International Journal of

Environmental Research
and Public Health

Review
Efficacy of Physiotherapy Treatment in Primary Dysmenorrhea:
A Systematic Review and Meta-Analysis
Remedios López-Liria 1, * , Lucía Torres-Álamo 2 , Francisco A. Vega-Ramírez 2,3 , Amelia V. García-Luengo 4, * ,
José M. Aguilar-Parra 5 , Rubén Trigueros-Ramos 5 and Patricia Rocamora-Pérez 1, *

1 Hum-498 Research Team, Health Research Centre, Department of Nursing, Physiotherapy and Medicine,
University of Almería, 04120 Almería, Spain
2 Hum-498 Research Team, Health Research Centre, University of Almería, 04120 Almería, Spain;
lucia.torres.alamo@gmail.com (L.T.-Á.); franavega@hotmail.com (F.A.V.-R.)
3 Distrito Sanitario Poniente, Jesús de Perceval, 22. El Ejido, 04700 Almería, Spain
4 FQM228-Research Team, Random Models and Design of Experiments, Department of Mathematics,
University of Almería, 04120 Almería, Spain
5 Hum-878 Research Team, Health Research Centre, Department of Psychology, University of Almería,
04120 Almería, Spain; jmaguilar@ual.es (J.M.A.-P.); rtr088@ual.es (R.T.-R.)
* Correspondence: rll040@ual.es (R.L.-L.); amgarcia@ual.es (A.V.G.-L.); rocamora@ual.es (P.R.-P.)

Abstract: Primary dysmenorrhea (PD) refers to painful cramps before and/or during menstruation.




There is a need for emphasis on alternative methods of conservative treatment, so as to reduce

 the dependence on drugs for alleviating the symptoms. The aim was to find out the effectiveness
Citation: López-Liria, R.; of some physiotherapy techniques in the treatment of PD. A systematic review and meta-analysis
Torres-Álamo, L.; Vega-Ramírez, F.A.; was conducted according to PRISMA standards. The descriptors were “dysmenorrhea”, “physical
García-Luengo, A.V.; Aguilar-Parra, the-rapy”, “physiotherapy”, and “manual therapy”. The search was performed in five databases:
J.M.; Trigueros-Ramos, R.; Scopus, PubMed, PEDro, Web of Science, and Medline, in February 2021. The inclusion criteria
Rocamora-Pérez, P. Efficacy of were randomized controlled trials over the last six years . Articles not related to the treatment of PD
Physiotherapy Treatment in Primary or using pharmacology as the main treatment were excluded. Nine articles met the objectives and
Dysmenorrhea: A Systematic Review
criteria, with a total of 692 participants. The most used scale to measure pain was the VAS (visual
and Meta-Analysis. Int. J. Environ.
analogue scale). The main techniques were isometric exercises, massage therapy, yoga, electrotherapy,
Res. Public Health 2021, 18, 7832.
connective tissue manipulation, stretching, kinesio tape, progressive relaxation exercises and aerobic
https://doi.org/10.3390/ijerph18157832
dance. Meta-analysis shows benefits of physiotherapy treatment for pain relief compared with
Academic Editors: Agnieszka
no intervention or placebo (MD: −1.13, 95% CI: −1.61 to −0.64, I2 : 88%). The current low-quality
Drosdzol-Cop and Anna Fuchs evidence suggests that physiotherapy may provide a clinically significant reduction in menstrual pain
intensity. Given the overall health benefits of physiotherapy and the low risk of side effects reported,
Received: 23 June 2021 women may consider using it, either alone or in conjunction with other therapeutic modalities.
Accepted: 20 July 2021
Published: 23 July 2021 Keywords: primary dysmenorrhea; pain; physical therapy; electrotherapy; manual therapy

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in
published maps and institutional affil- 1. Introduction
iations.
Dysmenorrhea is a menstrual disorder defined by the presence of painful cramps of
uterine origin that occur during menstruation. It is one of the most common causes of
pelvic pain and short-term absenteeism from school or work, among young and adult
women [1,2]. Based on its pathophysiology, dysmenorrhea is classified into two types:
Copyright: © 2021 by the authors.
- Primary dysmenorrhea (PD), which is menstrual pain associated with normal ovula-
Licensee MDPI, Basel, Switzerland.
tory cycles, without pelvic pathology, and a clear physiological etiology [2]. It is most
This article is an open access article
common in adolescents and young adults.
distributed under the terms and
- Secondary dysmenorrhea, which is menstrual pain associated with an identifiable disease
conditions of the Creative Commons
Attribution (CC BY) license (https://
(endometriosis, fibroids, adenomyosis, pelvic adhesions, polyps in the endometrium,
creativecommons.org/licenses/by/
pelvic inflammatory disease) or use of an intrauterine contraceptive device [3,4].
4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 7832. https://doi.org/10.3390/ijerph18157832 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 7832 2 of 19

The prevalence of PD is highest in the 16–25 year age group but is greatly underesti-
mated as many women consider pain a normal part of the menstrual cycle and do not seek
medical treatment, despite the considerable distress they experience [3,5,6]. A previous
systematic review on the impact of dysmenorrhea in adolescents reported that the preva-
lence is high and that it imposes a significant negative impact on academic performance [5],
restrictions on daily activities and sports or social and sexual relationships [7]. In terms of
incidence, PD decreases with increasing age, similarly affecting all nationalities [3,8,9].
The etiology of PD has been the source of many discussions. Despite research conti-
nues on aspects such as its causes and pathophysiology, the theory of prostaglandins
(PG) is increasingly consolidated [3,9,10]. Prostaglandins cause narrowing of the blood
vessels supplying the uterus, abnormal contractile activity of the uterus, which leads to
ischemia, hypoxia of the uterus and increased sensitivity of the nerve endings. It has
been demonstrated that prostaglandins are overproduced in dysmenorrhea [10]. PD is
characterized by suprapubic colic-type pain that begins a few hours before or after the
start of menstrual bleeding. The peak is usually between 24 and 48 h, coinciding with the
time of maximum blood flow, and pain usually subsides after 2 or 3 days, as the blood
volume decreases. In secondary dysmenorrhea, however, pain might begin before the start
of menstrual bleeding and remain after its end (8 to 72 h) [3,11–13].
The diagnosis of PD is made by means of an exclusion process, ruling out any organic
pathology of gynecological origin [3]. The treatment approach is mainly directed toward
relieving the pain through physiological mechanisms that underlie menstrual pain (produc-
tion of PG). The treatment is also aimed toward the improvement of the function, lea-ding
to fewer days lost at work, school or extracurricular activities [1,4,11,14].
There are different approaches to the treatment of PD. The drug approach is achieved
through PG inhibitors, which are non-steroidal anti-inflammatory drugs (NSAIDs) and
hormonal drugs such as contraceptives. Many NSAIDs which non-specifically inhibit
both COX-1 and COX-2 enzymes (e.g., ibuprofen) are the most common initial therapy
for dysmenorrhea [8,15–18], but their use is limited by side-effects, such as stomach irrita-
tion or ulcer (despite being administered together with gastric protectors) experienced by
some women [18]. The prolonged use of NSAIDs is also associated with cardiovascular,
hepatic and renal problems [3,18]. Likewise, oral contraceptives are not free from side
effects either, related as they are to the frequency of bleeding, weight gain, or the patient’s
basal risk of venous thromboembolism [1,19]. All this shows us that there is a need for
emphasis on alternative methods of conservative treatment as a non-pharmacological
and non-invasive therapy, safe and easy to use for obtaining relief from dysmenorrhea
symptoms, including acupuncture and acupressure, biofeedback, heat treatments, transcu-
taneous electrical nerve stimulation (TENS), exercises and relaxation techniques [20,21].
In addition, one study identifies the need for education on self-care and management of
menstrual pain [17].
On the other hand, these physiotherapeutic treatments, being supported by clinical
trial data, could be a very useful treatment alternative for women with PD [21], particularly
those who are not eligible for pharmacological therapy, since physiotherapy has no side
effects according to the analyzed studies [20,21]. Many reviews have evaluated the efficacy
of exercise [22–25] or individual physiotherapy interventions for PD [20,26–28]. In 2014, one
of these reviews determined the efficacy of physiotherapy modalities in the management of
pain [20]. However, the efficacy of physiotherapeutic treatment has not been systematically
verified in larger and homogeneous samples in randomized controlled trials and long-term
follow-up [3,29]. It is important to search for the most recent evidence for physiotherapy in
PD, particularly those studies published since Kannan and Claydon’s systematic review
(2014) [20], and also including important outcomes in relation to pain intensity. We have
updated the scientific literature to date as new trials have been published for the last
six years.
In addition, this systematic review provides practical examples illustrated with pho-
tographs (see figures annexed to this article) of isometric exercises, yoga techniques or
Int. J. Environ. Res. Public Health 2021, 18, 7832 3 of 19

