Depósi o de in es igación de la Uni e sidad de Se illa
h ps://idus.us.es/
Es a es la e sión acep ada del a ículo publicado en: Pain Medicine
This is a accep ed manusc ip o a pape published in: Pain Medicine
Pain Medicine (2014): 10 sep iemb e 2014
DOI: h ps://doi.o g/10.1111/pme.12404
El acceso a la e sión publicada del a ículo puede eque i la susc ipción de la
e is a.
Access o he published e sion may equi e subsc ip ion.
“This is a p e-copyedi ed, au ho -p oduced e sion o an a icle accep ed o
publica ion in [inse jou nal i le] ollowing pee e iew. The e sion o eco d
[Pain Medicine, Volume 15, Issue 9, 10 Sep embe 2014, Pages 1455–1463] is
a ailable online a : Ox o d Uni e si y P ess
[h ps://academic.oup.com/painmedicine/a icle/15/9/1455/1892723]
[h ps://doi.o g/10.1111/pme.12404]
Ti le:
Changes in Pain Pe cep ion a e Pel is Manipula ion in Women wi h P ima y
Dysmeno hea: A Randomized Con olled T ial
Au ho s and a ilia ions:
Sil ia Molins-Cube o, PT, DO,*
Cleo ás Rod íguez-Blanco, PT, DO, PhD,†
Ángel Oli a-Pascual-Vaca, PT, DO, PhD,†
Albe o M. He edia-Rizo, PT, PhD,†
Juan J. Boscá-Gandía, PT, DO,*
F ançois Rica d, DO*
* Depa men o Physical The apy, Facul y o Nu sing, Physio he apy and Podia y,
Uni e si y o Se illa, Se illa, Spain
† Mad id Os eopa hic School, Mad id, Spain
* Co esponding au ho :
Cleo ás Rod íguez-Blanco,
Depa men o Physical The apy. Facul y o Nu sing, Physio he apy and Podia y,
Uni e si y o Se illa, c/ A icena s/n, Se illa 41009, Spain.
Tel: (+34) 954486528; Fax: (+34) 954486527;
E-mail: [email p o ec ed].
Abs ac
Objec i e. This s udy aims o e alua e he immedia e e ec o a global pel ic
manipula ion (GPM) echnique, bila e ally applied, on low back pel ic pain in women
wi h p ima y dysmeno hea (PD).
Design. A p ospec i e, andomized, double-blind, con olled ial.
Se ing. Facul y o Nu sing, Physio he apy and Podia y. Uni e si y o Se illa, Spain.
Me hods. The sample g oup included 40 women (30 ± 6.10 yea s) ha we e di ided
in o an expe imen al g oup (EG) (N = 20) who unde wen a bila e al GPM echnique
and a con ol g oup (CG) (N = 20) who unde wen a sham (placebo) in e en ion.
E alua ions we e made o sel - epo ed low back pel ic pain ( isual analog scale),
p essu e pain h eshold (PPT) in sac oiliac join s (SIJs), and he endogenous esponse o
he o ganism o pain ollowing ca echolamines and se o onin elease in blood le els.
Resul s. The in ag oup compa ison showed a signi ican imp o emen in he EG in he
sel -pe cei ed low back pel ic pain (P = 0.003) and in he mechanosensi i i y in bo h
SIJs (P = 0.001). In he be ween g oup compa ison, he e was a dec ease in pain
pe cep ion (P = 0.004; F(1,38) = 9.62; R2 = 0.20) and an inc ease in he PPT o bo h
SIJs, in he igh side (P = 0.001; F(1,38) = 21.29; R2 = 0.35) and in he le side (P =
0.001; F(1,38) = 20.63;R2 = 0.35). The e we e no in e g oup di e ences o
ca echolamines plasma le els (ad enaline P = 0.123; no ad enaline P = 0.281;
dopamine P = 0.173), bu he e we e o se o onin le els (P = 0.045; F(1,38) = 4.296;
R2 = 0.10).
Conclusion. The bila e al GPM echnique imp o es in a sho e m he sel -pe cei ed
low back pel ic pain, he PPT in bo h SIJs, and he se o onin le els in women wi h PD.
I shows no signi ican di e ences wi h a sham in e en ion in ca echolamines plasma
le els.
