SNPG917 Evidence Into Practice

Management of Dysmenorrhea: A Literature Review

From a gynecological perspective, dysmenorrhea is one of the few medical conditions that affect most women across cultures and borders yet remains subject to non-standardized forms of treatment and management with every research reporting a different inclined recommendation. For every women of reproductive age, researchers tend to agree that between 20% and 95% of them remain prone to dysmenorrhea, a scenario which demands more attention, more so in an era of differentiated approach to treatment and management. Depending on the research at hand, more women within the prevalence group of dysmenorrhea either seek mechanisms of coping with pain, while a few more opt for both conventional and non-conventional approaches to treatment and management.

Conventional means of managing dysmenorrhea, such as the use of non-steroidal anti-inflammatory drugs prove to be one of the most preferred options of within the prevalence group. However, recent developments in research has not only raised unanswered on such approaches such as their correlation with undesirable side effects, but also seemingly lean towards physiotherapy as non-invasive techniques with potential clinical significance. It is in that regard that this paper questions, does the exploitation of physiotherapeutic modalities reduce the severity of primary dysmenorrhea in young women against a control group tested with conventional options? This paper presents a review of literature that align with the research question.

Research Strategy

The strategy exploited in the search for relevant literature that not only align with the research question but also present a primary approach replicated recommendations provided by Page (2008: 172). The strategy aimed at lessening the likely tediousness of the search to give more time for assessment as a critical step in ensuring that only the appropriate literature tandem with the research question was chosen. The search tool identified for the sourcing literate was PubMed since it more likely constituted a comprehensive list of literature and would also easily link to other relevant databases depending on the search terms. A breakdown of the research question into searchable terms was necessary to widen the possible reach within the database and provide a richer choice of options rather than enter the whole research questions.

Such key terms as “management of dysmenorrhea”, “managing dysmenorrhea”, physiotherapy options for dysmenorrhea” and “acupuncture in managing dysmenorrhea” were used for the search. The culling method involved an analysis of the topic followed by the abstract and then discussion segment of the paper. It was imperative right from the topic to the abstract and then to the discussion segment, the paper of choice reflected the inclination of the research question and therefore specifically sought answers to the question to say the least. Even though the abstract could provide a better view of the contents of the paper, the discussion segment, the discussion was key in understanding the scope, limitations of the paper, and future hypotheses.       

(Kannan and Claydon, 2014)

Summary

The study took the form of a systematic review dwelling on random trials complemented by meta-analysis to study how women with primary dysmenorrhea respond to a variety of physiotherapeutic interventions such as acupuncture, acupressure, yoga and transcutaneous electrical nerve stimulation (TENS). The target group was women of all ages, while the targeted outcome measures were reduction of menstrual pain intensity (primary) and quality of life (secondary). The study review 222 citations and finally settled on 11 of them. The meta-analysis found statistical significance for acupuncture and acupressure even though such results were more likely a “placebo” effect. There were significant reductions in pain in the use of heat, TENS, and yoga. The study recommends more of heat, TENS, and yoga interventions than acupuncture or acupressure.

Definition of Key Terms

Acupuncture & Acupressure: Acupuncture or acupressure are the physiotherapeutic processes of stimulating either through inserting needles (acupuncture) or applying pressure (acupressure) on loci on the human body surface to modify the individual’s perception of pain, normalize distorted physiological functions or alleviate pain (Baker, 1976: 15).

Transcutaneous Electrical Nerve stimulation (TENS): TENS is a non-pharmacological physiotherapeutic approach that uses low-voltage electrical impulses delivered through electrodes attached to established loci around the area of pain or established pressure point (Kwon and Reid, 1997: 959).

Primary Dysmenorrhea: Menstrual pain stemming from other causes other than identifiable organic disease. It is more common in younger women of reproductive age and tends to be a menace affecting education and quality of life. The more likely cause is the release of prostaglandins that trigger painful myometrial contractions (Proctor and Farquhar, 2006: 1134: Davis and Westhoff, 2001: 3).

