Sunita Sharma,Kamran Ali,Harneet Narula,Nitesh Malhotra,Richa Hirendra Rai,Nitesh Bansal,Karthick Balasubramanian,Sheetal Kalra,Ramya Ramasamy Sanjeevi,Aksh Chahal
Exercise Therapy and Electrotherapy as an Intervention for Primary Dysmenorrhea: A Systematic Review and Meta-Analysis
Dysmenorrhea,Electric stimulation therapy,Exercise,Primary dysmenorrhea,Treatment efficacy
Primary Dysmenorrhea (PD) is characterized by painful cramps before or during menstruation. It is generally treated with nonpharmacological methods. However, with the advancement of research and the passage of time, physiotherapy plays an increasingly important role in treating patients with PD. Electrotherapy and exercise therapy are conservative methods to treat PD. Alternative methods to minimize reliance on medicinal-based treatments are the need of the hour. This review aims to determine the efficacy of exercise-based therapies and electrotherapy modalities in treating PD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards have been used in the present systematic review and meta-analysis. Cochrane, PubMed, and Google Scholar were searched to facilitate the same. The articles from 2011 to 2021 were included in this review. The quality of the review was assessed using the Cochrane risk of bias tool. The visual analog scale was taken as a measure of pain intensity in the meta-analysis, and other outcomes have been included in the systematic review discussed. A total of 15 publications have been included, with a meta-analysis of 7. All included studies were of high quality (PEDro ≥ 5), and demonstrated the efficacy of exercise-based therapies and electrotherapy modalities in treating pain in females with PD. This review aims to check the impact of exercise and electrotherapy in females suffering from PD.
Exercise Therapy and Electrotherapy as an Intervention for Primary Dysmenorrhea: A Systematic Review and Meta-Analysis

Primary Dysmenorrhea (PD) is characterized by painful cramps before or during menstruation. It is generally treated with nonpharmacological methods. However, with the advancement of research and the passage of time, physiotherapy plays an increasingly important role in treating patients with PD. Electrotherapy and exercise therapy are conservative methods to treat PD. Alternative methods to minimize reliance on medicinal-based treatments are the need of the hour. This review aims to determine the efficacy of exercise-based therapies and electrotherapy modalities in treating PD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards have been used in the present systematic review and meta-analysis. Cochrane, PubMed, and Google Scholar were searched to facilitate the same. The articles from 2011 to 2021 were included in this review. The quality of the review was assessed using the Cochrane risk of bias tool. The visual analog scale was taken as a measure of pain intensity in the meta-analysis, and other outcomes have been included in the systematic review discussed. A total of 15 publications have been included, with a meta-analysis of 7. All included studies were of high quality (PEDro ≥ 5), and demonstrated the efficacy of exercise-based therapies and electrotherapy modalities in treating pain in females with PD. This review aims to check the impact of exercise and electrotherapy in females suffering from PD.

Menstrual cramps occurring during or shortly after menstruation in the lower abdomen referred as Primary Dysmenorrhea (PD). Basically, it occurs in the pelvic and or thigh region with no recognizable pelvic pathology [1]. Pain may start a couple of hours prior or at the beginning of menstruation, reaching its peak when the stream turns into the heaviest on the very first day or second day of the menstrual cycle [2]. Pathophysiology of the PD depends on increased emission of prostaglandin, leading to uterine contraction and decreased uterine blood flow. These contractions and reduced blood flow are known to induce pain during PD [3]. PD imposes negative effects on one’s lifestyle, school or work attendance and social or physical activity of the female [4,5]. But unfortunately, most females do not seek medical care to control dysmenorrhea pain [6]. According to a Canadian report comparing 1,546 female, 60% female experienced moderate to severe PD, 51% announced distress because of limited or restricted activities and 17% detailed non-attendance from work or school following PD. Pain diminishes with Non-Steroidal Anti-Inflammatory Drugs and oral preventative pills [7]. But unfortunately, these specialities are regularly connected with side effects such as breast tenderness, vomiting, diarrhoea, sleep disturbance, abdominal pain, cramps in thigh, back pain and inter-menstrual draining [8]. Thus, it is important to isolate alternative methods reducing from minimalist to in PD. Alternate methods had been proposed to provide relief from pain in thigh lower back, pelvis [9,10]. Alternative methods such as Acupuncture, Exercise plan based on Frequency, Intensity, Time and Type (FITT) protocol, Acupressure, Needling methods, Heat therapy, Stretching, Aerobic exercise, Relaxation therapy, Moxibustion, Electrical modalities-Transcutaneous electrical nerve stimulation (TENS), Interferential Therapy (IFT), Diadynamic Current etc., are actively being engaged in PD. Randomized controlled trials published in the last 10 years meeting the inclusion criteria were considered for included in the present review articles not relevant to treatment of PD or comparing pharmacology as primary therapy method were excluded. Aims and criteria were met by 15 articles focusing techniques comprised aerobic exercises, stretching, core strengthening, Zumba, TENS, FITT and Diadynamic Current as treatment methods in PD.

