Complementary Therapies in Clinical Practice 33 (2018) 1–6

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

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

dysmenorrhea: A randomized controlled trial
Serap Özgüla,∗, Esra Üzelpasacia, Ceren Orhana, Emine Barana, M. Sinan Beksaçb,
Türkan Akbayraka
a
Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, 06100, Samanpazarı, Ankara, Turkey
b
Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynecology, 06100, Samanpazarı, Ankara, Turkey

A R T I C LE I N FO A B S T R A C T

Keywords: Aim: To evaluate the short-term effectiveness of connective tissue manipulation (CTM) for relieving menstrual
Connective tissue massage pain and symptoms in primary dysmenorrhea (PD).
Connective tissue manipulation Methods: Forty-four women with PD were randomly assigned to treatment (n = 21) or control group (n = 23).
Dysmenorrhea While the control group was given only advising, the treatment group additionally received CTM. The primary
Massage
outcome was the menstrual pain intensity by Visual Analogue Scale. Secondary outcomes included the number
Primary dysmenorrhea
of pain medications, menstrual pain catastrophizing by Pain Catastrophizing Scale (PCS), menstrual symptoms
by Menstrual Symptom Questionnaire (MSQ) and menstrual attitude by Menstrual Attitude Questionnaire
(MAQ).
Results: Compared with the control group, CTM group showed statistically significant improvement in pain,
medication use, PCS, MSQ (p = 0.001) and in the perception of menstruation as a natural event (p = 0.029).
However, no significant differences were detected between groups for some aspects of MAQ (p > 0.05).
Conclusions: CTM seems to be an effective approach in the short-term in PD.

1. Introduction drugs (NSAIDs), analgesics, and oral contraceptives are the most
common medications for relieving menstrual pain [4]. However, these
Dysmenorrhea is defined as cyclic and spasmodic or cramping pain drugs are only temporarily effective in relieving pain and may induce
in the lower abdomen/pelvis just before and/or during menstruation, some side effects. Hence, many patients seek complementary and al-
which affects severely the quality of life and causes school and work ternative therapeutic options [8]. A non-pharmacological alternative is
abstinence. It is one of the most common gynecologic conditions with a physiotherapy, which includes therapeutic exercises, electrotherapy,
prevalence rate as high as 90%, especially in young women [1,2]. massage therapy, and complementary therapy, such as acupuncture,
Dysmenorrhea is classified as primary or secondary. Most often, dys- chiropractic, osteopathy, and spinal manipulation [1,9–12]. However,
menorrhea is primary, commencing shortly after menarche [3]. While most of the studies published in the area either have no control group or
there is no associated pelvic pathology in primary dysmenorrhea (PD), are studies of combined interventions.
secondary dysmenorrhea results from well-defined gynecological, Connective tissue manipulation (CTM), a manual reflex therapy,
pelvic, or orthopedic traumatic conditions [4]. Pain in PD is most severe targets the superficial connective tissues to stimulate segmental and
during the first and second day of menstruation and typically lasts for suprasegmental autonomic cutaneovisceral reflexes in order to restore
8–72 h. The pain is also frequently accompanied by systemic symptoms autonomic balance and reduce the dysfunction in the affected internal
[5]. The pathogenesis of PD is believed to be associated with increased organs. By the stimulation of segmental reflexes, therefore, CTM can be
prostaglandin production leading to increased uterine contractility and used to increase circulation to uterus, reducing congestion and men-
ischemia through vasoconstriction of uterine blood vessels [6,7]. strual pain in women with PD [13,14].
The therapeutic options for the treatment of dysmenorrhea are few Although CTM has been used for the treatment of broad range of
and not totally effective. They include pharmacological, non-pharma- health conditions including painful syndromes, vascular problems, or
cological, and surgical approaches. Non-steroidal anti-inflammatory bowel dysfunction [15–21], there is limited evidence for its use in PD

∗
Corresponding author. Hacettepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, 06100, Samanpazarı, Ankara, Turkey.
E-mail addresses: [email protected], [email protected] (S. Özgül), [email protected] (E. Üzelpasaci), [email protected] (C. Orhan),
[email protected] (E. Baran), [email protected] (M.S. Beksaç), [email protected] (T. Akbayrak).

https://doi.org/10.1016/j.ctcp.2018.07.007
Received 27 June 2018; Received in revised form 12 July 2018; Accepted 19 July 2018
1744-3881/ © 2018 Elsevier Ltd. All rights reserved.
S. Özgül et al. Complementary Therapies in Clinical Practice 33 (2018) 1–6

[22,23]. To the best of our knowledge, there is no randomized con-

trolled trial using CTM in the treatment of menstrual pain and symp-
toms. Therefore, the 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
be more effective than advising alone in women with PD.