Key Wo ds. P ima y Dysmeno hea; Manipula ion Spinal; Pel ic Pain; Pain Th eshold;
Se o onin; Ca echolamines.
In oduc ion
P ima y dysmeno hea (PD) is a common gynecological diso de in women o
childbea ing age [1,2]. PD is de ined by se e al symp oms ha p ecede mens ua ion, in
he absence o any o ganic pa hology, and las ing a ound 48–72 hou s [2]. The mos
common symp om is pain in he lowe abdomen ha adia es o bo h highs o o he
lumba -sac al egion. Pain is usually accompanied by less equen signs and symp oms,
such as i edness, headache, nausea, cons ipa ion, and dia hea [3,4]. The p e alence o
PD a ies be ween 45% and 95% o women o childbea ing age [4,5]. I is a common
cause o absen eeism om wo k o school, hus in e e ing wi h daily li e and
wi h many social cos s a ising om his [5].
The e ha e been many p oposals o in e en ions o PD in he scien i ic li e a u e. As
pel ic pain seems o be media ed by p os aglandin ac o 2Å~ [6], he mos common
he apeu ic app oach has been medical ea men ha usually in ol es he
adminis a ion o nons e oidal an i-in lamma o y d ugs (NSAIDs) o o al con acep i es
[7]. On one hand, NSAIDs a e pe iphe al inhibi o s o p os aglandin syn hesis [8]. On
he o he hand, o al con acep i es inhibi o ula ion and, consequen ly, he endome ium
educes in hickness he eby diminishing p os aglandin syn hesis [7].
The e iciency o hese ea men s a ies be ween 17% and 95% [4]. Howe e ,
pha macological ea men may in ol e some ad e se side e ec s, like gas oin es inal
bleeding, which inc eases hei in ole ance o some pa ien s [4,9]. Hence, i is common
o women o demand new and al e na i e he apeu ic ools wi h less pe cei ed
associa ed isks [10].

P e ious esea ch has analyzed he e ec s on pel ic pain pe cep ion a ising om PD
h ough al e na i e he apies such as: 1) con inuous low-le el opical hea a hypogas ic
le el [11]; 2) acupunc u e [12–14]; 3) anscu aneous elec ical ne e s imula ion
(TENS) and in e e en ial cu en [15]; 4) homeopa hy [16]; 5) Chinese he bal medicine
[17]; 6) acup essu e [18,19]; and e en 7) low a die s [20,21]. Many o hese he apies
ha e p o en o ha e a posi i e impac on pain. Howe e , hese esul s a e no
conclusi e enough o ecommend hei use ou inely, due o poo me hodological
designs in some cases [10,22].
Se e al s udies ha e e alua ed he e icacy o spinal manipula i e echniques on women
wi h PD [23–26]. Spinal manipula ion (SM) has p o en o ha e some in luence on pain
pe cep ion and mens ual c amps, and also on plasma le els o some chemical
media o s o pain [26–28]. E en hough he e a e no conclusi e obse a ions o p o e a
posi i e e ec o SM on pain associa ed wi h PD, he e is a lack o ag eemen on which
spinal egion needs o be manipula ed and on he echniques ha may be mos e ec i e.
Hence, he e is some need o de elop new s udies in his ield [29]. Hol zman e al. [25].
p oposed ha SM should be di ec ed o speci ic es ic ions in he lumba -sac al spine
(L5-S1) o alle ia e pain associa ed wi h PD.
Hypo hesis
The global pel ic manipula ion (GPM) echnique, bila e ally applied in women
su e ing om PD, imp o es pain pe cep ion on low back pel ic egion and has a
posi i e impac on he endogenous esponse o he o ganism o pain (ca echolamines
and se o onin elease in blood le els).
Objec i e
Based on he neu ophysiologic e ec s o SM echniques [30], he main aim o he s udy
is o assess he immedia e e ec s o a GPM echnique in low back pel ic pain
pe cep ion and in se e al nocicep i e bioma ke s in subjec s wi h PD.
Ma e ials and me hods
Design and Randomiza ion P ocedu e
A andomized, by means o a andomized numbe able designed by an In e ne websi e
(h p://www. andomized.o g), and double-blind con olled clinical ial was conduc ed.
