in the control group, was found during the second and third menstrual cycles. Dysmenorrheic symptoms A statistically significant reduction of symptoms was found in the treatment group, mainly during the second and third cycles (per-protocol population; Table 3; p < 0.05). Moreover, a statistically significant reduction of symptoms was not found in the three menstrual cycles evaluated in the control group (data not shown).
VAS (mm)
Fig. 1. Flow diagram for randomized participants.
50 40
Control Group
30
*
Experimental Group
20
**
*p<0.05 vs control **p<0.005 vs control
10 0 0
1
2
3
Menstrual cycle Fig. 2. Dysmenorrheic pain scores in the control and experimental groups. The participants were evaluated 3 menstrual cycles. Baseline = zero menstrual cycle (control group: n = 90 and experimental group: n = 92). Intention-to-treat population (One menstrual cycle. Control group: n = 84 and experimental group: n = 89). Per-protocol population (Second and third menstrual cycles. Control group: n = 77 and experimental group: n = 83). VAS = Visual Analogue Scale.
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Table 3 Effect of a physiotherapy program on the severity of symptoms in women with primary dysmenorrhea. The participants were evaluated for three menstrual cycles.
Colic pain in the lower abdomen Bloating Irritability Depression Pain or tenderness of breasts Back pain Gastrointestinal disorders Headache Leg edema (swelling)
Baseline
Menstrual cycle
Mean (MSD) n = 92
1st Mean (MSD) n = 89
1.62 1.50 0.72 0.67 0.75 1.46 0.57 0.95 0.43
1.35 1.25 0.51 0.52 0.55 1.30 0.40 0.77 0.22
(0.05) (0.05) (0.05) (0.05) (0.04) (0.06) (0.05) (0.05) (0.04)
(0.05)a (0.05) (0.05) (0.04) (0.04) (0.07) (0.04) (0.06) (0.03)a
2nd Mean (MSD) n = 83 0.95 0.88 0.31 0.20 0.37 0.71 0.34 0.41 0.12
(0.04)a,b (0.04)a,b (0.03)a (0.03)a,b (0.03)a,b (0.04)a,b (0.04)a (0.04)a,b (0.02)a
3rd Mean (MSD) n = 83 0.48 0.43 0.16 0.06 0.30 0.33 0.18 0.22 0.06
(0.03)a,b,c (0.03)a,b,c (0.02)a,b,c (0.01)a,b,c (0.03)a,b (0.03)a,b,c (0.03)a,b (0.03)a,b,c (0.03)a,b
a
p < 0.05 significantly different from baseline. p < 0.05 significantly different from 1st cycle. p < 0.05 significantly different from 2nd cycle. Data are represented as the mean of each symptom according to a Likert scale (zero to 4). b c
administration of estrogens and/or progestins or oral contraceptives [3–5]. Other treatments for dysmenorrhea, for which there are not enough data on effectiveness, include the administration of nitroglycerin, fish oil supplements, vitamin supplements, nifedipine, terbutaline, antispasmodics, acupuncture, surgical section of pelvic nerves, thermotherapy, physiotherapy, vegetarian diet, herbs, and others [3–6,16]. Patients suffering from primary dysmenorrhea usually do not go to the physician for care. Instead, they resort to non-drug remedies and self-medication. Several studies have found an important therapeutic failure or a small analgesic effect of NSAIDs [1,2]. Therefore, it is necessary to resort to other therapeutic measures to eliminate or ameliorate the symptoms that women experience with dysmenorrhea and to obtain clinical benefits in women as well as better school and/or work attendance. In our study, the application of a physiotherapy program for 3 menstrual cycles produced a statistically significant improvement in the symptoms of students with dysmenorrhea. The program included general stretching, jogging, specific exercises, exercises to strengthen the pelvic floor, and relaxation exercises for 50 min three days a week. The women showed improvement mainly during the second and third menstrual cycle. Our results are consistent with the results observed in four clinical studies, which found that physical exercise of different modalities and intensities performed by women was significantly correlated with reduced menstrual symptoms [11,12]. However, none of the four previous studies were experimental. The four studies were of a descriptive correlation design, and only surveys or questionnaires were applied to determine the symptoms of dysmenorrhea and its probable relationship with risk factors (which increase the symptoms) and protective factors (which reduce the symptoms). For example, significant effects of exercise on negative mood and physical symptoms caused by dysmenorrhea were demonstrated through a questionnaire applied to women attending sports clubs and gyms (women performed at least 5 h a week of exercise) [11]. Table 4 Response to physiotherapy. Menstrual cycle
No response to treatment (null) Low response to treatment Moderate response to treatment Satisfactory response to treatment (complete)
1st n (%) n = 89
2nd n (%) n = 83
3rd n (%) n = 83
25 29 35 0
0 4 58 21
0 0 11 72
(27.7) (32.6) (39.3) (0.0)
(0.0) (4.8) (69.9) (25.3)
(0.0) (0.0) (13.3) (86.7)