2. Materials and methods

2.1. Design

The study protocol of this prospective randomized controlled trial

was approved by the local ethics committee of university (approval no.:
GO 15/98-24), and all subjects provided written informed consent be-
fore participation. After the first screening for inclusion criteria, all
participants were provided with a 7-day pain diary and invited to re-
turn for a baseline 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 baseline as-
sessment, each participant was randomly assigned to either the treat-
ment 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 com-
puter-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. While the control group was given
only advising on lifestyle and stretching, the treatment group received
additional CTM.

2.2. Participants
Fig. 1. Directions of connective tissue strokes applied over the sacral, lumbar
Participants diagnosed with PD by the gynecologist were referred to and lower thoracic regions.
physiotherapy and rehabilitation department of university.
Demographic characteristics, and medical and gynecological history of
all participants were recorded.
The study included nulliparous women who met the following cri-
teria: aged over 18 years, having diagnosis of PD according to the
Primary Dysmenorrhea Consensus Guideline [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 ex-
cluded if they had gastrointestinal, urogynecologic, autoimmune or
psychiatric disease, other chronic pain syndromes, childbirth, positive
pregnancy test, intrauterine device, pelvic surgery, chronic 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 days variation between cycles),
and a history or an ultrasonographic observation of pathological con-
ditions indicating secondary dysmenorrhea. The Turkish-language
State-Trait Anxiety Inventory (STAI) was administered to all partici-
pants prior to and at the end of the study to measure the presence and
severity of the current symptoms of anxiety (STAI-I) and a generalized
propensity to be anxious (STAI-II) [25,26].

2.3. Interventions

2.3.1. Connective tissue manipulation

Pelvic zones including sacral, lumbar, lower thoracic (Fig. 1), and
anterior pelvic regions (Fig. 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 Fig. 1)
and long strokes (2, 4, 7, 10, 11 in Fig. 1, all in Fig. 2) were used during
manipulation [27]. Each stroke was repeated for three times first on the Fig. 2. Directions of connective tissue strokes on anterior pelvic region.
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 Fig. 1). Strokes shown in the back (Fig. 1) are only one-
sided.

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S. Özgül et al. Complementary Therapies in Clinical Practice 33 (2018) 1–6