Critical Review

The evidence presented in Kannan and Claydon (2014: 15-19) remains at par with expectation, primarily due its breadth and the depth and the presentation of the data and explanations to the audience. The evidence in the paper is detailed and comprehensive and expounds on the flow of the meta-analysis the particular characteristics of the included trials, and effect of intervention. The authors presented graphs and tables alongside the explanations and subsequently fleshed out how each set of studies presented its findings. The evidence is highly informative and clearly work towards arguing for and against the outlined research question that promoted the research.

Strengths and Limitations

The study presents a number of strengths that support the evidence and therefore build credibility of the argument and concluding remarks (Kannan and Claydon, 2014: 20). They include the use of two independent reviewers to analyze and reconstruct data presented in the 11 chosen papers, outcomes from the reviewed papers were backed by statistically significant findings, and identification of critical insights into contextualizing placebo effects that tend to inadvertently distort outcomes. However, the agglomeration of differently structured or even oriented studies presented result corroboration issues such as multiple interpretations of the characteristics of sham acupuncture that even though seemed to work, could have negatively impacted the argument. Additionally, the search left out “grey literature” that could have given more insight about the positive findings.

Relevance and Impacts

The findings from the review has cast a new light into how physiotherapy may be exploited in the management of dysmenorrhea. The low statistical significance between the sham trials and the use of both acupuncture and acupressure deals a blow to therapists who have often relied on the techniques. According to the discussion by Kannan and Claydon (2014: 20) it is now apparent that both acupuncture and acupressure are ineffective, and may only offer placebo-like benefits that remain unreliable to say the least. On the other hand, the finding of the study implicitly state that dysmenorrhea is better managed by using either heat, TENS, or even yoga.

Knowledge Gap

The paper concludes by affirming that yoga, TENS, and the use of heat exhibit significance effects in the management of dysmenorrhea and therefore implicitly recommends such interventions. However, worth mentioning is that the disqualification of both acupuncture and acupressure pointed to the lack of clinically significant results compared to sham experiments, thereby suggesting that acupuncture and acupressure may not be effective. To build credibility of yoga, TENS, and the use of heat as promising interventions in the management of dysmenorrhea, it would be worthwhile to further experiment how the results of such methods compare with carefully created “sham” experiments mimicking the same.

(Yang et al., 2017)

Summary

The research paper documents the findings of a pragmatic randomized open-labelled clinical trial that pitched the outcome of moxibustion as a form of physiotherapy against that of conventional drugs (ibuprofen). The research identified 152 participant with only 133 completing the regimen. Pain easement reduced from 6.38±1.28 to 2.54±1.41 for the experimental group and from 6.41±1.29 to 2.47±1.29 in the control group indicating the clinical significance of both approaches. There was little statistical difference between the two groups (P=0.76) even though three months, moxibustion proved to sustain its efficiency. The study concludes that both physiotherapy (moxibustion) and conventional drugs could alleviate dysmenorrhea in young women even though the results ought to be interpreted with care.

Definition of Key Terms

Moxibustion: the process is a therapeutic approach to pain relief implemented by burning dried leaves of the herb Artemisia vulgaris in the bid to induce neural impulses through acupuncture points (Chen et al. 2011: 227).

Randomization and Blinding: randomization is the bringing on board of randomly chosen individuals within the target population to reflect the diversity of the whole population. Blinding on the other hand is the concealment of how participants are located to either the experimental of the control group (Karanicolas, Farrokhyar and Bhandari, 2010: 345).    

Visual Analogue Scale (VAS): a research measurement instrument intended to quantify non-numeral phenomenological values such as pain that fall between a non-existent and a (hypothetical) extreme continuum (Chrichton, 2001: 706).

Critical Review

The random control trial conducted by the authors would conventionally provide a significant quantity of data more so since the study had been running for three months in addition to accompanying explanations that expound on how complete the data was, mishaps, as well as how the data relates to the research question. The evidence is comprehensive and self-explanatory in most case, and categorized into the recruitment and the flow of the study, background characteristic that also constituted evidence on the text group crucial for the outcome, as well as primary and secondary outcomes. Where necessary, the evidence is presented in elaborate tables or explained through words complemented by appropriate statistical inferences.