stretching exercises that women with PD can perform. Therefore, it can be interesting
not only for the scientific community or physiotherapists interested in the scientific evi-
dence that the techniques applied in clinical practice provide, but it is also aimed at the
women who suffer from this symptomatology since these exercises can be performed au-
tonomously.
The aim of the present study is to describe the effectiveness of different physiothe-rapy
techniques in the treatment of PD through a systematic review and a meta-analysis.

2. Materials and Methods

A systematic review was carried out in February 2021, following Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) standards [30]. Articles pu-
blished in the last six years , whose target population suffered from PD, were procured
from various databases, i.e., Scopus, PubMed, PEDro, Web of Science and Medline.
The following PICOS eligibility criteria were used for the selection of the articles
(participants, intervention, comparator, outcomes, study design):
Participants were females experiencing PD not using hormonal contraception.
Intervention was physiotherapy techniques (electrophysical agents, massage, exercise)
and other techniques also used by physiotherapist (yoga, aerobic dance) delivered for at
least two menstrual cycles. Comparator was any comparator that did not involve pharma-
cology. The outcome was pain intensity measured by a validated tool, and regarding the
study type, they had to be randomized controlled trials.
The inclusion criteria:
• Contained the following keywords in English “dysmenorrhea”, “physical therapy”,
“physiotherapy” and/or “manual therapy. The search strategy used for procuring
articles from the different databases is shown in Table 1.
• Randomized controlled trials.
• Physical therapy or conservative treatment techniques listed as the method of intervention.
• Published from 2015 onwards, until 1 February 2021.

Table 1. Search strategies in the different databases.

Databases and Search Terms Results Selected Articles

SCOPUS
1. “Physical therapy” AND “dysmenorrhea” 50
2. “Physiotherapy” AND “dysmenorrhea” 115 16
3. “manual therapy” AND “dysmenorrhea” 14
PUBMED
1. “Physical therapy” AND “dysmenorrhea” 38
10
2. “Physiotherapy” AND “dysmenorrhea” 43
3. “manual therapy” AND “dysmenorrhea” 3
PEDRO
1. “Physical therapy” AND “dysmenorrhea” 5
5
2. “Physiotherapy” AND “dysmenorrhea” 11
3. “manual therapy” AND “dysmenorrhea” 2
WEB OF SCIENCE
1. “Physical therapy” AND “dysmenorrhea” 26
4
2. “Physiotherapy” AND “dysmenorrhea” 11
3. “manual therapy” AND “dysmenorrhea” 3
MEDLINE
1. “Physical therapy” AND “dysmenorrhea” 16
4
2. “Physiotherapy” AND “dysmenorrhea” 11
3. “manual therapy” AND “dysmenorrhea” 3
Int. J. Environ. Res. Public Health 2021, 18, 7832 4 of 19

The exclusion criteria were:

• Treatment of other pathologies such as endometriosis or dyspareunia.
• Pharmacology as a method of treatment.
• Not written in English or Spanish.
A total of 351 articles were analyzed based on their title and abstract (Figure 1).
These were screened and 296 irrelevant studies were eliminated based on the inclusion
criteria. If there was any uncertainty regarding the eligibility of the study from the title
and abstract, the full text was retrieved and assessed for eligibility. The search strategy was
developed by two researchers (RLL and LTA), who consulted a third researcher if there was
any disagreement. After an initial review, 39 articles were considered potentially relevant
and an exhaustive reading of their full text was carried out, paying special attention to the
intervention (type of treatment), relief of symptoms, number of sessions and duration of
treatment. A total of nine articles were finally determined to meet the objective and criteria
proposed for this review.

Figure 1. Flowchart of articles selection process.

Data analysis were extracted from the intervention details, sample characteristics and
variables related to studies results. Two reviewers independently performed study selec-
tion, quality assessment and data extraction. Disagreements were resolved by discussion
between the reviewers until consensus was reached. Some authors were contacted for any
missing data in the included studies.
The Cochrane risk of bias tool was used to assess the included articles, as rec-
ommended by the Cochrane Handbook for systematic reviews of interventions [31,32].
The quality of the randomized controlled clinical trials (RCTs) was evaluated using the
PEDro scale [33]. This is an 11-item scale designed to help users quickly identify trials
that tend to be internally valid (criteria 2–9) and have sufficient statistical information to
guide clinical decision-making (criteria 10–11). The score, ranging from 0 to 10, could be
determined simply by counting the number of listed criteria that are clearly met in the
Int. J. Environ. Res. Public Health 2021, 18, 7832 5 of 19

trial report. Its interpretation is based on the fact that the higher the score, the better is the
methodological quality and the lower the risk of bias. The strength of evidence was assessed
by the Grading of Recommendations Assessment, Development and Evaluation (GRADE)
for menstrual pain intensity, using the GRADE Pro/Guideline Development Tool [34].
A meta-analysis was undertaken using Review Manager software (RevMan version
5.4.1) and limited, owing to the clinical heterogeneity of the included studies. The I2 statistic
was utilized to determine the degree of heterogeneity, where the percentages quantified
the magnitude of heterogeneity: 25% = low, 50% = medium and 75% = high heterogeneity.
Using this scale, if I2 was 50%, a random effects model was used. All the included outcomes
were of data of visual analogue scale (VAS), pain intensity scale (PPI) or numerical rating
scale (NRS) and the mean difference with 95% CI was used in analysis. Forest plots were
generated to illustrate the overall effect of interventions on pain relief and funnel plots
were produced to assess publication bias.

3. Results
The search strategy used to identify clinical trials for this review within the databases
is described in Table 1. Figure 1 shows the basis for the selection of articles meeting the
study objectives and the inclusion/exclusion criteria.
The nine final articles had a total of 692 participants. A summary of the main charac-
teristics of each study is described in Tables 2 and 3.

Table 2. Characteristics of the study and the participants.