The andomiza ion sequence was gua ded by an ex e nal consul an who gua an eed i s
concealmen om all pa icipan s in he s udy: subjec s, e alua o s and he apis in
cha ge o he in e en ions.
Pa icipan s
One hund ed (N = 100) pa icipan s who had a his o y o low back pain and medical
diagnosis o PD by a gynecologis , excluding any o he gynecological pa hology,
we e ec ui ed o he s udy. The clinical eco ds we e selec ed om he main
esea che ’s p ac ice. Six y women (N = 60) we e excluded om he s udy; 37
(N = 37) did no mee he inclusion/exclusion c i e ia, 14 women (N = 14) e used
pa icipa ion, and nine (N = 9) o hem we e excluded o easons ela ed mainly o ea
o blood ex ac ion o home add ess changes. Du ing he alloca ion phase, 40 (N = 40)
subjec s who en olled he s udy we e dis ibu ed in o wo g oups (N = 20). No losses
o ollow-up we e eco ded du ing da a collec ion and analysis phases [31] (Figu e 1).
Es ablished inclusion c i e ia we e: 1) age be ween 18 and 50 yea s old; 2) diagnosis o
PD acco ding o he P ima y Dysmeno hea Consensus Guideline [32]; 3) egula
mens ual cycle (28 ± 7 days); 4) mens ual pain o mode a e o se e e in ensi y (o e
50 mm in he isual analog scale [VAS]); and 5) subjec s who ga e he in o med
consen .
Exclusion c i e ia we e he ollowing: 1) o ha e an in au e ine de ice; 2) being
diagnosed as su e ing om seconda y dysmeno hea; 3) p e ious gynecological
in e en ions; 4) con aindica ions o he GPM echnique; 5) ha ing ecei ed p e ious
manipula i e ea men wi hin he 2 mon hs be o e he beginning o he s udy; and 6)
showing any s ess o ea o SM.
Sampling P ocess and Sample Size
The subjec s we e selec ed acco ding o nonp obabilis ic con enience sampling
echniques. The sample size was based on a pilo s udy [33], using he so wa e “ amaño
de la mues a 1.1”® (Hospi al Uni e si a io San Ignacio, Bogo á, Colombia). Taking
in o accoun a one- ailed hypo hesis, he in e g oup di e ence being o 20%, o an
α alue o 0.05, a a iabili y o 15%, a desi ed powe o 90%, and o an expec ed
a e age o 25% in he expe imen al g oup (EG) and o 5% in he con ol g oup (CG), a
sample size o 20 subjec s pe g oup was necessa y. The inal sample g oup consis ed o
40 women wi h PD wi h a mean age o 30 ± 6.10 yea s (19–48). They we e di ided in o
an EG (N = 20) and a CG (N = 20). The s udy ecei ed app o al and was designed
con o med o he guidelines o he Ins i u ional E hical Commi ee. I has been
egis e ed in he Aus alian and New Zealand Clinical T ials Regis y wi h egis a ion
numbe ACTRN12611001195943.
Blinding
All pa icipan s we e in o med o he gene al aspec s o he s udy wi h he in o med
consen o m (possible bene i s, isks, p ecau ions and side e ec s o he assessmen s,
and he in e en ions). They we e old be o e andomiza ion ha di e en ypes o
ea men s will be compa ed in he s udy. Subjec s and e alua o s who collec ed
o analyzed da a emained unawa e o he ea men alloca ion g oup and he speci ic
aims o he s udy o gua an ee pa icipan and ou come assesso blinding. The
he apis in cha ge o he manipula ion (in e en o ) did no pa icipa e in he
assessmen p o ocol. Measu es we e also aken o ensu e ha he in e en o emained
unawa e o he ea men alloca ion g oup (in e en o blinding).
S udy P o ocol
Subjec s we e con ac ed by phone. Once i was con i med ha hey quali ied unde he
inclusion/exclusion c i e ia and hei willingness o pa icipa e, hey we e e e ed o he
s udy se ing he i s day o he mens ual cycle. Then, he subjec comple ed he
in o med consen pape , which was p epa ed in acco dance wi h he Decla a ion
o Helsinki ( e sion 2008), and illed he pe sonal and clinical da a o m. The
measu emen p o ocol ook place in a oom equipped wi h a ea men able and a
s eady empe a u e be ween 18°C and 21°C. All e alua ions we e pe o med in bo h
g oups be o e and a e he in e en ion in he ollowing o de .
