Case reports
Multimodal Therapy Combining Spinal Manipulation, Transcutaneous Electrical Nerve Stimulation, and Heat for Primary Dysmenorrhea: A Prospective Case Study

https://doi.org/10.1016/j.jcm.2018.03.005Get rights and content

Abstract

Objective

The purpose of this case study was to report the effects of multimodal therapy as an adjunct to oral contraceptives on pain and menstrual symptoms in a patient with primary dysmenorrhea.

Clinical Features

A 27-year old nulligravid and nulliparous woman presented with low back pain, thigh pain, and menstrual symptoms associated with primary dysmenorrhea. Multimodal therapies (spinal manipulation, clinic-based transcutaneous electrical nerve stimulation, and heat applied at home) were delivered over 3 menstrual cycles. Outcome measures included pain (visual analogue scale) and menstrual symptoms (Menstrual Distress Questionnaire) from baseline to follow-up. She continued to take her oral contraceptives throughout the study period.

Intervention and Outcome

For both low back and thigh pain, the patient reported clinically important differences in average pain and worst pain after 2 and 3 months from baseline. There were no clinically important differences in current pain, best pain, or menstrual symptoms at follow-up. No adverse events were reported.

Conclusion

Some of this patient’s dysmenorrhea symptoms responded favorably to multimodal therapy over 5 months. The authors observed important short-term reductions in low back and thigh pain (average and worst pain intensity) during care.

Introduction

Primary dysmenorrhea is defined as painful menstruation in the absence of underlying pelvic pathology.1 Primary dysmenorrhea is a common uterine condition that affects nearly half of reproductive age girls and women.2 Previous studies reported a prevalence of primary dysmenorrhea in approximately 45% to 93% of women.3, 4, 5, 6 About 7% to 15% of women reported severe menstrual pain that limited work or daily activities3, 7, 8 or resulted in economic loss.9, 10

The etiology of primary dysmenorrhea is not well understood. Evidence suggests that it involves increased endometrial prostaglandin production, basal pressure, and uterine contractions, leading to higher blood flow impedance, uterine vasoconstriction, and subsequent pain.11, 12, 13 Traditionally, treatments have focused on managing these physiological responses, including nonsteroidal anti-inflammatory drugs and oral contraceptive pills.14, 15 Nonsteroidal anti-inflammatory drugs and oral contraceptive pills reportedly provide substantial benefits to approximately 75% of women with primary dysmenorrhea.3, 9, 10, 16, 17, 18 However, for women wishing contraception, combined oral contraceptives (specifically those combining ethinyl estradiol and chlormadinone) are preferred, thus eliminating the inherent risks associated with use of nonsteroidal anti-inflammatory drugs.13

Approximately 20% of women with primary dysmenorrhea do not receive adequate symptom relief from these pharmacologic treatments.19 Consequently, some women seek nonpharmacologic treatments for the management of their menstrual symptoms.19, 20, 21, 22, 23 Nonpharmacologic interventions commonly used by women include acupuncture, spinal manipulation, transcutaneous electrical nerve stimulation (TENS), and heat application.20, 24, 25, 26, 27, 28 In Australia, approximately 8% to 21% of women with cyclic perimenstrual pain and discomfort often received complementary and alternative medicine from chiropractors or other complementary and alternative medicine providers.22 Moreover, a qualitative study reported that some women experience dissatisfaction with painkillers and oral contraceptives for the management of dysmenorrhea.29 Despite the common use of nonpharmacologic interventions, there is limited evidence of their effectiveness.20, 24, 25, 26, 27, 28

Most studies examined interventions independently of one another or examined the therapy as an alternative to pharmacologic treatments. Such interventions include spinal manipulation,26, 30, 31, 32 TENS,28 and topical heat.27, 33, 34 Pragmatically, women with primary dysmenorrhea may try a number of therapies concurrently to improve pain and function. Thus, studies examining the effects of multimodal therapies may be more representative of the treatments provided in clinical practice. To the best of the authors’ knowledge, no high-quality studies have examined the effectiveness of combined nonpharmacologic therapies in a program of care for the management of women with primary dysmenorrhea.

