The Somatic Connection  |   April 2013
Manual Therapy May Benefit Women With Primary Dysmenorrhea
Author Affiliations
  • Hollis H. King, DO, PhD
    University of Wisconsin School of Medicine and Public Health, Madison
Article Information
The Somatic Connection   |   April 2013
Manual Therapy May Benefit Women With Primary Dysmenorrhea
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 359-360. doi:
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 359-360. doi:
Molins-Cubero S, Boscá-Gandía JJ, Rus-Martínez MA. Assessment of low back and pelvic pain after applying the pelvis global manipulation technique in patients with primary dysmenorrhea: a pilot study. Eur J Ost Clin Rel Res. 2012;7(1):29-38  
Primary dysmenorrhea is a gynecologic condition that affects 40% to 70% of women of childbearing age. Pain in the lower abdomen, followed by low back pain and pelvic pain, is the symptom most frequently associated with the disorder. Researchers in Spain conducted a double-blind, randomized controlled trial to assess the efficacy of a global pelvic manipulation (GPM) technique in improving low back and pelvic pain in women with primary dysmenorrhea. 
Women with primary dysmenorrhea diagnosed by a gynecologist were identified through searches of medical records at the principal investigator's clinic. Inclusion criteria were age between 18 and 40 years and a history of regular menstruation. Exclusion criteria were the presence of secondary dysmenorrhea or any gynecologic pathology other than primary dysmenorrhea, use of an intrauterine device, previous gynecologic interventions, contraindications to GPM, osteopathic therapy received within 2 months of initiation of the trial, and a fear of either blood tests or GPM. The 20 patients who were selected for the study were randomly assigned to an experimental group (n=10) or a control group (n=10). 
Outcome measures were the intensity of low back pain and pelvic pain, as well as the pressure pain threshold (PPT) in the left and right sacroiliac joints (SIJs) of the posterior superior iliac spine. Because the researchers' review of the literature suggested that chemical modulators of pain might be related to primary dysmenorrhea and might be affected by manual therapy, the researchers also performed tests to determine blood levels of serotonin and catecholamines (dopamine, noradrenaline, and adrenaline). 
On day 1 of their menstrual cycle, patients reported to the clinic to undergo a series of assessments and procedures. Pain intensity was assessed on a 100-mm visual analog scale (VAS), and the PPT of the SIJs was determined using a pressure algometer. A blood sample was obtained, an experienced osteopath then applied the GPM technique to each patient in the experimental group, and a placebo or sham procedure was applied to each patient in the control group. A second set of VAS and PPT measurements was then obtained, and at 30 minutes after application of the GPM technique or sham procedure, a second blood sample was obtained. 
Both the GPM technique and the sham procedure took 2 minutes to perform. The experimental group received 1 bilateral application of the GPM technique, which was administered to each SIJ and the lumbosacral joint area. The GPM technique, which was applied to each side of the pelvis, was described as a thrust technique that affects, or gaps, both the SIJs and the lumbosacral joints. No illustrations of the GPM technique were included in the article. However, a high-velocity, low-amplitude (HVLA) manipulation for sacral torsion somatic dysfunction that may be similar to the procedure described in this article is illustrated in the Outline of Osteopathic Manipulative Procedures: The Kimberly Manual 2006 (Updated 2008).1 Application of the sham procedure to the control group consisted of the osteopath placing a hand on the hypogastric region just above the pubic symphysis. 
The experimental group had a statistically significant improvement in postintervention measurements of the PPT for both SIJs, compared with the control group. No statistically significant differences between preintervention and postintervention assessments were noted for any of the other outcomes. 
The authors discussed the limitations of their study. They acknowledged that patient ingestion of nonsteroidal anti-inflammatory drugs could have influenced the pain measurements obtained at baseline. One possible way to avoid this potential bias would have been be to enforce exclusion of patients from the study if they ingested nonsteroidal anti-inflammatory drugs on the day before study initiation. The authors also explained that, because of the effects of circadian rhythm on catecholamine and serotonin levels, controlling the measurements of these biomarkers was difficult and could have been affected by such factors as unreported patient stress. I believe the authors should have acknowledged that their study involved only 1 brief intervention and speculated on the possible effects of applications involving multiple interventions. 
Despite the limitations of this study, I believe that the degree of pain reduction achieved in such a small number of patients, as measured with PPT algometry, suggests that the application of just 1 set of bilateral GPM procedures is an effective intervention and merits further study. 
   Section Editor's Note: The following 3 reviews share a theme and were selected to appear in this installment of “The Somatic Connection” because they report a possible benefit of manual therapy and osteopathic manipulative therapy in the treatment of patients with visceral disorders. Osteopathic manipulative treatment has been proven effective in the management of chronic low back pain and is accepted as a beneficial treatment for musculoskeletal disorders in general. In addition, according to the osteopathic tenet of the structure-function relationship, application of osteopathic manipulative treatment has a positive impact on physiological functions and shows benefit in the treatment of systemic disorders (King HH, Jänig W, Patterson MM, eds. The Science and Clinical Application of Manual Therapy. Edinburgh, Scotland: Churchill Livingstone/Elsevier; 2011:301-312.). These 3 studies were also selected because they represent the research of international practitioners of osteopathy and other manual therapy professions, which is relevant to osteopathic medical research on applicable techniques and outcome measurements.
Halma K, Lockwood MD, Snider E, Vick D. Outline of Osteopathic Manipulative Procedures: The Kimberly Manual 2006 (Updated 2008). Kirksville, MO: A.T. Still University of Health Sciences-Kirksville College of Osteopathic Medicine; 2008:208.