Accepted Manuscript

Short-term effects of connective tissue manipulation in women with primary

dysmenorrhea: A randomized controlled trial

Özgül Serap, Üzelpasaci Esra, Orhan Ceren, Baran Emine, Beksaç M. Sinan,
Akbayrak Türkan

PII: S1744-3881(18)30396-7
DOI: 10.1016/j.ctcp.2018.07.007
Reference: CTCP 896

To appear in: Complementary Therapies in Clinical Practice

Received Date: 27 June 2018

Revised Date: 12 July 2018
Accepted Date: 19 July 2018

Please cite this article as: Serap Öü, Esra Ü, Ceren O, Emine B, Sinan BeksaçM, Türkan A, Short-term
effects of connective tissue manipulation in women with primary dysmenorrhea: A randomized controlled
trial, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2018.07.007.

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 ACCEPTED MANUSCRIPT
Short-Term Effects of Connective Tissue Manipulation in Women with Primary

Dysmenorrhea: A Randomized Controlled Trial

ÖZGÜL Serap, PT, PhD, Assoc. Prof.a, ÜZELPASACI Esra, PT, MSca, ORHAN

Ceren, PT, PhDa, BARAN Emine, PT, MSca, BEKSAÇ M. Sinan, MD, Prof.b,

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AKBAYRAK Türkan, PT, PhD, Prof.a

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a
Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and

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Rehabilitation, 06100, Samanpazarı, Ankara, TURKEY.
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Hacettepe University, Faculty of Medicine, Department of Obstetrics and

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Gynecology, 06100, Samanpazarı, Ankara, TURKEY.
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Corresponding author: Serap ÖZGÜL, Hacettepe University, Faculty of Health
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Sciences, Department of Physiotherapy and Rehabilitation, 06100, Samanpazarı,

Ankara, TURKEY, Facsimile: +903123052012, Tel: +903123052533-147, e-mail:

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serapky@yahoo.com, ORCID NO of corresponding author: 0000-0002-2362-6773

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Esra ÜZELPASACI: uzelpasaciesra@gmail.com

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Ceren ORHAN: cerengursen@yahoo.com

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Emine BARAN: eminekbaran@gmail.com

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Sinan BEKSAÇ: beksac@hacettepe.edu.tr

Türkan AKBAYRAK: takbayrak@yahoo.com

Declaration of interest: none

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ABSTRACT

AIM: To evaluate the short-term effectiveness of connective tissue manipulation (CTM) for

relieving menstrual pain and symptoms in primary dysmenorrhea (PD).

METHODS: Forty-four women with PD were randomly assigned to treatment (n=21) or

control group (n=23). While the control group was given only advising, the treatment group

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additionally received CTM. The primary outcome was the menstrual pain intensity by Visual

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Analogue Scale. Secondary outcomes included the number of pain medications, menstrual

pain catastrophizing by Pain Catastrophizing Scale (PCS), menstrual symptoms by Menstrual

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Symptom Questionnaire (MSQ) and menstrual attitude by Menstrual Attitude Questionnaire

(MAQ).

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RESULTS: Compared with the control group, CTM group showed statistically significant
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improvement in pain, medication use, PCS, MSQ (p=0.001) and in the perception of
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menstruation as a natural event (p=0.029). However, no significant differences were detected

between groups for some aspects of MAQ (p>0.05).

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CONCLUSIONS: CTM seems to be an effective approach in the short-term in PD.

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KEY WORDS: connective tissue massage, connective tissue manipulation, dysmenorrhea,

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massage, primary dysmenorrhea.