Assessmen o Low Back Pel ic Pain
A VAS was used o measu e sel - epo ed pain. VAS is conside ed o be a alida ed,
e ec i e, accu a e, sensi i e, easy o use, and ep oducible me hod o assess acu e
and ch onic pain [34]. The subjec ma ked on he VAS he cu en in ensi y o low back
pel ic pain. The esul was exp essed in millime e s (mm), anged om 0 mm o
100 mm.
Assessmen o P essu e Pain Th eshold (PPT) in Sac oiliac Join s (SIJs)
PPT is de ined as he minimum amoun o p essu e needed o e oke discom o o pain
[35]. A digi al dynamome e (PCE, FM model 200, Meschede, Ge many) was used o
which makes i di icul o ind solid conclusions.
In ega d o plasma le els o nocicep i e bioma ke s, Degenha d e al. [27] ound no
signi ican changes o se o onin le els a e os eopa hic manual he apy (OMT) in
subjec s wi h low back pain. This esul sugges s ha he e ec s o he OMT wi hou
applying HVLA echniques may no be media ed by he se o one gic pa hway bu
p obably by endogenous opioids and cannabinoids. On he con a y, Skyba e al. [28]
demons a ed in an animal model ha join manipula ion augmen s he se o onin
concen a ion, which can p oduce analgesia h ough he descending inhibi o y pa hway.
When compa ing be ween-g oups, we obse ed a signi ican inc ease o se o onin
concen a ion in he EG. I may be easonable o s a e ha his esul is due o he
dec ease ound in he se o onin le el in he CG (14.93 Å} 36.58 ng/mL), because he
inc ease in he EG le el was small (4.98 ± 22.51 ng/ mL). We ind no de ini e
explana ion o hese esul s in he CG. Some s udies ha e shown no s a is ical changes
on ni ic oxide concen a ion blood le els a e al e na i e he apies (yoga and
acup essu e) in women wi h PD [51,52]. I emains an issue o u u e s udies o
complemen he p esen e alua ions wi h he assessmen o ni ic oxide le els a e SM.
I may help o ge a be e unde s anding o he clinical e ec o manipula i e
echniques in PD.
Limi a ions
The s udy has ce ain limi a ions. Fi s , he subjec ’s in ake o NSAIDs and/o cyclo-
oxygenase-2 speci ic inhibi o s was no con olled. This could be a plausible
explana ion o unde s and he baseline in e g oup di e ences in he pe cei ed pain. I
could be also a gued ha he in ake o o al con acep i es, which has been ela ed o
pel ic pain alle ia ion [7], was highe in he EG (25% o subjec s).

Low-back pel ic pain seems o be associa ed wi h hype mobili y, s ain o he join s,
and body mass index [50]. Pa icipan s’ heigh and weigh we e no measu ed in his
ial. Unlike p e ious esea ch [23,25], no e alua ion o speci ic lumba -sac al mo ion
es ic ions was pe o med ei he . Second, he indings mus be cau iously in e p e ed
because he s udy has only assessed immedia e e ec s. Long- e m esul s should be
e alua ed in u u e s udies [53]. Finally, he measu emen o ca echolamines and
se o onin plasma le el is complex because i is in luenced by ood in ake, s ess, and
pa ien posi ion, and i shows a ci cadian hy hm [54]. Subjec s we e always placed
du ing measu emen s in a si ing posi ion, and hey we e a es be ween each blood
ex ac ion. The s udy was always pe o med be ween 8:00 PM and 9:00 PM o a oid
in luencing he baseline le els. Howe e , i any woman had a ea o SM o blood
ex ac ion and ailed o epo such eeling, ca echolamines le els may ha e been
al e ed in he pos in e en ion e alua ion.
Conclusions
The GPM echnique, bila e ally applied o women wi h PD, appea s o inc ease
signi ican ly he PPT in he SIJ and educe he sel - epo ed low–back pel ic pain in a
sho e m.