During manipulation, the pad of the middle finger was in contact as a natural event (MAQ-III), prediction and anticipation of the onset of
with the patient's skin. The finger was placed on the skin at 45° angle menstruation (MAQ-IV), and the denial of any effect of menstruation
with distal interphalangeal joint in flexion and moved to cause traction. (MAQ-V) [40].
Treatment was performed by a trained physiotherapist (EB). Treatment
was completed approximately in 10 min. During the treatment of back, 2.5. Treatment satisfaction
the participant was instructed to sit erect, with hips, knees, and ankles
at 90° flexion; the thighs and feet were fully supported. During the Patients' satisfaction with CTM and/or lifestyle advices was assessed
treatment of anterior pelvic region, the patient was in a supine position by two questions on a rating scale of 0–10. Q1: How satisfied were you
with pillows placed under the head and knees. with the overall treatment you received?, Q2: Would you recommend
this treatment and/or advices to someone you know who has menstrual
2.3.2. Lifestyle advising and stretching exercises pain?
All participants in the treatment and control groups were advised
for exercising regularly, limiting caffeine, sugar, and alcohol intake,
2.6. Compliance with advices
reduction or cessation of smoking if they smoke, or avoiding of ex-
posure to environmental tobacco smoke. In exercise advising, 30-min
A four-point scale (never, somewhat, to a large extent, completely)
general stretching exercises (totally 6 movements including the quad
was used to determine the participants' compliance with advices.
stretch, the standing hamstring stretch, the standing side stretch, chest
stretch, shoulder stretch and the seated back twist) combined with deep
2.7. Statistical analyses
abdominal breathing were shown and all patients were recommended
to get a minimum of 2½ hours/week of moderate-intensity aerobic
All statistical analyses were performed using SPSS software (version
activity by using the talk test [28]. Participants were supplied with a
21, SPSS, Inc., Chicago, IL, USA). Visual (histograms, probability plots)
brief instruction leaflet on these advices and a second control ap-
and analytical (Kolmogorov-Smirnov test) methods were used to de-
pointment was booked for one-week later. In this second visit, exercises
termine whether variables were normally distributed. Data were ex-
and recommendations were repeated and checked within about 40 min.
pressed as mean ± standard deviation or as median (interquartile
range) for numerical variables and as numbers (percentages) for cate-
2.4. Outcome measures
gorical variables. Study groups were assessed for comparability by the
use of the Mann-Whitney U test for numerical variables and the chi-
All measurements were completed at baseline and immediately after
squared test for categorical variables. The Wilcoxon test was used to
the first menstruation following the intervention period under the su-
compare changes in variables between baseline and at the end of the
pervision of a therapist who was blinded to group allocation (EÜ).
study period. A probability (p) value of < 0.05 was considered to be
statistically significant.
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 3. Results
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 A total of 59 women were screened, of whom 47 met the inclusion
lasts for 8–72 h, we used the day-1 score and the average score of first criteria and 44 accepted to participate in the study. All participants
three days from 7-day pain diaries. The VAS has been shown to be a were at least high school graduates. Following the initial screening,
valid and reliable tool for measuring experimental and clinical pain, each participant was randomized to either the treatment (n = 21) or
which is also sensitive to changes with treatment of clinical pain and to the control group (n = 23). A total of 4 patients (1 from the treatment
small changes in pain intensity [29–32]. group and 3 from the control group) withdrew from the trial during the
study period. Only one women discontinued the CTM because her acute
2.4.2. Secondary outcomes respiaratory medical condition prevented her attending the massage
Number of pain medications: The number of pain medications sessions. Consequently, 20 participants in the treatment group and 20
taken in the last menstruation including NSAIDs and analgesics were participants in the control group completed the trial (Fig. 3). The
recorded. number of CTM sessions ranged from 10 to 15 (12.2 ± 1.7).
Menstrual Pain Catastrophizing Score: The Turkish-Pain At baseline, there were no significant differences between groups in
Catastrophizing Scale (PCS) was used to assess catastrophizing about terms of demographic, physical, and menstrual characteristics (Table 1)
menstrual pain during the last menstruation [33]. PCS is a 13-item or for outcome measures (Table 2) (p > 0.05). There were also no
instrument [34], indicating the degree to which women experienced statistically significant inter-group differences in terms of STAI-I and
each of 13 thoughts or feelings when experiencing menstrual pain on a STAI-II scores at baseline (p = 0.946 and 0.180, respectively) and at the
5-point scale from 0 (not at all) to 4 (all the time). The PCS total score end of the study period (p = 0.101 and 0.217, respectively), indicating
was computed by summing responses to all 13 items, ranging from 0 to that the inter-group differences in outcome parameters were not related
52. to anxiety levels.
Menstrual Symptom Score: The Turkish-Menstrual Symptom
Questionnaire (MSQ) was used to assess menstrual symptoms [35]. The 3.1. Primary outcome measure
MSQ is a 24 item self-report measure and the score of each item ranges
from 1 (never) to 5 (always). Higher total scores indicates more The Pain Intensity Score: Participants in the treatment group reported
symptoms [36,37]. significantly lower scores (on day-1 and on average) than those in the
Menstrual Attitude Score: The Turkish-Menstrual Attitude control group (p = 0.001). The intra-group analysis revealed a sig-
Questionnaire (MAQ) was used to assess women's beliefs about and nificant improvement in both scores of CTM group (p = 0.001), while
attitudes towards menstruation. It consists of 31 positive and negative deterioration was found in the control group (p = 0.045, 0.001)
items scored on a 5-point Likert scale (1 = strongly disagree; (Table 2).
5 = strongly agree) [38,39]. The MAQ is divided into five subscales: All participants (100%) in the CTM group reported improvement in
menstruation as a psychologically and physically debilitating event pain intensity. However, none of the participants was observed to be
(MAQ-I), menstruation as a bothersome event (MAQ-II), menstruation cured (zero at VAS).

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Fig. 3. Flow-chart of the study.