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1. INTRODUCTION

Dysmenorrhea is defined as cyclic and spasmodic or cramping pain in the lower

abdomen/pelvis just before and/or during menstruation, which affects severely the quality of

life and causes school and work abstinence. It is one of the most common gynecologic

conditions with a prevalence rate as high as 90%, especially in young women.[1, 2]

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Dysmenorrhea is classified as primary or secondary. Most often, dysmenorrhea is primary,

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commencing shortly after menarche.[3] While there is no associated pelvic pathology in

primary dysmenorrhea (PD), secondary dysmenorrhea results from well-defined

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gynecological, pelvic, or orthopedic traumatic conditions.[4] Pain in PD is most severe

during the first and second day of menstruation and typically lasts for 8-72 h. The pain is also

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frequently accompanied by systemic symptoms.[5] The pathogenesis of PD is believed to be
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associated with increased prostaglandin production leading to increased uterine contractility
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and ischemia through vasoconstriction of uterine blood vessels.[6, 7]

The therapeutic options for the treatment of dysmenorrhea are few and not totally
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effective. They include pharmacological, non-pharmacological, and surgical approaches.

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Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and oral contraceptives are the

most common medications for relieving menstrual pain.[4] However, these drugs are only
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temporarily effective in relieving pain and may induce some side effects. Hence, many

patients seek complementary and alternative therapeutic options.[8] A non-pharmacological

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alternative is physiotherapy, which includes therapeutic exercises, electrotherapy, massage

therapy, and complementary therapy, such as acupuncture, chiropractic, osteopathy, and

spinal manipulation.[1, 9-12] However, most of the studies published in the area either have

no control group or are studies of combined interventions.

Connective tissue manipulation (CTM), a manual reflex therapy, targets the superficial

connective tissues to stimulate segmental and suprasegmental autonomic cutaneovisceral

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reflexes in order to restore autonomic balance and reduce the dysfunction in the affected

internal organs. By the stimulation of segmental reflexes, therefore, CTM can be used to

increase circulation to uterus, reducing congestion and menstrual pain in women with PD.[13,

14]

Although CTM has been used for the treatment of broad range of health conditions

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including painful syndromes, vascular problems, or bowel dysfunction,[15-21] there is limited

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evidence for its use in PD. [22, 23] To the best of our knowledge, there is no randomized

controlled trial using CTM in the treatment of menstrual pain and symptoms. Therefore, the

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aim of this randomized controlled trial was to assess the therapeutic effect of CTM in primary

dysmenorrheic women. Our hypothesis was that the CTM in addition to lifestyle advising will

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be more effective than advising alone in women with PD.
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2. MATERIALS AND METHODS
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2.1. Design

The study protocol of this prospective randomized controlled trial was approved by the
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local ethics committee of university (approval no.: GO 15/98-24), and all subjects provided
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written informed consent before participation. After the first screening for inclusion criteria,

all participants were provided with a 7-day pain diary and invited to return for a baseline
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assessment immediately after the menstruation that followed their admission to the study. In

this diary, Visual Analog Scale (VAS) was used for scoring daily menstrual pain. After
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baseline assessment, each participant was randomly assigned to either the treatment or the

control group. A block randomization method was used to assign blocks of four subjects to

either study arm using opaque and sealed envelopes containing a group allocation number

from a computer-generated random number table. The randomization table was restricted to

the principal researcher (SÖ), and this researcher did not take any further part in the trial.
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While the control group was given only advising on lifestyle and stretching, the treatment

group received additional CTM.

2.2. Participants

Participants diagnosed with PD by the gynecologist were referred to physiotherapy

and rehabilitation department of university. Demographic characteristics, and medical and

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gynecological history of all participants were recorded.

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The study included nulliparous women who met the following criteria: aged over 18

years, having diagnosis of PD according to the Primary Dysmenorrhea Consensus Guideline

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[24], having regular menstrual cycles (28 ± 7 days), and menstrual pain rated higher than 40

mm on a VAS considering the last 6 months [3]. Women were excluded if they had

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gastrointestinal, urogynecologic, autoimmune or psychiatric disease, other chronic pain
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syndromes, childbirth, positive pregnancy test, intrauterine device, pelvic surgery, chronic
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medication including oral contraceptives or antidepressants for at least 6 months prior to

study, irregular menstrual cycles (defined as lasting <21 or >35 days and/or with more than 4
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days variation between cycles), and a history or an ultrasonographic observation of