The purpose of this prospective case study aimed to examine the effects of chiropractic care using multimodal therapy (ie, spinal manipulation, TENS, and heat) as an adjunct to oral contraceptives on pain and menstrual symptoms in a woman with primary dysmenorrhea.

Section snippets

Case Report

The authors conducted a prospective case study in a woman with primary dysmenorrhea by administering multimodal therapy over 3 menstrual cycles. The research ethics board at the Canadian Memorial Chiropractic College, Toronto, Canada approved this study (REB #1103CR3). Written informed consent from the participant and the licence to use the Menstrual Distress Questionnaire (MDQ) were obtained before conducting the study.

Outcomes

For low back and thigh pain, there were no clinically important differences in mean scores for “current pain” and “best pain” across all menstrual cycles (Table 1, Fig 2, Fig 3). However, there were clinically important reductions in “average pain” and “worst pain” in menstrual cycles 3 and 4, when compared to baseline for both low back and thigh pain. These differences were not maintained in menstrual cycle 5 (when no multimodal intervention was given). There were no clinically important

Discussion

To the best of the authors' knowledge, this is the first prospective case study to describe the effects of a multimodal therapy combining chiropractic spinal manipulation, TENS, and heat as an adjunct to oral contraceptives for the treatment of symptoms of primary dysmenorrhea. For low back and thigh pain, the authors found clinically important reductions in average pain and worst pain in menstrual cycles 3 and 4, when compared to baseline. These differences were not maintained in menstrual

Conclusion

In this case study, the patient reported short-term improvements in low back and thigh pain (average and worst pain intensity) after a course of multimodal therapy combining spinal manipulation, TENS, and topical heat as an adjunct to oral contraceptives. No adverse events were reported.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

  • Concept development (provided idea for the research) J.J.W., M.L., S.M.

  • Design (planned the methods to generate the results) J.J.W., M.L., S.M.

  • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript) S.M.

  • Data collection/processing (responsible for experiments, patient management, organization, or reporting data) J.J.W., S.M.

  • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results) J.J.W., S.M.

References (50)

  • P Kannan et al.

    Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review

    J Physiother

    (2014)
  • MA Hondras et al.

    Spinal manipulative therapy versus a low force mimic maneuver for women with primary dysmenorrhea: a randomized, observer-blinded, clinical trial

    Pain

    (1999)
  • MD Akin et al.

    Continuous low-level topical heat in the treatment of dysmenorrhea

    Obstet Gynecol

    (2001)
  • CM Rogers et al.

    Biomechanical measure validation for spinal manipulation in clinical settings

    J Manipulative Physiol Ther

    (2003)
  • C Mannheimer et al.

    Transcutaneous electrical nerve stimulation (TENS) in angina pectoris

    Pain

    (1986)
  • W Herzog

    The biomechanics of spinal manipulation

    J Bodyw Mov Ther

    (2010)
  • AS Downie et al.

    Quantifying the high-velocity, low-amplitude spinal manipulative thrust: a systematic review

    J Manipulative Physiol Ther

    (2010)
  • IS Fraser

    Prostaglandins, prostaglandin inhibitors and their roles in gynaecological disorders

    Baillieres Clin Obstet Gynaecol

    (1992)
  • J Johnson

    Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea

    J Adolesc Health Care

    (1988)
  • JC Robinson et al.

    Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic

    Am J Obstet Gynecol

    (1992)
  • M Bernardi et al.

    Dysmenorrhea and related disorders

    F1000Res

    (2017)
  • G Sundell et al.

    Factors influencing the prevalence and severity of dysmenorrhoea in young women

    Br J Obstet Gynaecol

    (1990)
  • MY Dawood

    Dysmenorrhea

    Clin Obstet Gynecol

    (1983)
  • MY Dawood

    Dysmenorrhea

    Clin Obstet Gynecol

    (1990)
  • M Akerlund et al.

    Primary dysmenorrhoea and vasopressin

    Br J Obstet Gynaecol

    (1979)
  • View full text