Sample Size
Author, Year Type of Study Age Measured Variables Ain Results
(Participants)
Significant improvement in pain
102 participants intensity in both EGs (massage
Pain (VAS), duration of
Azima et al. [35] Randomized 34: EG 1 EG1 and isometric EG2), but
19–23 years old pain (hours) and
2015 clinical trial 34: EG 2 greater in massage therapy group
anxiety (STAI).
34: CG (p < 0.001) in the 2nd and 3rd
cycle.
Prospective, Significant reduction of pain in
173 participants VAS, presence and
Ortiz et al. [36] parallel-group, EG according to VAS from the
89: EG 18–22 years old magnitude of
2015 randomized 2nd and 3rd menstrual cycles
84: CG symptoms (LS).
clinical trial (p < 0.05) compared with the CG.
VAS; quality of life
Statistically significant differences
34 participants (SF-36); flexibility (SR),
Yonglitthipagon Randomized in yoga EG in terms of pain
17: EG 18–22 years old and back and leg
et al. [37] 2017 clinical trial intensity, flexibility, and muscle
17: CG strength
strength (p < 0.02).
(dynamometer).
Pain Intensity was Both groups had a decrease in
measured with PPI (0–4 pain, but the effect was more
52 participants
Thabet et al. [38] Randomized scale); pain relief scale; pronounced in the HILT group
26: EG 1 18–24 years old
2017 clinical trial and prostaglandin (p < 0.05). There was a decrease in
26: EG 2
PG2α concentration the PG2α level in both groups
with blood samples. (p < 0.001).
Pain intensity (VAS and
CTM group showed statistically
PCS),
Randomized 44 participants significant improvement in pain,
Özgül et al. [39] aged over anxiety level (STAI),
controlled 21: EG medication use, PCS, MSQ
2018 18 years old menstrual symptoms
clinical trial 23: CG (p = 0.001) and in the perception
(MSQ) and menstrual
of menstruation (p = 0.029).
attitude (MAQ).
Both groups showed a reduction
Pre- and 30 participants
Tharani et al. Stress (DASS-21) and in pain and stress, but aerobic
post-comparative 15: EG 1 17–23 years old
[40] 2018 pain (VAS). dance was significantly more
experimental study 15: EG 2
efficient (p < 0.001).
88 participants Pain intensity (NRS,
Placebo- Thermotherapy reduced pain
22: EG 1 Br-MPQ), pressure pain
Machado et al. controlled, intensity compared to TENS
22: EG 2 18–44 years old threshold (PPT) and
[41] 2019 double-blind (p = 0.01) and placebo (p = 0.05)
22: EG 3 conditioned pain
clinical trial after 20, 110 min, and 24 h.
22: CG modulation (CPM).
Int. J. Environ. Res. Public Health 2021, 18, 7832 6 of 19

Table 2. Cont.

Sample Size
Author, Year Type of Study Age Measured Variables Ain Results
(Participants)
The decreases in pain, anxiety
45 participants
A randomized VAS, anxiety level levels, and menstrual complaints
Celenay et al. 15: EG1
sham- 18–35 years old (STAI), and menstrual were higher in the KT group than
[42] 2020 15: EG2
controlled trial complaints. those in the other two groups
15: CG
(p < 0.05).
Çelik and Apay A randomized 124 participants VAS and a Progressive relaxation exercises
[43] prospective 64: EG 18–22 years old dysmenorrhea are an effective method for
2021 controlled trial 60: CG monitoring form. reducing PD.
EG: Experimental Group; CG: Control Group; PD: Primary Dysmenorrhea; VAS: Visual Analogue Scale; STAI: State Trait Anxiety Inventory;
LS: Likert Scale; SR: Sit and Reach test; HILT: High Intensity Laser Therapy; PPI: Present Pain Intensity scale; CTM: Connective Tissue
Manipulation; PCS: Pain Catastrophizing Scale; MSQ: Menstrual Symptom Questionnaire; MAQ: Menstrual Attitude Questionnaire;
DASS-21: Depression, Anxiety and Stress Scale; TENS: Transcutaneous Electrical Nerve Stimulation; PPT: Pressure Pain Threshold; CPM:
Conditioned Pain Modulation; NRS: Numerical Rating Scale; Br–MPQ: McGill Pain Questionnaire; KT: kinesio tape.

Table 3. Characteristics of the intervention of the selected studies.

Author, Year Description INTERVENTION Duration of Sessions Follow-Up Support

Effect of massage therapy and EG1: two consecutive cycles Pain intensity and
isometric exercises on PD. of effleurage massage duration were
Exercises
EG 1. Massage therapy: (15 min each). On the first measured in 3
modified and
effleurage massage in the pubic day of onset of menstrual consecutive cycles (at
Azima et al. confirmed by a
symphysis and navel area with pain and the following day. the peak of PD).
[35] 2015 specialized
lavender oil. EG2: from 3rd day of The level of anxiety
rehabilitation
EG 2. Isometric exercises. These menstruation for 8 weeks, was measured 4 and
consultant.
exercises included 7 stages. 5 days/week, 2 sessions/day, 8 weeks after the
CG. No intervention. and 10 times/session. treatment.
Effectiveness of physical therapy
treatment in relieving PD.
5-phases of the The program was
EG. Physiotherapy program:
physiotherapy program, for Measurements within led and
Ortiz et al. [36] Stretching, specific stretches,
50 min, 3 times/week, 5 days after the last monitored by
2015 Kegel exercises, jogging,
for 3 menstrual cycles (three day of menstruation. three trained
and relaxation exercises,
months). researchers.
performed 5–10 repetitions.
CG. No intervention.
Effect of a yoga program
designed for non-athletic
women with PD. The booklet
EG yoga for 30 min. per day, Evaluation at the
Yonglitthipagon EG Yoga. Poses of Shavasana, “Yoga for PD”
twice a week, for 12 weeks at beginning and at
et al. [37] 2017 Surya Namaskar, Supta was given to
home. 12 weeks.
Vajrasana, Janu Sirsasana and participants.
Pashimottanasana
GC. No intervention.
Pain was assessed
Efficacy HILT compared to before and after the
PEMF. 3 sessions, 3 consecutive treatment, along with The devices were
Thabet et al. EG 1. High Intensity Laser menstrual cycles, when pain its relief after each calibrated at the
[38] 2017 Therapy group. 15 min./ session was intolerable (1st and 2nd treatment, and blood Department of
EG 2. Pulsed Electromagnetic day of menstrual flow). samples were physical therapy.
Field group. 30 min./ session. collected before and
after 3 months.
Int. J. Environ. Res. Public Health 2021, 18, 7832 7 of 19

Table 3. Cont.

Author, Year Description INTERVENTION Duration of Sessions Follow-Up Support

Short-term effectiveness of
Measurements were
Connective Tissue Manipulation
taken at the
(CTM). The EG received CTM for Treatment was
beginning and
Özgül et al. [39] EG. CTM in pelvic zones (sacral, 5 days/week, from ovulation performed by a
immediately after the
2018 lumbar, lower thoracic) and until the beginning of the trained
first menstruation in
anterior pelvic regions.CG. next period. physiotherapist.
postintervention
Lifestyle tips and stretching
period.
exercises.
Effects of stretching exercises in
PD compared to aerobic dance.
Stretching EG1 and aerobic The evaluation was Carried out in the
Tharani et al. EG 1. Stretching and advice.
dance EG2, 45 min. for performed before and Faculty of
[40] 2018 EG 2. Aerobic dance.
3 days/week, for 8 weeks. after the treatment. Physiotherapy.
Both avoided exercise during the
menstrual cycle.
Effects of thermotherapy and
TENS, PPT and CTM in women
The evaluation was
with PD.
performed: at the
EG1. Thermotherapy and TENS. One session
Machado et al. beginning, after 20, Physiotherapy
EG2. Thermotherapy Thermotherapy 20 min.
[41] 2019 50 and 110 min., Department
(microwave diathermy, 20 min.) TENS 30 min.
and 24 h. after the
EG3. TENS (200 µs, 100 Hz, 30
intervention.
mi)
CG. Placebo
Effects of kinesio tape (KT)
Applied by an
application on pain, anxiety,
experienced
and menstrual complaints in KT 2 days a week, from the
Celenay et al. Before and after the physical therapist
women with PD. ovulation until the next
[42] 2020 applications. (Kenzo Kase’s
EG1. Kinesio Tape period begins.
Kinesio Taping
EG2. Sham Tape
Method).
CG. No tape application
Effects of progressive relaxation
exercises on pain in PD. Exercises, average of 30 min. Values measured at Exercises were
Çelik and Apay
EG. Progressive relaxation for two months, every day or the first, second, self-administered
[43] 2021
exercises at least three times a week. and third cycles. via compact disc.
CG. No intervention
EG: Experimental Group; CG: Control Group; PD: Primary Dysmenorrhea; HILT: High Intensity Laser Therapy; PEMF: Pulsed Electromag-
netic Field; CTM: Connective Tissue Manipulation; TENS: Transcutaneous Electrical Nerve Stimulation; KT: Kinesio tape; min: minutes;
h: hour.