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pathological conditions indicating secondary dysmenorrhea. The Turkish-language State-Trait

Anxiety Inventory (STAI) was administered to all participants prior to and at the end of the
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study to measure the presence and severity of the current symptoms of anxiety (STAI-1) and a
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generalized propensity to be anxious (STAI-2).[25, 26]

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2.3. Interventions

2.3.1. Connective Tissue Manipulation

Pelvic zones including sacral, lumbar, lower thoracic (figure 1), and anterior pelvic

regions (figure 2) were manipulated respectively five days per week, from the estimated day

of ovulation (cycle length in days minus 14) until the next period begins. Both short (1,3,6,8,9

in figure 1) and long strokes (2, 4, 7, 10, 11 in figure 1, all in figure 2) were used during
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manipulation.[27] Each stroke was repeated for three times first on the right and then on the

left side of all manipulated regions. All sessions were ended with bilateral long strokes to the

iliac crest and subcostal regions (4,7 in figure 1). Strokes shown in the back (figure 1) are

only one-sided.

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Figure 1. Directions of connective tissue strokes applied over the sacral, lumbar and lower
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thoracic regions
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Figure 2. Directions of connective tissue strokes on anterior pelvic region

During manipulation, the pad of the middle finger was in contact with the patient’s

skin. The finger was placed on the skin at 45 degree angle with distal interphalangeal joint in
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flexion and moved to cause traction. Treatment was performed by a trained physiotherapist

(EB). Treatment was completed approximately in 10 minutes. During the treatment of back,

the participant was instructed to sit erect, with hips, knees, and ankles at 90° flexion; the

thighs and feet were fully supported. During the treatment of anterior pelvic region, the

patients was in a supine position with pillows placed under the head and knees.

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2.3.2. Lifestyle Advising and Stretching Exercises

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All participants in the treatment and control groups were advised for exercising

regularly, limiting caffeine, sugar, and alcohol intake, reduction or cessation of smoking if

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they smoke, or avoiding of exposure to environmental tobacco smoke. In exercise advising,

30-minutes general stretching exercises (totally 6 movements including the quad stretch, the

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standing hamstring stretch, the standing side stretch, chest stretch, shoulder stretch and the
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seated back twist) combined with deep abdominal breathing were shown and all patients were
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recommended to get a minimum of 2½ hours/week of moderate-intensity aerobic activity by

using the talk test. [28] Participants were supplied with a brief instruction leaflet on these
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advices and a second control appointment was booked for one-week later. In this second visit,
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exercises and recommendations were repeated and checked within about 40 minutes.

2.4. Outcome Measures

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All measurements were completed at baseline and immediately after the first
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menstruation following the intervention period under the supervision of a therapist who was
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blinded to group allocation (EÜ).

2.4.1. Primary Outcome

The Pain Intensity Score: A 10-cm VAS anchored from zero (no pain at all) to 10 (the worst

pain I have ever felt) was used to determine the severity of each subject’s menstrual pain.

Since the pain in PD is most severe during the first and second day of menstruation and

typically lasts for 8-72 h, we used the day-1 score and the average score of first three days
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from 7-day pain diaries. The VAS has been shown to be a valid and reliable tool for

measuring experimental and clinical pain, which is also sensitive to changes with treatment of

clinical pain and to small changes in pain intensity. [29-32]

2.4.2. Secondary Outcomes

Number of pain medications: The number of pain medications taken in the last menstruation

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including NSAIDs and analgesics were recorded.