This type of study might have errors or biases due to inadequate recording and control of the risk factors and protective factors. Our prospective experimental study might be better compared with the experimental study by Israel et al. [10], which demonstrated that the performance of walking or jogging for 30 min three times a week for three menstrual cycles significantly reduced the symptoms caused by dysmenorrhea. However, our exercise program was very different than the program in the study by Israel et al. [10] because our program included general and specific stretching exercises, jogging, exercises to strengthen the pelvic floor, and relaxation exercises for 50 min three days a week [7,8,16]. In this sense, our proposal of a physiotherapy intervention program included first performing overall stretching exercises for 10 min 3 times a week. The purpose of these exercises is to prevent, or reduce as much as possible, the pain radiating to the lumbar zone and to the adductor muscles of the lower extremities; this pain is common in women with dysmenorrhea [16]. In the early 1940s, Billig [8] suggested that dysmenorrheic pain is due to contractions of ligamentous bands in the abdomen of the women. He suggested a series of exercises to reduce menstrual cramps, which consisted of stretching exercises of the connective tissue around the pelvis, hip flexors and muscles in the medial thigh [7,8,16]. In the present study, exercises similar to those of Billig were included for 10 min 3 times a week. The purpose of these exercises was to achieve a reduction of pain radiating mainly in the lumbar muscles and adductors of the lower limbs [7,8,16]. ‘‘Physical activity’’ is considered as any bodily movement produced by skeletal muscles that require energy expenditure. Physical inactivity is the fourth most important risk factor for mortality worldwide [19]. Physical inactivity is widespread in many developing and developed countries and is considered to be a risk factor for hypertension, hyperglycemia, overweight and obesity. Therefore, it is estimated that physical inactivity is among the leading causes of different types of cancers, diabetes, and ischemic heart disease [19,20]. It has been widely demonstrated that regular physical activity might reduce the risk of diabetes, hypertension, colon cancer, breast cancer and coronary heart disease and stroke. There is also a relationship between physical activity and decreased anxiety and depression, increased selfesteem, academic performance, decreased use of some substances of abuse, and appreciation of a more satisfying life [19–21]. Likewise, physical activity is a conclusive energy utilization factor and is therefore critical for achieving energy balance and adequately controlling the weight of the person [19,20]. In the present study, we included 10 min of jogging three times a week as the third phase in our program [7,10,16]. Among the recommendations for physical activity that the WHO gives for adults 18–64
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years of age, aerobic activity should be performed in 10-min sessions. A sensation of euphoria and satisfaction after a sports effort are accompanied by the release of endogenous opioids and by the production and release of other hormones and catecholamines [22,23]. This effect might help reduce sensitivity to pain and other symptoms experienced by women with primary dysmenorrhea. In the early 1940s, the gynecologist Kegel created a series of exercises of the perineal musculature [16,24,25]. In the case of dysmenorrhea in women, these exercises are intended to increase local blood supply, which apparently favors more rapid elimination of prostaglandins, which has been suggested to decrease the duration and intensity of menstrual pain [16,24,25]. In the present study, as the fourth phase in our physiotherapy program, these exercises were included for 10 min 3 times a week. Finally, in the fifth phase in our program, we included 10 min three times a week of relaxation exercises. The result of the relaxation is decreased activity of the sympathetic nervous system and reduction of pain. Relaxation also serves to distract the attention away from pain and provides a tool for controlling pain and reducing negative emotions accompanying pain or injury [3,16,17]. It is likely that the therapeutic effect observed in the present study is due to a synergism of the five phases of the program. The observed final effect was greater than the sum of the effects that the exercises could produce individually. Conclusion The physiotherapy program was more effective in reducing dysmenorrheic pain and symptoms than was no intervention. The results demonstrated that strengthening, stretching and muscle relaxation techniques plus jogging are effective in reducing the symptoms caused by primary dysmenorrhea when these exercises are performed regularly. Conflict of interest The authors state that no conflicts of interest exist. References [1] Ortiz MI, Rangel-Flores E, Carrillo-Alarco´n C, Veras-Godoy HA. Prevalence and impact of primary dysmenorrhea among Mexican high school students. Int J Gynecol Obstet 2009;107:240–3.