Rega ding he plasma le els o chemical modula o s o pain (ca echolamines and
se o onin), he GPM echnique inc eases se o onin le els, wi h a small e ec size. I
shows no s a is ical signi icance in compa ison wi h a sham (placebo) in e en ion o
ca echolamines plasma le els.
Re e ences
1 Kennedy S. P ima y dysmeno hoea. Lance 1997;349:1116.
2 Mish PC, ed. Webs e ’s Nin h New Collegia e Dic iona y. Sp ing ield, MA: Me iam-
Webs e Inc.; 1986.
3 Dawood MY. Dysmeno hea. Clin Obs e Gynecol 1990;33(1):168–78.
4 P oc o M, Fa quha C. Diagnosis and managemen o dysmeno hoea. BMJ
2006;332:1134–8.
5 Pola A, Celik H, Gu a es B, e al. P e alence o p ima y dysmeno hea in young adul
emale uni e si y s uden s. A ch Gynecol Obs e 2009;279(4):527–32.
6 Nasi L, Bope ET. Managemen o pel ic pain om dysmeno hea o endome iosis. J
Am Boa d Fam P ac 2004;17:S43–7.
7 P en ice A, Dea y AJ, Bland E. P oges agens and an i-p oges agens o pain
associa ed wi h endome iosis. Coch ane Da abase Sys Re 2000;(2):CD002122.
8 Zhang WY, Li Wan Po A. E icacy o mino analgesics in p ima y dysmeno hea: A
sys ema ic e iew. B J Obs e Gynaecol 1998;105(7):780–9.
9 Taylo D, Miaskowski C, Kohn J. A andomized clinical ial o he e ec i eness o an
acup essu e de ice ( elie b ie ) o managing symp oms o dysmeno hea. J Al e n
Complemen Med 2002;8(3):357–70.
10 P oc o ML, Hing W, Johnson TC, Mu phy PA. Spinal manipula ion o p ima y and
seconda y dysmeno hoea. Coch ane Da abase Sys Re 2001;(4):CD002119.
11 Akin MD, Weingand KW, Hengehold DA, e al. Con inuous low-le el opical hea in
he ea men o dysmeno hea. Obs e Gynecol 2001;97(3):343–9.
12 Shi GX, Liu CZ, Zhu J, e al. E ec s o acupunc u e a Sanyinjiao (SP6) on
p os aglandin le els in p ima y dysmeno hea pa ien s. Clin J Pain 2011;27(3):258–61.
13 Ma YX, Ma LX, Liu XL, e al. A compa a i e s udy on he immedia e e ec s o
elec oacupunc u e a Sanyinjiao (SP6), Xuanzhong (GB39) and a nonme idian
poin , on mens ual pain and u e ine a e ial blood low, in p ima y dysmeno hea
pa ien s. Pain Med 2010;11(10):1564–75.
14 Liu CZ, Xie JP, Wang LP, e al. Immedia e analgesia e ec o single poin
acupunc u e in p ima y dysmeno hea: A andomized con olled ial. Pain Med 2011;
12(2):300–7.
15 Tugay N, Akbay ak T, Demi ü k F, e al. E ec i eness o anscu aneous elec ical
ne e s imula ion and in e e en ial cu en in p ima y dysmeno hea. Pain Med
2007;8(4):295–300.
16 Wi CM, Lüd ke R, Willich SN. Homeopa hic ea men o pa ien s wi h
dysmeno hea: A p ospec i e obse a ional s udy wi h 2 yea s ollow-up. A ch
Gynecol Obs e 2009;280(4):603–11.
17 Jang JB, Yoon YJ, Pa k JH, e al. The apeu ic e ec s o Chiljehyangbuhwan on
p ima y dysmeno hea: A andomized, double blind, placebo-con olled s udy.
Complemen The Med 2009;17(3):123–30.
18 Lin JA, Wong CS, Lee MS, e al. Success ul ea men o p ima y dysmeno hea by
colla e al me idian acup essu e he apy. J Manipula i e Physiol The 2010;33(1):70–5.
19 Wong CL, Lai KY, Tse HM. E ec s o SP6 acup essu e on pain and mens ual
dis ess in young women wi h dysmeno hea. Complemen The Clin P ac 2010;
16(2):64–9.