In addition, an analysis of the content of the studies has been carried out using the
following variables:

3.1. Evaluation or Questionnaires

One of the most important aspects of all the studies was the measurement of pain.
The Visual Analogue Scale (VAS, where “0” and “10” represent the minimum and maximum
pain level) was used in seven studies [35–37,39,40,42,43]. The Present Pain Intensity Scale
(PPI, a 0–4 point scale, 0 equal no pain, 4 mean unbearable pain) was used in one of
the studies [38], the Numerical Rating Scale (NRS, an 11-point numeric rating scale) [41],
and the McGill Pain Questionnaire (Br-MPQ) were also used in one study [41], and the
Pain Catastrophizing Scale (PCS, a 13-item instrument, about thoughts or feelings when
experiencing menstrual pain on a 5-point scale) also in one study [39].
The participants’ anxiety level was also taken into account using the State Trait Anxiety
Inventory in three of the studies [35,39,42]. Stress was studied using the Depression,
Anxiety and Stress Scale (DASS-21) [39], Pressure Pain Threshold (PPT) and Conditioned
Pain Modulation (CPM) [40].
Int. J. Environ. Res. Public Health 2021, 18, 7832 8 of 19

Menstrual symptoms were measured according to their presence and magnitude

using the Menstrual Symptom Questionnaire (MSQ) and the Menstrual Attitude Question-
naire (MAQ) [39].
Finally, the level of PG2α was measured from blood samples [38].

3.2. Interventions or Treatment

The treatment interventions were diverse in the selected articles. One of them used
massage therapy and isometric exercises [35]. The technique chosen was effleurage ma-
ssage, performed by applying lavender oil and massaging the area above the pubic symph-
ysis and around the navel, for 15 min, following the direction of the clock. This is a simple,
relaxing massage that is carried out with gentle, rotating strokes on the area and is easily
tolerated by patients who are in pain. The isometric exercise group had a 7-phase protocol.
The seven exercises performed were (Appendix A, Figure A1): 1. Supine position, with legs
extended side by side, pressing feet against each other; 2. Supine position, with feet crossed,
pressing one against the other; 3. Supine position, knees bent with a pillow between them,
pressing the pillow; 4. Same position as in number 3, putting one hand under the waist,
pressing against the floor; 5. Supine position, hips and knees bent, lifting head and neck off
the floor and holding; 6. Supine position, hips and knees bent, lifting head and neck off the
ground turning the head to the right side; 7. Repeat exercise 6, but this time turning to the
left side. All exercises were held for five seconds. In addition, deep abdominal breathing
was recommended (in supine position, with knees bent, breathing through the nose and
directing air into the abdomen) [35].
In another article, a physical therapy program was developed [36], which consisted
of 5 phases performed consecutively for 50 min per session. Most of the exercises were
performed with 5 to 10 repetitions: 10 min of general stretching; 10 min of specific stretching
of the iliopsoas, adductors, and calf muscles; 10 min of jogging at 60–70% of maximum
heart rate; 10 min of Kegel exercises to strengthen the pelvic floor muscles; and finally
10 min of relaxation exercises using diaphragmatic breathing techniques [36].
Yoga was another intervention option [37]. A book named “Yoga for PD” was given to
each of the participants. This book included detailed descriptions on how to perform each of
the following positions (Appendix A, Figure A2): Shavasana (5 min), Surya Namaskar (9 min),
Supta Vajrasana (2 min), Janu Sirsasana (6 min), Pashimottanasana (3 min), and Shavasana
(5 min) [37].
Electrotherapy was used in two of the studies [38,41]. One compared High-Intensity
Laser Therapy (HILT) to Pulsed Electromagnetic Field (PEMF) [38]. For the HILT group,
high levels of energy density (fluidity of 810–1780 MJ/cm), very short pulse duration,
between 120–150 µs, a duty cycle of approximately 0.1%, and frequencies of 10–40 Hz were
used. Treatment was applied in 3 phases with a total energy of 880 J. During the initial
phase, treatment was applied to the suprapubic and paravertebral regions of L4-S3. During
the intermediate phase, treatment was applied using a nine-point head, three suprapubic
points while the patient was in supine position and six points over the lumbosacral region
of L4-S3. The final phase was the same as the initial phase, but with a slow exposure and a
total time of 15 min [38]. In the PEMF group, the treatment was applied to the patient in a
lateral position. The therapy was applied for 30 min with one electrode on the suprapubic
region and another on the lumbosacral region of L4-S3, with a frequency of 50 Hz and an
intensity of 60 gauss [38].
In another study [41], the effects of thermotherapy and TENS were compared. Ther-
motherapy was applied by means of a microwave-type diathermy device. The intensity
was set when the patient referred moderate heat sensation. With the patient lying in the
supine position, a reflector was directed toward the lower abdomen, kept 5 cm away from
the skin surface and held for 20 min. The same unit was used in the placebo group, but the
intensity was not adjusted. The application parameters for TENS were: high frequency,
in continuous mode, at 100 Hz and 200 µs, with a strong but comfortable intensity accord-
ing to the sensations of each patient, for 30 min, in the lower abdomen. In the placebo
Int. J. Environ. Res. Public Health 2021, 18, 7832 9 of 19

group, TENS was applied with an identical placebo unit. The electrodes in both cases were
placed on both sides of the abdomen, at D10-D11 level [41].
Connective Tissue Manipulation (CTM) was applied in one of the studies [39]. The placebo
group participants performed stretching exercises, and all participants were given lifestyle
advice. In the CTM group, the pelvic regions, including the sacral, lumbar, and lower
thoracic areas, as well as the anterior pelvic regions, were manipulated with short and
long strokes, respectively. Each stroke was repeated three times, first to the right and then
to the left of all the manipulated regions. All sessions ended with bilateral long strokes
on the iliac crests and subcostal areas. During the manipulation, the third fingertip was
always in direct contact with the patient’s skin. While applying treatment to the back areas,
the patient was placed in a seated position, with triple 90◦ flexion of the lower limbs and
feet resting flat. On the other hand, while applying treatment to the anterior pelvic region,
the patient was placed in a supine position with pillows under the head and knees [39].
Lifestyle tips given to the patients of both the groups were to exercise regularly, limit
caffeine, sugar, and alcohol intake, reduce or quit smoking and avoid exposure to tobacco
smoke [39]. Stretching exercises included general stretching exercises to be performed for
about 30 min (a total of 6 exercises of quadriceps, calves, both sides of the trunk in bipedal
and sitting positions, chest and shoulders), all of them combined with deep abdominal
breathing. In addition, a minimum of two and a half hours of moderate-intensity aerobic
exercise per week was recommended [39].
Kinesio tape was applied using the ligament technique (75–100% stretch) on the sacral
and suprapubic regions in an experimental group compared with a control group and sham
tape group (applied on the trochanter major with no tension or technique). Three I-shaped
Kinesio tapes with a width of 5 cm and thickness of 0.5 mm were used [42].
Recently, Çelik and Apay [43] conducted progressive relaxation exercises with a CD
as the interventional material prepared by the Turkish Psychological Association. First,
the researcher performed the exercises and then the students were instructed to do the
exercises on their own and were called by phone once a week to remind them to do the
exercises regularly. Relaxation exercises start with deep breathing exercises, accompanied
by music, and continue with muscle-stretching exercises (tension for 5–7 s, and then
loosening the muscles for 15–20 s in the hands, arms, neck, shoulder, face, chest, abdomen,
thighs, legs, feet and fingers).
Finally, one of the articles compared stretching exercises to aerobic dance to relieve
pain due to PD [40]. Six stretching exercises were recommended (Appendix A, Figure A3):
1. Stand behind a chair, bend the upper part of the body by bending at the hip joint, keeping
the back straight and parallel to the floor; 2. Stand about 10–20 cm behind a chair, lift
one foot off the floor and place it on the chair to stretch, repeat the same with the other;
3. In standing position, spread the feet to shoulder width, bend the knees and maintain
a squatting position; 4. Stand with feet shoulder-width apart and try to touch the left
ankle with the right hand, while keeping the head on the mid-line and left hand above the
head, then turn the head to look at the left hand. Repeat the same for the opposite side;
5. In supine position, with shoulders, back and feet kept on the ground, the knees are bent
with the help of the hands and brought toward the chin; 6. Stand upright, against a wall,
placing the hands behind the head with elbows pointing forward. Then, without bending
the spine, contract the abdominal muscles [40].
The dance group received aerobic dance 3 days/week for 45 min (10 min warm-up,
25 min dance training, and 10 min cool down). The steps were: walk, one side-slip step,
forward and backward steps, two side-slip steps, side step crossing legs, V-step, knee lift,
heel to buttock, walk forward, side stride, “L” step and jumping jacks [40].
Int. J. Environ. Res. Public Health 2021, 18, 7832 10 of 19

3.3. Methodological Quality of the Included Articles

The methodological quality of the included clinical trials has been evaluated using the
PEDro scale [33] (Table 4):

Table 4. Summary of the quality of the randomized clinical trials included in this review based on the PEDro scale.