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Menstrual Pain Catastrophizing Score: The Turkish-Pain Catastrophizing Scale (PCS) was

used to assess catastrophizing about menstrual pain during the last menstruation.[33] PCS is a

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13-item instrument [34], indicating the degree to which women experienced each of 13

thoughts or feelings when experiencing menstrual pain on a 5-point scale from 0 (not at all) to

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4 (all the time). The PCS total score was computed by summing responses to all 13 items,
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ranging from 0-52.
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Menstrual Symptom Score: The Turkish-Menstrual Symptom Questionnaire (MSQ) was

used to assess menstrual symptoms.[35] The MSQ is a 24 item self-report measure and the
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score of each item ranges from 1 (never) to 5 (always). Higher total scores indicates more
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symptoms.[36, 37]

Menstrual Attitude Score: The Turkish-Menstrual Attitude Questionnaire (MAQ) was used
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to assess women’s beliefs about and attitudes towards menstruation. It consists of 31 positive

and negative items scored on a 5-point Likert scale (1= strongly disagree; 5= strongly
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agree).[38, 39] The MAQ is divided into five subscales: menstruation as a psychologically

and physically debilitating event (MAQ-I), menstruation as a bothersome event (MAQ-II),

menstruation as a natural event (MAQ-III), prediction and anticipation of the onset of

menstruation (MAQ-IV), and the denial of any effect of menstruation (MAQ-V).[40]

2.5. Treatment Satisfaction

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Patients’ satisfaction with CTM and/or lifestyle advices was assessed by two questions

on a rating scale of 0-10. Q1: How satisfied were you with the overall treatment you

received?, Q2: Would you recommend this treatment and/or advices to someone you know

who has menstrual pain?.

2.6. Compliance with Advices

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A four-point scale (never, somewhat, to a large extent, completely) was used to

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determine the participants’ compliance with advices.

2.7. Statistical analyses

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All statistical analyses were performed using SPSS software (version 21, SPSS, Inc.,

Chicago, IL, USA). Visual (histograms, probability plots) and analytical (Kolmogorov-

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Smirnov test) methods were used to determine whether variables were normally distributed.
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Data were expressed as mean±standard deviation or as median (interquartile range) for
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numerical variables and as numbers (percentages) for categorical variables. Study groups

were assessed for comparability by the use of the Mann-Whitney U test for numerical
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variables and the chi-squared test for categorical variables. The Wilcoxon test was used to
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compare changes in variables between baseline and at the end of the CTM program. A

probability (p) value of <0.05 was considered to be statistically significant.

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3. RESULTS
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A total of 59 women were screened, of whom 47 met the inclusion criteria and 44
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accepted to participate in the study. All participants were at least high school graduates.

Following the initial screening, each participant was randomized to either the treatment

(n=21) or the control group (n=23). A total of 4 patients (1 from the treatment group and 3

from the control group) withdrew from the trial during the study period. Only one women

discontinued the CTM because her acute respiaratory medical condition prevented her

attending the massage sessions. Consequently, 20 participants in the treatment group and 20
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participants in the control group completed the trial (Figure 3). The number of CTM sessions

ranged from 10 to 15 (12.2±1.7).

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Figure 3. Flow-chart of the study

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At baseline, there were no significant differences between groups in terms of

demographic, physical, and menstrual characteristics (Table1) or for outcome measures

(Table 2) (p>0.05). There were also no statistically significant inter-group differences in terms

of STAI-1 and STAI-2 scores at baseline (p= 0.946 and 0.180, respectively) and at the end of
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the study period (p= 0.101 and 0.217, respectively), indicating that the inter-group differences

in outcome parameters were not related to anxiety levels.

Table 1. Comparison of baseline characteristics of participants

Characteristic
Treatment group Control group p value
(n=20) (n=20)

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Age (years) 20.5 (20.0-23.0) 20.0 (19.0-22.7) 0.524
BMI (kg/m2) 20.3 (18.5-24.1) 21.3 (19.0-24.3) 0.507
Age at menarche (y) 13.0 (12.0-13.0) 13.0 (13.0-14.0) 0.103

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Time since menarche (y) 8.0 (7.0-10.0) 7.0 (6.0-9.7) 0.321
Pain duration (y) 7.0 (5.2-8.7) 6.0 (4.2-8.0) 0.218
Pain intensity during last 6 m 6.7 (6.2-7.5) 6.4 (5.4-7.8) 0.551
STAI-I 48.0 (43.5-56.5) 48.5 (42.7-54.7) 0.946

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STAI-II 44.0 (39.0-47.0) 46.5 (44.2-49.7) 0.101
BMI: Body mass index, y: year, STAI-I: State Anxiety Scale, STAI-II: Trait Anxiety Scale, p:
comparison of patient characteristics at baseline, Mann-Whitney U test.