Strengths and Limitations

A key strength of the evidence of the study is that it exploits sound methodology in the study of a phenomenon that has not been properly studied or studied by explored through inappropriate study designs and methodologies. It therefore provides valuable insights into the moxibustion and how future research inquiries can tackle the subject without contamination from often unjustly compared physiotherapeutic approaches such as acupuncture (Yang et al., 2017: 11). However, the study lacks in a few crucial areas that challenge its authority and reciprocity. The limitations include restriction of the menstrual symptom scale to VAS and COX which are more subjective than objective, the lack of a participant blinding approach which could had negative effects on the authenticity of the outcome, and restriction of the test group to college students (Yang et al., 2017: 13).

Relevance and Impact

As an intervention targeting dysmenorrhea more so in the recent past, there is little knowledge about the clinical significance of moxibustion and therefore findings from the study would be crucial in widening the scope of the knowledge and paving the way for further research inquiries. Furthermore, there are few comprehensive studies into the phenomenon and its application in managing dysmenorrhea and therefore this study would positively impact the subject by adding the findings of a primary research into the knowledge repository. The authors however encourage a careful interpretation of the findings since the baseline of the findings indicate that moxibustion is effective in managing dysmenorrhea and not (conclusively) efficient in that regard.       

Knowledge Gap

Akin to the study by Kannan and Claydon (2014), Yang et al. (2017: 12-13) acknowledge that moxibustion may help regulate dysmenorrhea by “rewarding brain physiology” which subsequently trigger processes that control if not alleviate pain. The knowledge gap that exist from such an insinuation and that could further enlighten research inquiries within the context of the moxibustion intervention is the hypothesis that the process (moxibustion) may not only regulate the way the target organ functions but may extend to complex brain physiological processes. More studies may therefore be needed to verify the hypothesis and influence how therapists approach dysmenorrhea.

Conclusion

Dysmenorrhea is a common condition that affects the majority of women in the reproductive age bracket thereby presenting even more concern for research into ways of alleviating the pain. There is no standardized approach to treating or managing dysmenorrhea and therefore there is bound to be a variety of options for women depending on the geography, culture, and access to knowledge and information. Many women opt for non-steroidal anti-inflammatory drugs which may not be as sufficient as would be expected. The findings from the study by Kannan and Claydon (2014: 15-19) recommends using either heat, TENS, or even yoga, while Yang et al (2017: 12) opt for moxibustion as a more effective treatment. Nonetheless, both studies are bound by limitations and knowledge gaps that demand further research inquiry into the conclusiveness of their findings.           

References

Baker, C.J., 1977. Acupuncture in physiotherapy. Australian Journal of Physiotherapy, 23(1), pp.15-20.

Chen, M., Chen, R., Xiong, J., Yi, F., Chi, Z. and Zhang, B., 2011. Effectiveness of heat-sensitive moxibustion in the treatment of lumbar disc herniation: study protocol for a randomized controlled trial. Trials, 12(1), p.226.

Crichton, N., 2001. Visual analogue scale (VAS). J Clin Nurs, 10(5), pp.706-6.

Davis, A.R. and Westhoff, C.L., 2001. Primary dysmenorrhea in adolescent girls and treatment with oral contraceptives. Journal of Pediatric and Adolescent Gynecology, 14(1), pp.3-8.

Kannan, P. and Claydon, L.S., 2014. Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea: a systematic review. Journal of Physiotherapy, 60(1), pp.13-21.

Karanicolas, P.J., Farrokhyar, F. and Bhandari, M., 2010. Blinding: Who, what, when, why, how? Canadian Journal of Surgery, 53(5), p.345.

Kwon, J.S. and Reid, R.L., 1997. Dysmenorrhoea. Journal SOGC, 19(9), pp.955-962.

Page, D., 2008. Systematic literature searching and the bibliographic database haystack. The Electronic Journal of Business Research Methods, 6(2), pp.171-180.

Proctor, M. and Farquhar, C., 2006. Diagnosis and management of dysmenorrhoea. BMJ: British Medical Journal, 332(7550), p.1134.

Yang, M., Chen, X., Bo, L., Lao, L., Chen, J., Yu, S., Yu, Z., Tang, H., Yi, L., Wu, X. and Yang, J., 2017. Moxibustion for pain relief in patients with primary dysmenorrhea: A randomized controlled trial. PloS one, 12(2), p.e0170952.