Item (PEDro Scale) 1 2 3 4 5 6 7 8 9 10 11 Total Score

Azima et al. [35] 2015 X X N N N N N X N X X 5
Ortiz et al. [36] 2015 X X X X N N X N X X N 7
Yonglitthipagon et al. [37] 2017 N X X X N N N N N X X 5
Thabet et al. [38] 2017 N X N X N N N N N X X 4
Özgül et al. [39] 2018 X X X X N N X X N X X 8
Tharani et al. [40] 2018 N X N X N N N N N X X 4
Machado et al. [41] 2019 N X X X X N X N N X X 7
Celenay et al. [42] 2020 N X N X N N N X N X X 5
Çelik and Apay [43] 2021 X X X X X N N N N X X 7
N: the criterion is not satisfied; X: the criterion is satisfied.

Of the nine articles included in this review, only four of them obtained a score greater
than or equal to 7 on the PEDro scale [36,39,41,43]. These are the ones with the highest
methodological quality. The remaining articles had a lower score, with the article by
Tharani [40] and Thabet [38], scoring the lowest of all. These articles did not meet many of
the items on the scale, as no assignments were made, and neither therapists nor assessors
were blinded to the study.
Additionally, the Cochrane risk of bias tool [31,32] was used to assess this aspect of
the included articles (Figure 2).

Figure 2. Summary of Risk of Bias in included studies.

Int. J. Environ. Res. Public Health 2021, 18, 7832 11 of 19

Some included studies were at high risk of bias in multiple areas of study design, or
they did not report sufficiently so as to reach a conclusion about the risk of bias. The ran-
domization process was described for most studies, except Tharani et al. [40] and allocation
concealment was performed in all studies. Due to the nature of the intervention and
self-reported outcomes, we rated most trials at high risk of bias in both performance
and detection bias. Registered protocol was found in two study [41,42], and we rated
them at low risk of reporting bias. Results were sometimes reported incompletely [35].
Some studies reporting follow up loss did not use intention-to-treat analysis [35,36,39,41].

3.4. Meta-Analysis or Quantitative Analysis of the Included Articles

Meta-analysis of the nine trials with a total of 692 participants demonstrated that
physiotherapy was also better in pain dysmenorrhea than control group (no intervention
or placebo) (MD: −1.13, 95% CI: −1.61 to −0.64, I2 : 88%) (Figure 3).

Figure 3. Pooled MD (95% CI) of effect of physiotherapy in pain relief.

Table 5 shows the strength of evidence for physiotherapy treatment compared to

control group for young women with primary dysmenorrhea.

Table 5. Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profile.
Certainty Assessment No of Patients Effect

No of Other Con- Physiotherapy Control Relative Absolute Certainty Importance

Study Design Risk of Bias Inconsistency Indirectness Imprecision
Studies siderations Treatment Group (95% CI) (95% CI)

MD 1.13
lower
randomised ⊕⊕##
9 serious a serious b not serious not serious none 381 371 - (1.61 lower IMPORTANT
trials LOW
to 0.64
lower)

Question: Physiotherapy treatment compared to control group for young women with primary dysmenorrhea. Outcome (assessed with:
VAS, PPI, NRS) CI: Confidence interval; Menstrual pain intensity, measured by various outcome measures including VAS (visual analogue
scale), PPI (present pain intensity scale) and NRS (numeric rating scale) at the end of the intervention. Lower scores indicate less intense
menstrual pain. a Downgraded one level for serious risk of bias: all included trials are at a high risk of bias for performance and detection
bias. b Downgraded one level for serious inconsistency: while heterogeneity is very high (I2 = 88%), all effects are in the same direction,
favouring physiotherapy.

The quality of evidence was low, the main limitations were inconsistency (studies
showed very different results, control groups were clinically heterogeneous) and risk of
bias related to blinding (where researchers or participants knew what treatment they
were getting).
The current low-quality evidence suggests that physiotherapy may provide a clinically
significant reduction in menstrual pain intensity of around 11 mm on a 100 mm VAS. Given
Int. J. Environ. Res. Public Health 2021, 18, 7832 12 of 19

the overall health benefits of physiotherapy and the low risk of side effects reported (0 per
100), women may consider using it, either alone or in conjunction with other therapeutic
modalities, to manage menstrual pain.

4. Discussion
This review describes various conservative alternatives for the treatment of PD in light
of clinical trials carried out over the last six years . The aim of this systematic review has
been to find out the effectiveness of some physiotherapy techniques in the treatment of PD:
isometric exercises, massage therapy, yoga, electrotherapy, connective tissue manipulation,
stretching, kinesio tape, progressive relaxation exercises and aerobic dance. Meta-analysis
has shown benefits of physiotherapy treatment for pain relief compared with no interven-
tion or placebo. Physiotherapy techniques can be considered as potential alternatives to
analgesic medication. However, difficulties in controlling for non-specific effects, along
with potential for bias, may influence study findings.
PD is described in the scientific literature as one of the most frequent dysfunctions in
gynecological consultations [44]. It is also cited as one of the most common reasons behind
short-term school or work absenteeism among young and adult women [1]. The treatment of
PD is mainly aimed toward relieving the pain and other associated symptoms (as back and leg
pain, anxiety, stress and other symptoms that affect quality of life [37,39,40,42]. Most women
opt for drug treatment to alleviate the symptoms despite its many side effects [10,17,21].
As described by García et al. [3], Kannan and Claydon [20], or Corral-Moreno et al. [45],
physiotherapy can be a very effective treatment for PD, offering different alternatives,
and with the advantage that it can sometimes be performed autonomously by the patient.
There are authors who also recommend treatment through electrotherapy [26,38,41,45],
and others who recommend the use of manual therapy [35,39,45], acupressure [28,45,46],
Kinesio tape [42,47,48], progressive relaxation exercises [43] or therapeutic exercise [22,24,49,50].
Machado et al. [41], suggested that thermotherapy and TENS can serve as good options
of treatment, highlighting in their article the value of thermotherapy for symptom reduction.
The electrotherapy modality was already used for the treatment of PD by Vance et al. [51],
who, being the pioneers in applying microwave-type diathermy, began to describe its
effectiveness and suggested its comparison with TENS. The effectiveness of TENS therapy
has also been supported by other authors such as Wang et al. [52], Arik et al. [26], or Tugay
et al. [53]. These last mentioned authors compared the use of TENS and interferential
currents, concluding that both the treatments are effective in reducing symptoms.
According to Thabet et al. [38], PD can be treated with High Intensity Laser Therapy
(HILT) and Pulsed Electromagnetic Field (PEMF), the former being more effective in
reducing pain and blood PG levels. This type of intervention was supported by Shin
et al. [54], who reaffirmed the effectiveness of laser therapy in the symptomatic relief of
PD, and suggested that pain caused by abnormal functioning of the smooth muscles of the
uterus can be treated by means of this therapy [54]. Therefore, all the studies mentioned
here [38,41,52–54] considered electrotherapy to be a useful therapeutic option for reducing
the pain and other symptoms of PD, with the advantage of having no side effects.
Authors such as Azima et al. [35], chose to propose aromatic massage as an interven-
tion method, in concordance with the study carried out by Apay et al. [55]. Both defended
the effectiveness of massage therapy for pain relief and, if it is done with aromatic oils,
the benefit is greater. It is easy to apply, safe, low cost and without side effects.
According to Özgül et al. [39], connective tissue manipulation is an effective method
that can be adopted for short-term pain relief. This study, in conjunction with the ob-
servational pilot study previously conducted by Reis et al. [56], showed improvement
through this therapy. However, both the studies pointed out the need for more randomized,
placebo-controlled studies to confirm the results. These studies also advocated long-term
follow-up to test whether it is possible to achieve full remission of symptoms or if it is only
effective for pain relief [39,56].
Int. J. Environ. Res. Public Health 2021, 18, 7832 13 of 19