This systemic review and meta-analysis has been formulated following PRISMA guideline [11]. Prefer reporting items for systemic review and meta-analysis in addition. This review is also registered done in PROSPERO (International prospective registration of systemic reviews). This study is based on systemic searches picked up from databases such as PubMed, Google Scholar, and Cochrane. All the published randomized controlled trials and clinical trials (CT) are included in the study. The included articles were published till May 2021. Medical Subject Heading (MESH) terms or titles/abstracts keywords and synonyms are used and modified for every database. Systemic searches were performed for the possible combinations of two categories of keywords to know any particular eligible studies every reference of the included study were assessed. The strategy for the search was built in such a way that the risk of possible selection and selection bias was reduced. Manual screening was there for all the studies in order to know the other related studies (Fig. 1). The study was approved by the Institutional Review Board of Maharishi Markandeshwar (Deemed to be University), Mullana, Ambala (MMDU/IEC/1827).

Summary of articles included for review is shown in Table 1. The initial searches identified potentially relevant papers. In final 15 articles were taken with total of 1,179 participants. The main consideration for every included study was “Pain”. Visual Analog Scale (VAS) is an outcome measure, where 0 to 10 show from minimum to maximum level of pain respectively. McGill pain scale was also used in a few studies and the Menstrual Symptom Questionnaire (MSQ) was used to measure menstrual symptoms in relation to pressure and magnitude. The therapy interventions were varied In the publications that were chosen random allocation, groups that were similar at baseline, disguised allocation, 15% dropout rate and reports of between-group differences were satisfied by almost all of the trials. Data pooled from all RCTs were methodological of moderate quality, providing grade evidence for impact of exercise when compared with control. Trials used VAS to assess pain severity, and the results showed that the effect was statistically significant. A total of 15 studies were carefully reviewed with seven of them being qualified for meta-analysis. The methodological quality of the systematic review was moderate, with a mean of 5.75 out of 10 on the Pedro quality scale. The included trials produced sample sizes ranging from 28 to 150. The participants in the included studies ranged in age from 15 to 40 years old. Assessment of methodological quality (risk of bias) to lessen risk of bias search was done independently, and the quality of each RCT was assessed by Pedro scale. Methodological quality assessment of Pedro was given as 0–2 = unacceptable, reject; 3–5 = low-quality high risk of bias; 6–8 = acceptable quality moderate risk of bias; 9–10 = high-quality low risk of bias. Table 2 shows the methodological quality of included study. We included 15 RCT in this review and 7 for the meta-analysis. Cochrane risk of bias assessment tool is also followed to evaluate the risk of bias and these biases are also further divided in integrated studies grades as high risk, low risk, and unclear risk. This meta-analysis included only articles published in the English. Conference abstracts, dissertations and grey literature are not included. Initially, publications were chosen based on their relevant titles and abstracts, and then the full-text description of each study was examined for methodological excellence.

The systematic review and meta-analysis is part of a main study titled “exercise therapy and electrotherapy as an intervention for primary dysmenorrhea. A systematic review and meta-analysis.” PROSPERO, Centre for Review and Dissemination 42021268923.

Using Google Scholar + PubMed + Cochrane database, 21,970 article searches were conducted. Fifteen publications were included in the systematic review with meta-analysis of 7. Those studies were included based on the pre-and post-mean with standard deviation previously mentioned in the VAS scale outcome or subgroup 1.1 VAS, studies = 7, Participants = 512, Statistical Method: Std. mean difference (IV, Random, 95% CI) 8.15 (3.97, 12.33) and test for overall effect is 3.82. Pedro scores of included trial (n = 7). Representation of the forest plot for comparison of exercise therapy and electrotherapy in addition to pain.

From this Plot, we confirm 7 studies (A to G) and their respective (95% CI). Green box represents effect size (in this case, OR) of each study. Bigger the box more the study weight (i.e., bigger sample size) and vice versa. The black diamond shape represents the pooled OR of the 7 studies. We can see the blue diamond cross the vertical line OR = 1, indicating no significance for the association as the diamond is almost equalized on both sides. We can also confirm this from the 95% confidence interval that includes one and the p-value > 0.05. Meta-analysis forest plot Fig. 2; from this plot, we can see seven studies (A to G) and their respective OR (95% CI). The green box represents the effect size (in this case, OR) of each study. The bigger the box means the study weighted more (i.e., bigger sample size). The black diamond shape represents the average of the seven studies’ odd ratios. The blue diamond crosses the vertical line OR = 1, indicating that the association has no significance because the diamond is about equal on both sides. The 95% CI, which contains one and the p-value > 0.05, also confirms this. Biennial risk shows a graph that depicts the risk of bias. Risk of bias for every item showed the judgment of the authors for the study.