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[2] Ortiz MI. Primary dysmenorrhea among Mexican university students: prevalence, impact and treatment. Eur J Obstet Gynecol Reprod Biol 2010;152:73–7. [3] Latthe PM, Champaneria R, Khan KS. Dysmenorrhoea. Clin Evid (Online) 2011. pii: 0813. [4] French L. Dysmenorrhea. Am Fam Physician 2005;71:285–95. [5] Zahradnik HP, Hanjalic-Beck A, Groth K. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief from dysmenorrhea: a review. Contraception 2010;81:185–96. [6] Morgan PJ, Kung R, Tarshis J. Nitroglycerin as a uterine relaxant: a systematic review. J Obstet Gynaecol Can 2002;24:403–9. [7] Brown J, Brown S. Exercise for dysmenorrhoea. Cochrane Database Syst Rev 2011;17:CD004142. [8] Billig HE. Dysmenorrhoea, the result of a postural defect. Arch Surg 1943;46: 611–3. [9] Prior JC, Vigna Y. Conditioning exercise and premenstrual symptoms. J Reprod Med 1987;32:423–8. [10] Israel RG, Sutton M, O’Brien KF. Effects of aerobic training on primary dysmenorrhea symptomatology in college females. J Am Coll Health 1985;33:241–4. [11] Aganoff JA, Boyle GJ. Aerobic exercise, mood states and menstrual cycle symptoms. J Psychosom Res 1994;38:183–92. [12] Choi PYL, Salmon P. Symptom changes across the menstrual cycle in competitive sportswomen, exercisers and sedentary women. Br J Clin Psychol 1995;34:447. [13] Harlow SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Br J Obst Gynaecol 1996;103:1134. [14] Sandoval J, Madrid A, Sandoval S, et al. Factors affecting dysmenorrhea in adolescents, according to socioeconomic. Rev Per Ginecol Obstet 2013;59:95. [15] Cabrera de Leo´n A, Rodrı´guez-Pe´rez M del C, Rodrı´guez-Benjumeda LM, et al. Sedentary lifestyle: physical activity duration versus percentage of energy expenditure. Rev Esp Cardiol 2007;60:244. [16] Garcı´a B, Chillo´n R, Rebollo J, et al. Primary dysmenorrhea and physiotherapy. Fisioterapia 2005;27:327. [17] Escamilla R, Wickham R. Fitness and rehabilitation through exercise. In: Kolt G, Zinder-Mackler L, editors. Sports physical therapy and exercise. Elsevier; 2004. p. 145–63. [18] Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM. Behavioural interventions for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2007;3:CD002248. [19] World Health Organization (WHO). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva; 2009, http://www. who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf [accessed 25.01.14]. [20] Madden KM. Evidence for the benefit of exercise therapy in patients with type 2 diabetes. Diabetes Metab Syndr Obes 2013;6:233. [21] Valois RF, Zullig KJ, Huebner ES, et al. Physical activity behaviors and perceived life satisfaction among public high school adolescents. J Sch Health 2004;74:59. [22] Gallo R. Physiological changes in female athletes. Educ Fı´sica Deporte 1995; 17:103. [23] Weinstein A, Weinstein Y. Exercise addiction – diagnosis, bio-psychological mechanisms and treatment issues. Curr Pharm Des 2014;20:4062. [24] Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can 2003;25:487. [25] Beales D, Hope JB, Hoff TS, et al. Current practice in management of pelvic girdle pain amongst physiotherapists in Norway and Australia. Man Ther 2015;20:109.