Authors Celenay et al. [42], Boguszewki [47] and Hanife [48] agree on KT application
appearing to be an effective method in decreasing pain, anxiety level and some menstrual
complaints such as abdominal and leg pain, fatigue, vomiting, diarrhea and nausea, as well
as in reducing medication use. KT is an effective, easy and complementary tool for reducing
symptoms in PD and improving quality of life and body awareness [48]. However, further
studies using objective investigative tools are needed (e.g., the measurement of underbelly
muscle tone or thermography).
Several studies included in this review proposed guided exercise treatments [22,36,37,40]
or progressive relaxation exercises [43] that could be performed autonomously by the
patients. Four studies conducted by Azima [35], Ortiz [36], Tharani [40] and Yonglit-
thipagon et al. [37], applied a physical therapy program for PD (isometric exercises, stretch-
ing exercises, aerobic dance or yoga, respectively). They all opted for dynamic treatments,
showing positive results in improving the symptoms and quality of life of sedentary
women, thereby aiding the prevention of numerous other complications that may arise due
to the lack of physical exercise. Similarly, Carroquino et al. [22] conclude in their systematic
review that the most effective exercise programs were stretching and isometric exercises for
8 weeks for pain intensity and duration, yoga for 12 weeks for pain intensity and quality of
life and aerobic exercises for 12 weeks for quality of life. Gotpagar and Devi [49] study the
effect of Bosu Pilates (exercises like stretching and core strengthening exercises performed
on bosu ball) which helped to reduce pain on PD.
However, the effectiveness of these programs in women who regularly practice sports
is unclear. There is heterogeneity with respect to the the way to apply exercise for dysmen-
orrhea [23]. In the Cochrane review conducted by Armour et al., the available evidence
supporting the use of exercise to treat PD was examined and concluded to be low-quality
evidence suggesting that exercise, performed for about 45 to 60 min each time, three times
per week or more, may provide a clinically significant reduction in menstrual pain intensity
of around 25 mm on a 100 mm VAS [23].
In Kim’s meta-analysis [24] it was concluded that yoga is an effective intervention for
alleviating menstrual pain in women. Kirmizigil and Demiralp [50] confirm the positive
effects of a regular and combined exercise program, which reduces pain severity in the
low back and abdomen, and other menstrual symptoms, and improves sleep quality pain.
For its part, progressive relaxation exercises, performed on a regular basis, have an impact
on improving immune function, reducing depression and enhancing daily life; Çelik and
Apay suggest the usage of these relaxation exercises to decrease dysmenorrhea pain and
for analgesic use [43].
Sharghi´s review [27] included 17 papers, 10 of which on complementary medicine
(medicinal plants), three on drug therapies, and four on acupuncture and acupressure.
Further trials are required to confirm the benefits of the procedures described and ensure
the absence of complications. Kannan and Claydon´s review [20] identified that heat,
TENS, and yoga can each significantly reduce the pain of dysmenorrhoea. The 11 included
trials compared intervention as TENS, spinal manipulation, continuous low-level heat,
yoga, acupuncture and acupressure. Although acupuncture and acupressure reduced pain
severity in dysmenorrhea, this appears to be a placebo effect. Kannan and Claydon´s data
confirmed similar results for the physiotherapy techniques we have considered, including
isometric exercises, massage therapy, yoga, electrotherapy, connective tissue manipulation
or stretching. Given that the costs and risks of these interventions are low, they could be
considered for clinical use.
The studies included in this review used various scales, such as the VAS
scale [35–37,39,40,42,43], the NRS scale [41] and the PPI scale [38] to assess pain, which itself
is the main symptom in dysmenorrhea. These trials reported data suitable to be included in
the meta-analysis although further research is required, using validated outcome measures,
adequate blinding and suitable comparator groups reflecting current best practice.
One of the limitations of the present study is the use of a small sample size in some of
the studies included in the analysis. Another drawback is that none of the studies selected
Int. J. Environ. Res. Public Health 2021, 18, 7832 14 of 19

for this review applied the treatment for longer than three months, i.e., three menstrual
cycles. Many other keywords or MESH terms related to “physiotherapy topic” could have
been included in the search strategy; thus, some studies might have been missed. Likewise
for databases as EMBASE or CINAHL. We are aware that some literature on physiotherapy
may be excluded from the main databases: grey literature sources or studies identified in
other different languages than English or Spanish were not considered. A high I2 statistic
suggests that variations in effect estimates may be due to differences between trials, because
studies evaluated a wide range of physiotherapy interventions. Finally, the risk of bias was
unclear for many domains in most of the included studies.
Therefore, studies with a larger sample size are required. Future research should be
carried out over longer periods to measure long-term outcomes. The results of the present
analysis suggest that in order to improve the quality of life of women suffering from PD,
new clinical trials with a physiotherapy protocol for dysmenorrhea should be carried out
in the future, keeping in view the limitations of the current studies. This would ensure
high quality studies to be carried out on treatments aimed toward achieving the reduction
of symptoms in as many women as possible.
The practical implications of this analysis could be a reduction in the use of pharma-
cological treatment by using physiotherapy as a treatment alternative. This would, in turn,
lead to less side effects and a reduction in the financial expenditure on NSAIDs, contracep-
tive pills or any other drugs that are commonly used by PD patients. Physiotherapy offers
a varied, sufficient arsenal of techniques that could be applied in an individualized way to
each patient, so as to reduce the secondary effects after its application, and thereby improv-
ing women’s quality of life. The need and importance of educating patients to consider PD
as something that can and should be treated must be stressed. It is a matter of importance
to free women from their position of acceptance and conformity in regards to this issue,
and to encourage them to seek solutions that, until now, have been kept unknown to a
great majority. Given the overall health benefits of exercise, and the reported relatively low
risk of side effects of physiotherapy in the general population, women may consider using
these conservative treatments. But not everything that might be done will be beneficial,
independently of what and how it is performed, it is necessary for a physiotherapist to
supervise the adequacy and correct performance of the selected techniques, individually.
For example, the mere use of pictures and written explanation may be misleading if one
does not receive a face-to-face explanation on how to perform a given exercise accurately,
which could lead to malperformance and, as a result, decrease in any effectiveness that this
exercise may have.

5. Conclusions
The current low-quality evidence suggests that conservative treatments, such as
certain physiotherapy techniques, may provide clinically significant symptoms reduction
with the advantage of no side effects.

Author Contributions: Conceptualization, methodology, and writing (original draft preparation,

review and editing): R.L.-L., L.T.-Á., P.R.-P., F.A.V.-R., J.M.A.-P., R.T.-R., A.V.G.-L. Formal analysis
and approve final manuscript: R.L.-L., L.T.-Á., P.R.-P., A.V.G.-L. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Environ. Res. Public Health 2021, 18, 7832 15 of 19

Appendix A

Figure A1. Isometric Exercises [35].

Int. J. Environ. Res. Public Health 2021, 18, 7832 16 of 19

Figure A2. Yoga positions for dysmenorrhea [37].