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Table 2. Outcome Parameters in Participants Allocated to Either Treatment or Control Group

Treatment group (n=20) Control group (n=20)
∆1 ∆2

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Parameters Baseline 2nd ass. Baseline 2nd ass. p1 p2 p3 p4
PIS 7.1 2.5 4.1 7.0 7.2 -0.2 0.946 0.001* 0.045* 0.001*
(day-1) (6.2- 7.4) (2.1- 3.2) (2.6- 4.7) (5.2- 8.6) (5.4- 8.8) (-0.3- -0.1)
PIS 4.3 1.2 3.0 3.7 3.9 0.2 0.860 0.001* 0.001* 0.001*

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(average) (2.6- 5.1) (0.9- 2.2) (1.6- 4.0) (2.7- 5.5) (2.9- 5.7) (-0.2- -0.1)
Medication 2.0 0 1.0 1.0 1.0 0 0.663 0.001* 0.763 0.001*
(number) (1.0- 2.0) (0- 1.0) (0.2- 2.0) (1.0- 2.0) (1.0-2.0) (0-0)

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PCS 28.0 14.0 13.5 31.0 36.0 -4.0 0.146 0.001* 0.001* 0.001*
(24.0- 30.7) (8.2- 22.7) (6.0- 20.7) (25.7- 39.0) (30.0- 43.5) (-5.7- -2.0)
MSS 47.5 27.5 20.5 48.0 51.0 -4.5 0.607 0.001* 0.001* 0.001*
(41.2- 61.5) (20.5- 35.7) (14.7- (38.5- 53.5) (42.5- 57.7) (-5.0- -3.2)
25.0)

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MAQ-I 23.0 22.5 0 22.0 23.0 -1.0 0.424 0.834 0.223 0.344
(22.0- 23.7) (21.0- 24.7) (-2.0- 2.0) (21.0- 24.7) (21.0- 24.7) (-1.7- 0.7)

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MAQ-II 16.0 16.5 -1.0 15.5 17.5 0.5 0.624 0.446 0.669 0.633
(13.5- 18.0) (14.2- 18.0) (-2.0- 1.7) (14.0- 19.7) (13.2- 20.0) (-2.0- 1.0)
MAQ-III 17.5 19.0 2.0 18.0 18.0 0.5 0.744 0.047* 0.875 0.029*
(15.2- 19.7) (17.0- 20.7) (0.2- 3.7) (14.2- 20.0) (15.0- 20.7) (-1.7- 1.0)
MAQ-IV 27.0 26.5 0 26.5 27.0 -0.5 0.263 0.856 0.830 0.673

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(26.0- 30.0) (25.0- 30.0) (-2.0- 2.7) (25.0- 28.0) (26.0- 28.0) (-2.0- 2.5)
MAQ-V 12.0 12.0 1.0 10.5 11.0 0 0.238 0.424 0.563 0.538
(11.0- 12.7) (10.0- 13.7) (-2.0- 2.0) (9.0- 13.5) (10.0- 13.0) (-1.0- 1.0)

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PIS: Pain Intensity Score, PCS: Pain Catastrophizing Score, MSS: Menstrual Symptom Score, MAQ: Menstrual Attitude Questionnaire
ass.: assessment, ∆1 and ∆2: Change in outcome parameters from baseline to 2nd assessment, p1: Comparison of outcome parameters
at baseline, Mann–Whitney U test, p2: Comparison of changes in outcome variables between baseline and last visit in treatment

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group, Wilcoxon test, p3: Comparison of changes in outcome variables between baseline and last visit in control group, Wilcoxon test,
p4: Comparison of changes (Δ1 and Δ2) between treatment and control group, Mann–Whitney U test, * p< 0.05.
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3.1. Primary Outcome Measure

The Pain Intensity Score: Participants in the treatment group reported significantly

lower scores (on day-1 and on average) than those in the control group (p=0.001). The

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intra-group analysis revealed a significant improvement in both scores of CTM group

(p=0.001), while deterioration was found in the control group (p=0.045, 0.001) (Table

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2).