Measurement of risk of bias for the studies included for review is depicted in Fig. 3.

Risk of bias for every item that showed the judgment for the study of the authors.

As viewed by authors’ best search it is found that no other meta-analysis is done on the “Effectiveness of exercise therapy and electrotherapy in patients with respect to primary dysmenorrhea”. Seven studies have met the inclusion criteria for meta-analysis and 15 studies for the review but only randomized controlled trials were included. Menstrual discomfort is a common occurrence, but it is a social taboo for discussion. As a result, it is difficult to make any diagnosis and identify an acceptable treatment plan. Communication between the doctor and the patient is also a critical obstacle. Moreover, a multidisciplinary therapy plan varies on the patients’ specific experiences, needs, and goals. In this study, fifteen studies were analysed for concluding the different effects of exercise therapy and electrotherapy in PD patients. Onur et al. [12] performed a study in 2012 to find the impact of the home environment on PD patients. It included 48 participants’ outcome measures which were based upon VAS, International Physical Activity Questioner, and Metabolic Equivalent scores. All the outcome measures significantly improved. The conclusion was regarding the positive impact reflected in the quality of life (p < 0.05). Similarly, Shahr-jerdy et al. [13] conducted randomized clinical research to see if stretching exercises could help adolescent females with PD. A total of 124 females were requested to stretch at home, whereas 55 females were merely required to complete a questionnaire. Researcher discovered that stretching exercises help female with PD and can the reduce pain severity and the number of medicines they take (p < 0.001). According to Chaudhuri et al. [14] conducted a randomized controlled experiment in 2013 to study any impact of combination could help exercise and hot water combination could helpful in PD. The outcome measure was based upon VAS, and mental distress questionnaire (NSQ). 53 girls were given exercise therapy and 75 girls received hot water bottle treatment. They concluded both, can be used in a home setting to relieve menstrual pain (p < 0.0001). Similarly, Muragod et al. [15] in 2014 performed a study in which they included 32 subjects for the effectiveness of transcutaneous electrical nerve stimulation and diadyamic current on electric stimulation. Outcome measures were based upon VAS, McGill pain questionnaire, MDQ. They divided the subjects into two groups for two different treatments and the results were significant for 1st intragroup with p < 0.001 but insignificant for 2nd intergroup with p = 0.53. So, the concluded that Diadynamic current has better results than TENS in relieving pain in PD. Similarly Lee et al. [16] performed a study in 2015 to investigate the efficacy and safety of combined therapy with high-frequency TENS and thermotherapy in reliving PD pain. It comprised 115 participants. VAS was the outcome measure and the results showed that this combination was effective in relieving acute pain in women with PD. Another study Saleh et al. [17] performed a randomized controlled trial in 2016 and included 150 participants for the stretching or core strengthening exercise for managing primary dysmenorrhea which had VAS as the outcome measure. 44 females were referred for stretching exercises and 44 females for strengthening exercises and 38 females were in the controlled group and the conclusion was a decrease in pain intensity with these exercises (p < 0.001). Similarly Sutar et al. [18] in 2016 performed a systematic review on the effect of aerobic activities on PD in college students, with 100 participants randomized into two groups equally and randomly. The outcome measures were the Short Form 36 Health Survey Questionnaire for quality of life and VAS for pain. The criteria were interventional and control groups, and they concluded that aerobic activities may be the best treatment because it is also post-effective. Bai et al. [19] performed a study on 134 participants to know the effectiveness of TENS as compared to sham TENS in PD in 2017. Outcome measures were based upon NPRS, VAS, World Health Organization Quality of Life-Brief Version-BREF score. Participants of the sham group received TENS. The conclusion was derived that TENS was more effective and safe in relieving pain. Tharani et al. [20] performed a study on a comparison of the effects of stretching exercise vs. aerobic exercises for PD in 2018. It included 30 subjects divided into two groups. It used outcome measure as VAS and it concluded that aerobic dance is effective in reducing symptoms of PD [20] and Samy et al. [21] performed a study in 2019 on 98 participants to know the effect of Zumba exercise on young women with PD. Two groups were divided and intervention and control and VAS were taken as the outcome measure. It was identified that Zumba exercise can reduce the severity of pain. Heidarimoghadam et al. [22] performed a study in 2019 to investigate the effect of exercise based on the specific protocol on the severity and duration of PD. In the study, 86 students were involved; with 43 students in the intervention and 43 students in the controlled group. The exercise was based on the FITT protocol. McGill pain scale research was analysed using SPSS 20.0 (SPSS Inc.). The result can be summarized as sports