20 Spea s LG. A na a i e e iew o medical, chi op ac ic, and al e na i e heal h
p ac ices in he ea men o p ima y dysmeno hea. J Chi op Med 2005;4(2):76–
88.
21 Ba na d ND, Scialli AR, Hu lock D, Be on P. Die and sex-ho mone binding
globuline, dysmeno hea and p emens ual symp oms. Obs e Gynecol 2000;95(2):
245–50.
22 Zhu X, P oc o M, Bensoussan A, Wu E, Smi h CA. Chinese he bal medicine o
p ima y dysmeno hoea. Coch ane Da abase Sys Re 2008;(2):CD005288.
23 Boesle D, Wa ne M, Alpe s A, Finne y EP, Kilmo e MA. E icacy o high- eloci y
low-ampli ude manipula i e echnique in subjec s wi h low-back pain du ing mens ual
c amping. J Am Os eopa h Assoc 1993;93(2):203–8213-4.
24 Hond as MA, Long CR, B ennan PC. Spinal manipula ion he apy s a low o ce
mimic maneu e o women wi h p ima y dysmeno hea: A andomized, obse e -
blinded clinical ial. Pain 1999;81(1–2):105–14.
25 Hol zman DA, Pe occo-Napuli KL, Bu ke JR. P ospec i e case se ies on he e ec s
o lumbosac al manipula ion on dysmeno heal. J Manipula i e Physiol The
2008;31(3):237–46.
26 Kokjohn K, Schmid DM, T iano JJ, B ennan PC. The e ec o spinal manipula ion
on pain and p os aglandin le els en women wi h p ima y dysmeno heal. J
Manipula i e Physiol The 1992;15(5):279–85.
27 Degenha d BF, Da mani NA, Johnson JC, e al. Role o os eopa hic manipula i e
ea men in al e ing pain bioma ke s: A pilo s udy. J Am Os eopa h Assoc
2007;107(9):387–400.
28 Skyba DA, Radhak ishnan R, Rohlwing JJ, W igh A, Sluka KA. Join manipula ion
educes hype algesia by ac i a ion o monoamine ecep o s bu no opioid o GABA
ecep o s in he spinal co d. Pain 2003;106(1–2):159–68.
29 P oc o ML, Hing W, Johnson TC, Mu phy PA. Spinal manipula ion o p ima y and
seconda y dysmeno hoea. Coch ane Da abase Sys Re 2006;(3):CD002119.
30 Picka JG. Neu ophysiological e ec s o spinal manipula ion. Spine J
2002;2(5):357–71.
31 Tu ne L, Shamsee L, Al man DG, e al. Consolida ed s anda ds o epo ing ials
(CONSORT) and he comple eness o epo ing o andomized con olled ials (RCTs)
published in medical jou nals. Coch ane Da abase Sys Re 2012;(11):MR000030.
32 Le eb e G, Pinsonneaul O, An ao V, e al. P ima y dysmeno hea consensus
guideline. J Obs e Gynecol Can 2005;27(12):1117–46.
33 Molins-Cube o S, Boscá-Gandía JJ, Rus-Ma ínez MA. Assessmen o low back and
pel ic pain a e applying he pel is global manipula ion echnique in pa ien s wi h
p ima y dysmeno hea: A pilo s udy. Eu J Os Clin Rel Res 2012;7(1):29–38.
34 Ca lsson AM. Assessmen o ch onic pain. I. Aspec s o he eliabili y and alidi y o
he isual analogue scale. Pain 1983;16(1):87–101.
35 Fische AA. P essu e algome y o e no mal muscles. S anda d alues, alidi y and
ep oducibili y o p essu e h eshold. Pain 1987;30(1):115–26.
36 He edia-Rizo AM, Oli a-Pascual-Vaca A, Rod íguez-Blanco C, e al. Immedia e
changes in mas ica o y mechanosensi i i y, mou h opening, and head pos u e a e
myo ascial echniques in pain- ee heal hy pa icipan s: A andomized con olled ial. J
Manipula i e Physiol The 2013;36(5):310–8.
37 Eisenho e G, Golds ein DS, S ull R, e al. Simul aneous liquid-ch oma og aphic
de e mina ion o 3,4-dihyd oxyphenylglycol, ca echolamines, and 3,4-

dihyd oxyphenylalanine in plasma, and hei esponses o inhibi ion o monoamine
oxidase. Clin Chem 1986;32(11):2030–3.