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All participants (100%) in the CTM group reported improvement in pain

intensity. However, none of the participants was observed to be cured (zero at VAS).

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3.2. Secondary Outcome Measures
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Number of pain medications: Compared with those in the control group, patients in the

treatment group reported significantly lower number of pain medication use (p=0.001).
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The intra-group analysis revealed a significant improvement in the treatment group (p =

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0.001), while no change was found in the control group (p = 0.763) (Table 2).

Menstrual Pain Catastrophizing and Menstrual Symptoms: The participants in the

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treatment group had significantly lower pain catastrophizing and symptom scores
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(p=0.001). Comparison of pre- and post-treatment results within groups showed an

improvement in CTM group (p=0.001) and a deterioration in the control group

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(p=0.001) (Table 2).

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Menstrual Attitude Score: The between-group comparison showed also a difference for

change in the MAQ score-III (“menstruation as a natural event” subscale) (p=0.029).

There were no intergroup differences for other subscales of the MAQ (MAQ-

I,II,IV,V)(p>0.05) The intra-group analysis showed a significant improvement only in

MAQ score-III in CTM group (p=0.047). (Table 2).

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3.3. Treatment Satisfaction

Patients in the treatment group reported higher satisfaction scores with

treatment (7.4±1.4 and 8.0±1.4 for Q1 and Q2, respectively) than patients in the control

group (2.1±0.5 and 2.8±0.7 for Q1 and Q2, respectively).

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3.4. Compliance with Advices

None of the participants reported full compliance with advices. There was no

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significant differences between the groups for the compliance with advices (χ²=1.543,

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df=2, p=0.462).

3.5. Adverse Events

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There was no report of any adverse events.
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3.6. Statistical Power

Post hoc power analysis using the Mann-Whitney U test results for the pain
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score on day 1 showed that a total sample size of 40 achieved a power of 99.0 % to
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detect an average 4 points difference between groups in VAS score with a significance
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level of 0.05.

4. DISCUSSION
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This is the first randomized controlled trial investigating the effects of CTM in

PD. Our results demonstrated that a combination of one-cycle of CTM with lifestyle
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advising is more effective than lifestyle advising alone for relieving menstrual pain and
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symptoms in dysmenorrheic women. Except for some aspects of menstrual attitude, the

superiority of CTM was noted in all outcome parameters including menstrual pain and

symptoms, pain medication and pain catastrophizing.

Physiotherapy for PD has been mainly focused on heat therapy, electrotherapy,

spinal manipulation, and exercises.[41] On the other hand, CTM has been used for the
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treatment of broad range of health conditions including painful conditions, such as

fibromyalgia, migraine, or mechanical neck pain,[15, 17, 19, 20, 42] vascular

problems,[21] or bowel dysfunction[16, 43], the evidence for its use in PD is very

limited.

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There are only two studies reporting the effects of CTM in PD.[22, 23] One of

them is a pilot observational cohort study [22] and the other one is a comparative study

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comparing the CTM and foot reflexology.[23] Both studies have no control group and

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reported significant improvement in menstrual pain and symptoms as well as in

medication use with CTM.