Int. J. Environ. Res. Public Health 2021, 18, 7832 17 of 19

Figure A3. Stretching Exercises [40].

References
1. Bernardi, M.; Lazzeri, L.; Perelli, F.; Reis, F.M.; Petraglia, F. Dysmenorrhea and related disorders. F1000Research 2017, 6, 1645.
[CrossRef] [PubMed]
2. Harel, Z. Dysmenorrhea in Adolescents and Young Adults: Etiology and Management. J. Pediatr. Adolesc. Gynecol. 2006,
19, 363–371. [CrossRef] [PubMed]
3. García Hurtado, B.; Chillón Martínez, R.; Rebollo Roldán, J.; Orta Pérez, M.A. Dismenorrea primaria y fisioterapia. Fisioterapia
2005, 27, 327–342. [CrossRef]
4. Proctor, M.; Farquhar, C. Diagnosis and management of dysmenorrhoea. BMJ 2006, 332, 1134–1138. [CrossRef] [PubMed]
5. Armour, M.; Parry, K.; Manohar, N.; Holmes, K.; Ferfolja, T.; Curry, C. The Prevalence and Academic Impact of Dysmenorrhea in
21,573 Young Women: A Systematic Review and Meta-Analysis. J. Women’s Health 2019, 28, 1161–1171. [CrossRef] [PubMed]
6. Ramos-Pichardo, J.D.; Ortega-Galán, Á.M.; Iglesias-López, M.T.; Abreu-Sánchez, A.; Fernández-Martínez, E. Why Do Some
Spanish Nursing Students with Menstrual Pain Fail to Consult Healthcare Professionals? Int. J. Environ. Res. Public Health 2020,
17, 8173. [CrossRef] [PubMed]
7. Orhan, C.; Celenay, S.T.; Demirtuerk, F.; Ozgul, S.; Uzelpasaci, E.; Akbayrak, T. Effects of menstrual pain on the academic
performance and participation in sports and social activities in Turkish university students with primary dysmenorrhea: A case
control study. J. Obstet. Gynaecol. Res. 2018, 44, 2101–2109. [CrossRef]
Int. J. Environ. Res. Public Health 2021, 18, 7832 18 of 19

8. Dawood, M.Y. Primary Dysmenorrhea. Obs. Gynecol. 2006, 108, 428–441. [CrossRef]
9. Iacovides, S.; Avidon, I.; Baker, F.C. What we know about primary dysmenorrhea today: A critical review. Hum. Reprod. Update
2015, 21, 762–778. [CrossRef]
10. Barcikowska, Z.; Rajkowska-Labon, E.; Grzybowska, M.E.; Hansdorfer-Korzon, R.; Zorena, K. Inflammatory markers in dysmen-
orrhea and therapeutic options. Int. J. Environ. Res. Public Health 2020, 17, 1191. [CrossRef]
11. Ryan, S.A. The Treatment of Dysmenorrhea. Pediatr. Clin. N. Am. 2017, 64, 331–342. [CrossRef]
12. Monterrosa Castro, A. Dismenorrea primaria: Visión actual. Rev. Colomb. Obs. Ginecol. 2001, 52, 342–354. [CrossRef]
13. Burnett, M.; Lemyre, M. No. 345-Primary Dysmenorrhea Consensus Guideline. J. Obstet. Gynaecol. Can. 2017, 39, 585–595.
[CrossRef] [PubMed]
14. Daley, A.J. Exercise and Primary Dysmenorrhoea. Sport Med. 2008, 38, 659–670. [CrossRef]
15. Yacubovich, Y.; Cohen, N.; Tene, L.; Kalichman, L. The prevalence of primary dysmenorrhea among students and its association
with musculoskeletal and myofascial pain. J. Bodyw. Mov. Ther. 2019, 23, 785–791. [CrossRef] [PubMed]
16. French, L. Dysmenorrhea in Adolescents. Pediatr. Drugs 2008, 10, 1–7. [CrossRef] [PubMed]
17. Parra-Fernández, M.L.; Onieva-Zafra, M.D.; Abreu-Sánchez, A.; Ramos-Pichardo, J.D.; Iglesias-López, M.T.; Fernández-Martínez,
E. Management of primary dysmenorrhea among university students in the South of Spain and family influence. Int. J. Environ. Res.
Public Health 2020, 17, 5570. [CrossRef]
18. Zahradnik, H.-P.; Hanjalic-Beck, A.; Groth, K. Nonsteroidal anti-inflammatory drugs and hormonal contraceptives for pain relief
from dysmenorrhea: A review. Contraception 2010, 81, 185–196. [CrossRef] [PubMed]
19. Baird, D.T.; Collins, J.; Crosignani, P.G.; Glasier, A.; Jacobs, H.S.; La Vecchia, C. Noncontraceptive health benefits of combined oral
contraception. Hum. Reprod. Update 2005, 11, 513–525.
20. Kannan, P.; Claydon, L.S. Some physiotherapy treatments may relieve menstrual pain in women with primary dysmenorrhea:
A systematic review. J. Physiother. 2014, 60, 13–21. [CrossRef] [PubMed]
21. Fernández-Martínez, E.; Onieva-Zafra, M.D.; Parra-Fernández, M.L. The impact of dysmenorrhea on quality of life among
spanish female university students. Int. J. Environ. Res. Public Health 2019, 16, 713. [CrossRef] [PubMed]
22. Carroquino-Garcia, P.; Jiménez-Rejano, J.J.; Medrano-Sanchez, E.; de la Casa-Almeida, M.; Diaz-Mohedo, E.; Suarez-Serrano, C.
Therapeutic Exercise in the Treatment of Primary Dysmenorrhea: A Systematic Review and Meta-Analysis. Phys. Ther. 2019,
99, 1371–1380. [CrossRef]
23. Armour, M.; Ee, C.C.; Naidoo, D.; Ayati, Z.; Chalmers, K.J.; Steel, K.A. Exercise for dysmenorrhoea. Cochrane Database Syst. Rev.
2019, 9, CD004142. [CrossRef] [PubMed]
24. Kim, S.D. Yoga for menstrual pain in primary dysmenorrhea: A meta-analysis of randomized controlled trials. Comple-
ment. Ther. Clin. Pract. 2019, 36, 94–99. [CrossRef]
25. Matthewman, G.; Lee, A.; Kaur, J.G.; Daley, A.J. Physical activity for primary dysmenorrhea: A systematic review and meta-
analysis of randomized controlled trials. Am. J. Obstet. Gynecol. 2018, 219, 255.e1–255.e20. [CrossRef]
26. Arik, M.I.; Kiloatar, H.; Aslan, B.; Icelli, M. The effect of tens for pain relief in women with primary dysmenorrhea: A systematic
review and meta-analysis. Explore 2020, 29, 2541. [CrossRef] [PubMed]
27. Sharghi, M.; Mansurkhani, S.M.; Larky, D.A.; Kooti, W.; Niksefat, M.; Firoozbakht, M.; Behzadifar, M.; Azami, M.; Servatyari, K.;
Jouybari, L. An update and systematic review on the treatment of primary dysmenorrhea. JBRA Assist. Reprod. 2019, 23, 51–57.
[CrossRef]
28. Abaraogu, U.O.; Igwe, S.E.; Tabansi-Ochiogu, C.S. Effectiveness of SP6 (Sanyinjiao) acupressure for relief of primary dysmenorrhea
symptoms: A systematic review with meta- and sensitivity analyses. Complement. Ther. Clin. Pract. 2016, 25, 92–105. [CrossRef]
[PubMed]
29. Rodrigues Gerzson, L.; Falcão Padilha, J.; Medeiros Braz, M.; Gasparetto, A. Physiotherapy in primary dysmenorrhea: Literature
review. Rev. Dor São Paulo 2014, 15, 290–295.
30. Moher, D.; Liberati, A.; Tetzlaff, J.; Altman, D.G. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA
statement. J. Clin. Epidemiol. 2009, 62, 1006–1012. [CrossRef]
31. Higgins, J.P.; Altman, D.G.; Gøtzsche, P.C.; Jüni, P.; Moher, D.; Oxman, A.D.; Savovic, J.; Schulz, K.F.; Weeks, L.; Sterne, J.A.
The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011, 343, d5928. [CrossRef]
32. Higgins, J.P.T.; Green, S. Assessing risk of bias in included studies. In Cochrane Handbook for Systematic Reviews of Interventions;
Higgins, J.P.T., Green, S., Eds.; Wiley: Chichester, UK, 2008; pp. 187–241.
33. Herbert, R.; Moseley, A.; Sherrington, C.; Maher, C. Physiotherapy Evidence Database. Physiotherapy 2000, 86, 55. [CrossRef]
34. GRADE Working Group, McMaster University. GRADEpro GDT. Version. Hamilton (ON): GRADE Working Group, McMaster
University. 2015. Available online: https://gdt.gradepro.org/app/handbook/handbook.html (accessed on 17 June 2021).
35. Azima, S.; Bakhshayesh, H.R.; Kaviani, M.; Abbasnia, K.; Sayadi, M. Comparison of the Effect of Massage Therapy and Isometric
Exercises on Primary Dysmenorrhea: A Randomized Controlled Clinical Trial. J. Pediatr. Adolesc. Gynecol. 2015, 28, 486–491.
[CrossRef]
36. Ortiz, M.I.; Cortés-Márquez, S.K.; Romero-Quezada, L.C.; Murguía-Cánovas, G.; Jaramillo-Díaz, A.P. Effect of a physiotherapy
program in women with primary dysmenorrhea. Eur. J. Obstet. Gynecol. Reprod. Biol. 2015, 194, 24–29. [CrossRef] [PubMed]
Int. J. Environ. Res. Public Health 2021, 18, 7832 19 of 19

