Changes in pain perception after pelvis manipulation in women with primary dysmenorrhea: a randomized controlled trial

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. 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