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In the study of Reis et al. [22], sacral, lumbar, last thoracic vertebra and
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subcostal regions were manipulated twice a week during three menstrual cycles

following admission while the patients were not menstruating. In this study, the number
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of massage sessions varied between 16 and 39 (mean: 23). In the other study by
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Demirtürk et al. [23], whole back region (sacral, lumbar, lower thoracic, scapular,

interscapular, cervical, and occipital) were manipulated five days a week from the third
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or fourth day of menstruation till the first day of the following menstruation. In this
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study, there is no information about the number of CTM sessions. Although there is no

definition for regular menstrual cycle length in this study, when we calculate the
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number of sessions for this study based on 28±7 days cycle length, it equals to 16-32
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sessions of CTM therapy.

In the present study, we manipulated only menstrual pain zones from the

estimated day of ovulation till the next period begins.[27] The number of sessions

varied between 10 and 15. Therefore, compared with other studies, improvement in

outcome parameters was achieved with fewer sessions in a shorter time period and
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narrower application. Based on these findings, necessity of manipulating the areas

beyond menstrual zones and optimal intensity and duration of CTM should be

questioned in further studies. Additionally, we reported less pain catastrophizing, better

perception of menstruation as a natural event, and higher satisfaction scores with CTM

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in the present study.

Although all participants reported improvement in menstrual pain in the present

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study, no subjects were cured. This finding is similar to the results of the study of

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Demirtürk et al.,[23] which also performed a one-cycle CTM. Reis et al.[22] reported a

total pain remission in 23% of the subjects after three cycles of CTM. Based on this

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result, the cure of menstrual pain with CTM seems possible. Therefore, further placebo-
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controlled studies are needed to determine or confirm if longer therapy will improve the

cure rate.
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In treatment follow-ups, one study [23] reported that the improvement in

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outcome parameters was maintained after the first menstruation following treatment.

Another study [21] presented relatively small increase in average pain and medication
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use after the cessation of the three cycles of therapy. Since the results are contradictory,
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further studies with long-term follow-up are needed.

In the present study, the lack of differences in some subscales of MAQ may also
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be attributed to the study duration. Therefore, long-term follow-up will also clarify the
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effect of CTM on other aspects of the menstrual attitude of dysmenorrheic patients.

On the other hand, the deterioration in some parameters (pain, pain

catastrophizing and menstrual symptoms) in the control group of the present study may

be related to increased perception of the patient's own situation and the expectation of
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other therapeutic approaches from therapist by aggregating their present situation.

However, these parameters showed statistically significant improvement in CTM group.

Despite the effectiveness of NSAIDs, which is reported to be first line of

treatment for PD, they are associated with many adverse reactions, such as neurological

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and gastrointestinal reactions, which become more apparent and severe with long-term

use.[44] The women in our study reported no adverse effects and also reduced pain

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medication use, suggesting less drug-related side effects. These results emphasize once

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again that the further studies should particularly focus on such conservative options.

The strengths of our study were the randomized controlled design and the use of

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reliable and valid specific tools for pain and symptom assessment. Given the limited
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effectiveness of the current pharmacological agents and the increasing demand for non-

pharmacological/conservative alternatives for dysmenorrhea, using CTM as a non-

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pharmacological option in this common gynecological pain condition may be another

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strength of our study.

This study has some limitations. First is the lack of a sham massage/therapy
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group to eliminate the placebo effect of CTM. However, compared with sham
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treatments, massage was found superior in common chronic pain syndromes

including low back pain and fibromiyalgia [45-47] and in vascular problems [21].
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Secondly, due to the nature of interventions used in both groups and patient reported
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outcomes, blinding the patient and/or assessor, thus a double-blind design, was not

possible.

In conclusion, CTM seems to be an effective physiotherapy approach for

improving menstrual pain, menstrual pain catastrophization, menstruation-related

symptoms and menstrual perception in patients with PD. Further randomized placebo-
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controlled studies are needed to confirm the results of the present study. Long-term

follow up will also clarify if cure is possible with CTM or whether it continues to be

effective.

DISCLOSURE OF INTERESTS

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There is no conflict of interest.

FUNDING

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This research did not receive any specific grant from funding agencies in the public,

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commercial, or not-for-profit sectors.

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