37. Yonglitthipagon, P.; Muansiangsai, S.; Wongkhumngern, W.; Donpunha, W.; Chanavirut, R.; Siritaratiwat, W. Effect of yoga on
the menstrual pain, physical fitness, and quality of life of young women with primary dysmenorrhea. J. Bodyw. Mov. Ther. 2017,
21, 840–846. [CrossRef] [PubMed]
38. Thabet, A.A.E.-M.; Elsodany, A.M.; Battecha, K.H.; Alshehri, M.A.; Refaat, B. High-intensity laser therapy versus pulsed
electromagnetic field in the treatment of primary dysmenorrhea. J. Phys. Ther. Sci. 2017, 29, 1742–1748. [CrossRef] [PubMed]
39. Özgül, S.; Üzelpasaci, E.; Orhan, C.; Baran, E.; Beksaç, M.S.; Akbayrak, T. Short-term effects of connective tissue manipulation
in women with primary dysmenorrhea: A randomized controlled trial. Complement Ther. Clin. Pract. 2018, 33, 1–6. [CrossRef]
[PubMed]
40. Tharani, G.; Dharshini, E.; Rajalaxmi, V.; Kamatchi, K.; Vaishnavi, G. To compare the effects of stretching exercise versus aerobic
dance in primary dysmenorrhea among collegiates. Drug Invent. Today 2018, 10, 2844–2848.
41. Machado, A.F.P.; Perracini, M.R.; Rampazo, É.P.; Driusso, P.; Liebano, R.E. Effects of thermotherapy and transcutaneous electrical
nerve stimulation on patients with primary dysmenorrhea: A randomized, placebo-controlled, double-blind clinical trial.
Complement. Ther. Med. 2019, 47, 102188. [CrossRef]
42. Celenay, S.T.; Kavalci, B.; Karakus, A.; Alkan, A. Effects of kinesio tape application on pain, anxiety, and menstrual complaints
in women with primary dysmenorrhea: A randomized sham-controlled trial. Complement. Ther. Clin. Pract. 2020, 39, 101148.
[CrossRef]
43. Çelik, A.S.; Apay, S.E. Effect of progressive relaxation exercises on primary dysmenorrhea in Turkish students: A randomized
prospective controlled trial. Complement. Ther. Clin. Pract. 2021, 42, 101280. [CrossRef]
44. Torres-Pascual, C. Alternativas al tratamiento farmacológico de las alteraciones menstruales en adolescentes y jovenes adultas.
Med. Natur. 2016, 10, 15–20.
45. Corral-Moreno, V.; Munuera-Jiménez, F.J.; Cascos-Vicente, L.; Juárez-Díaz, E.; Rodríguez-Almagro, D.; Obrero-Gaitán, E.;
Ibáñez-Vera, A.J. Tratamiento fisioterapéutico para la dismenorrea primaria: Una revisión sistemática. Fisioterapia 2021. [CrossRef]
46. Zhai, S.; Ruan, Y.; Liu, Y.; Lin, Z.; Xia, C.; Fang, F.F.; Zhou, Q.H. Time-effective analgesic effect of acupressure ankle strip pressing
wrist and ankle acupuncture point on primary dysmenorrhea: Study protocol clinical trial (SPIRIT compliant). Medicine 2020,
99, e19496. [CrossRef]
47. Boguszewski, D.; Borowska, J.; Szymańska, A.; Adamczyk, J.G.; Lewandowska, M.; Białoszewski, D. Effectiveness of kinesiotaping
for the treatment of menstrual pain. Physiother. Quart. 2020, 28, 20–24. [CrossRef]
48. Doğan, H.; Eroğlu, S.; Akbayrak, T. The effect of kinesio taping and life style changes on pain, body awareness and quality of life
in primary dysmenorrhea. Complement. Ther. Clin. Pract. 2020, 39, 101120. [CrossRef] [PubMed]
49. Gotpagar, M.T.; Davi, P. Effect of Bosu Pilates on Primary Dysmenorrhea in Adolescent Girls. Indian J. Forensic Med. Toxicol. 2020,
14, 2039–2044.
50. Kirmizigil, B.; Demiralp, C. Effectiveness of functional exercises on pain and sleep quality in patients with primary dysmenorrhea:
A randomized clinical trial. Arch. Gynecol. Obstet. 2020, 302, 153–163. [CrossRef]
51. Vance, A.R.; Hayes, S.H.; Spielholz, N.I. Microwave Diathermy Treatment for Primary Dysmenorrhea. Phys. Ther. 1996,
76, 1003–1008. [CrossRef] [PubMed]
52. Wang, S.-F.; Lee, J.-P.; Hwa, H.-L. Effect of Transcutaneous Electrical Nerve Stimulation on Primary Dysmenorrhea. Neuromodul.
Technol. Neural Interface 2009, 12, 302–309. [CrossRef] [PubMed]
53. Tugay, N.; Akbayrak, T.; Demirtürk, F.; Karakaya, I.; Kocaacar, Ö.; Tugay, U. Effectiveness of Transcutaneous Electrical Nerve
Stimulation and Interferential Current in Primary Dysmenorrhea. Pain Med. 2007, 8, 295–300. [CrossRef] [PubMed]
54. Shin, Y.-I.; Kim, N.-G.; Park, K.-J.; Kim, D.-W.; Hong, G.-Y.; Shin, B.-C. Skin adhesive low-level light therapy for dysmenorrhoea:
A randomized, double-blind, placebo-controlled, pilot trial. Arch. Gynecol. Obstet. 2012, 286, 947–952. [CrossRef]
55. Apay, S.E.; Arslan, S.; Akpinar, R.B.; Celebioglu, A. Effect of Aromatherapy Massage on Dysmenorrhea in Turkish Students.
Pain Manag. Nurs. 2012, 13, 236–240. [CrossRef] [PubMed]
56. Reis, C.A.; Hardy, E.; Sousa, M.H. The effectiveness of connective tissue massage in the treatment of primary dysmenorrhea
among young women. Rev. Bras. Saúde Matern. Infant. 2010, 10, 247–256. [CrossRef]