38 Rica d F. T a amien o os eopá ico de las algias lumbopél icas, 3ª edi ion. Mad id,
España: Paname icana; 2005.
39 Posadzki P. Is spinal manipula ion e ec i e o pain? An o e iew o sys ema ic
e iews. Pain Med 2012;13(6):754–61.
40 Hägg O, F i zell P, No dwall A, Swedish Lumba Spine S udy G oup. The clinical
impo ance o changes in ou come sco es a e ea men o ch onic low back pain. Eu
Spine J 2003;12(1):12–20.
41 Chen MN, Chien LW, Liu CF. Acupunc u e o acup essu e a he sanyinjiao (SP6)
acupoin o he ea men o p ima y dysmeno hea: A me a-analysis. E id
Based Complemen Al e na Med 2013;2013: 493038.
42 Fe nández-Ca ne o J, Cleland JA, A bizu RL. Examina ion o mo o and hypoalgesic
e ec s o ce ical s ho acic spine manipula ion in pa ien s wi h la e al
epicondylalgia: A clinical ial. J Manipula i e Physiol The 2011;34(7):432–40.
43 Wille E, Heb on C, K ouwel O. The ini ial e ec s o di e en a es o lumba
mobilisa ions on p essu e pain h esholds in asymp oma ic subjec s. Man The
2010;15(2):173–8.
44 He nández Xume JE. Dolo y es a egias e apéu icas en os eopa ía (II). Os eopa ía
Cien i ica 2009;4(1):33–6.
45 Walsh MJ, Polus BI. A andomized, placebo con olled clinical ial on he e icacy
o chi op ac ic he apy on p emens ual synd ome. J Manipula i e Physiol The
1999;22(9):582–5.
46 G ayson JE, Ba on T, Cabo PJ, Sou lis T. Spinal manual he apy p oduces apid
onse analgesia in a oden model. Man The 2012;17(4):292–7.
47 Paungmali A, Si ile pisan P, Taneyhill K, Pi unsan U, U haikhup S. In a a e
eliabili y o pain in ensi y, issue blood low, he mal pain h eshold, p essu e
pain h eshold and lumbo-pel ic s abili y es s in subjec s wi h low back pain. Asian J
Spo s Med 2012;3(1):8–14.
48 Co onado RA, Gay CW, Bialosky JE, e al. Changes in pain sensi i i y ollowing
spinal manipula ion: A sys ema ic e iew and me a-analysis. J Elec omyog
Kinesol 2012;22(5):752–67.
49 Bialosky JE, Bishop MD, P ice DD, Robinson ME, Geo ge SZ. The mechanisms o
manual he apy in he ea men o musculoskele al pain: A comp ehensi e model. Man
The 2009;14(5):531–8.
50 Mog en IM. BMI, pain and hype -mobili y a e de e minan s o long- e m ou come
o women wi h low back pain and pel ic pain du ing p egnancy. Eu Spine J
2006;15(7):1093–102.
51 Wang MC, Hsu MC, Chien LW, Kao CH, Liu CF. E ec s o au icula acup essu e on
mens ual symp oms and ni ic oxide o women wi h p ima y dysmeno hea. J Al e n
Complemen Med 2009;15(3):235–42.
52 Chien LW, Chang HC, Liu CF. E ec o yoga on se um homocys eine and ni ic
oxide le els in adolescen women wi h and wi hou dysmeno hea. J Al e n
Complemen Med 2013;19(1):20–3.
53 Cook CE. Immedia e e ec s om manual he apy: Much a do abou no hing? J Man
Manipula i e The 2011;19(1):3–4.
54 Fuen es A de iu X, Cas iñei as Lacamb a MJ, Que al ó Compañó JM. Bioquímica
clínica y pa ología molecula (Vol. 2), 2ª edi ion. Ba celona, España: Re e é; 1998.
Figu e 1. Flowcha diag am acco ding o CONSORT s a emen o he epo o
andomized con olled ials.
Figu e 2. Global pel ic manipula ion echnique.
Whi e a ows indica e he impulses’ di ec ion.