activity based on a certain and organized protocol which could improve dysmenorrhea p < 0.001. George et al. [23] performed a study in 2019 to evaluate the effect of physical activity and relaxation techniques in reducing the function of primary dysmenorrhea. In this study, 36 subjects were involved and VAS pain scale was the outcome measure. The participants were divided into intervention and control groups. The intervention group received stretching, strengthening and relaxation techniques. The controlled group received only relaxation techniques. The protocol given to the experiment group was effective in reducing symptoms. Kirmizigil and Demiralp [24] study in 2020 was on 28 subjects for examining the effectiveness of functional exercise on pain and sleep quality of patients suffering from primary dysmenorrhea. VAS and MSQ were the outcome measure used in the study. Subjects were divided into two groups-the exercise group and the Controlled group. Combined exercises were effective in reducing the symptoms of primary dysmenorrhea (p < 0.05). Similarly Fallah et al. [25] in 2018 evaluated effect of three exercises programs on reducing symptoms of PD in 70 students who were randomly divided into 4 groups stretch, massage, combined and control a group. Outcome measure were based upon McGill questionnaire, VAS, where the exercises reduced the quality and quantity of pain in primary dysmenorrhea and Lauretti et al. [26] in 2015 performed a randomized controlled trial which used a new portable transcutaneous electrical nerve stimulation device that was efficient in the control of PD cramp pain. Here 50 female were analysed and VAS was the outcome measure. The results concluded significant (p < 0.001). Limitation of studies are discusses below, thus with all the above electro and exercise therapy intervention showing one direction on reducing pain related symptoms on PD we can state that the above conservative intervention can be treatment of choice for female with PD. One of the limitations is the use of small sample size in some of the studies. Another drawback is that none of the studies continued the treatment for longer than three months, i.e., three menstrual cycles fluid intake, which is known to be an effective factor on menstrual symptoms and was not questioned in this study, the prostaglandin levels could not be evaluated objectively during periods, Hospital Anxiety and Depression scale was not used, anxiety and depression results of individuals were obtained, the possible effect of emotional changes on the perception of pain could also be seen. The last limitation was the small sample size of the study [24]. Exercise did not affect severity and duration of PD, but they were affected by weight, fat mass and quality of life. Pain assessment scale is the limitation [22]. Participants have not received any follow-up assessments after the 8 weeks of intervention study was limited up to the nonathletic students aged 18–25 years. Further studies should be conducted for among other populations, such as athlete women, and older adults with same protocol, finally, there was a small sample size, and lack of blinding of participants and outcome assessors, as well as subjective outcome measures with inconsistent assessment so further studies should be to improve this [21]. They have not evaluated dieting behaviour and habitual eating routines, there is lack of any radiological exam such as colour and also there was small sample size [25]. Small sample size, short study duration, no long-term follow-up of the subjects, a study was done only between the age group of 17–23 years, only students were taken as subjects [20]. The researchers were not blinded to the assigned intervention or outcomes, and the lack of a control group (“sham”exercise) may have exaggerated the effect of the intervention [12]. The cross-sectional nature of the research, as it does not reflect any temporal changes. Furthermore, the study was performed on a relatively small sample; therefore, generalizations of results in terms of the entire female population ought to be made with caution [13]. The diagnosis of primary dysmenorrhea was depending on history and since blinding was not feasible in these behavioural interventions, there may have been some bias among the respondents in subjective measurement of pain and menstrual distress [14]. The present study was conducted by giving treatment for duration of one cycle. Long term benefits couldn’t be observed in the same. The treatment protocol can be given in increased frequency of either two or three times a day, since our study is limited to only once in a day [15]. Many additional keywords or MESH terms linked to “physiotherapy topic” could have been included in the search method; this has resulted in the omission of certain papers. Likewise, for databases such as PubMed or Cochrane, many other databases could have been involved in the study.

This study’s practical applications can cause a reduction in the usage of pharmaceutical treatment which is in favour of physiotherapy-based treatment options. As a result, there would be fewer side effects and patients will spend less money on Non-Steroidal Anti-Inflammatory Drugs, contraceptive pills, and other medications. Exercise and electrotherapy provide a diverse and sufficient arsenal of treatments that if implemented in a tailored manner then can help the patients to lessen the side effects and improve their quality of life.