Table 1 natural event” subscale) (p = 0.029). There were no intergroup dif-

Comparison of baseline characteristics of participants. ferences for other subscales of the MAQ (MAQ-I,II,IV,V) (p > 0.05)
Characteristic Treatment group Control group p value
The intra-group analysis showed a significant improvement only in
(n = 20) (n = 20) MAQ score-III in CTM group (p = 0.047). (Table 2).

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
3.3. Treatment satisfaction
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 Patients in the treatment group reported higher satisfaction scores
Pain intensity during last 6.7 (6.2–7.5) 6.4 (5.4–7.8) 0.551 with treatment (7.4 ± 1.4 and 8.0 ± 1.4 for Q1 and Q2, respectively)
6m
than patients in the control group (2.1 ± 0.5 and 2.8 ± 0.7 for Q1 and
STAI-I 48.0 (43.5–56.5) 48.5 (42.7–54.7) 0.946
STAI-II 44.0 (39.0–47.0) 46.5 (44.2–49.7) 0.101 Q2, respectively).

BMI: Body mass index, y: year, STAI-I: State Anxiety Scale, STAI-II: Trait
Anxiety Scale, p: comparison of patient characteristics at baseline, Mann- 3.4. Compliance with advices
Whitney U test.
None of the participants reported full compliance with advices.
3.2. Secondary outcome measures There was no significant differences between the groups for the com-
pliance with advices (χ2 = 1.543, df = 2, p = 0.462).
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). The intra-group analysis 3.5. Adverse events
revealed a significant improvement in the treatment group (p = 0.001),
while no change was found in the control group (p = 0.763) (Table 2). There was no report of any adverse events.
Menstrual Pain Catastrophizing and Menstrual Symptoms: The
participants in the treatment group had significantly lower pain cata-
strophizing and symptom scores (p = 0.001). Comparison of pre- and 3.6. Statistical power
post-treatment results within groups showed an improvement in CTM
group (p = 0.001) and a deterioration in the control group (p = 0.001) Post hoc power analysis using the Mann-Whitney U test results for
(Table 2). the pain score on day 1 showed that a total sample size of 40 achieved a
Menstrual Attitude Score: The between-group comparison showed power of 99.0% to detect an average 4 points difference between
also a difference for change in the MAQ score-III (“menstruation as a groups in VAS score with a significance level of 0.05.

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Table 2
Outcome parameters in participants allocated to either treatment or control group.
Parameters Treatment group (n = 20) Control group (n = 20) p1 p2 p3 p4

Baseline 2nd ass. Δ1 Baseline 2nd ass. Δ2

PIS (day-1) 7.1 (6.2–7.4) 2.5 (2.1–3.2) 4.1 (2.6–4.7) 7.0 (5.2–8.6) 7.2 (5.4–8.8) −0.2 (−0.3–−0.1) 0.946 0.001* 0.045* 0.001*
PIS (average) 4.3 (2.6–5.1) 1.2 (0.9–2.2) 3.0 (1.6–4.0) 3.7 (2.7–5.5) 3.9 (2.9–5.7) 0.2 (−0.2–−0.1) 0.860 0.001* 0.001* 0.001∗
Medication (number) 2.0 (1.0–2.0) 0 (0–1.0) 1.0 (0.2–2.0) 1.0 (1.0–2.0) 1.0 (1.0–2.0) 0 (0–0) 0.663 0.001* 0.763 0.001∗
PCS 28.0 (24.0–30.7) 14.0 (8.2–22.7) 13.5 (6.0–20.7) 31.0 (25.7–39.0) 36.0 (30.0–43.5) −4.0 (−5.7–−2.0) 0.146 0.001* 0.001* 0.001∗
MSS 47.5 (41.2–61.5) 27.5 (20.5–35.7) 20.5 (14.7–25.0) 48.0 (38.5–53.5) 51.0 (42.5–57.7) −4.5 (−5.0–−3.2) 0.607 0.001* 0.001* 0.001∗
MAQ-I 23.0 (22.0–23.7) 22.5 (21.0–24.7) 0 (−2.0–2.0) 22.0 (21.0–24.7) 23.0 (21.0–24.7) −1.0 (−1.7–0.7) 0.424 0.834 0.223 0.344
MAQ-II 16.0 (13.5–18.0) 16.5 (14.2–18.0) −1.0 (−2.0–1.7) 15.5 (14.0–19.7) 17.5 (13.2–20.0) 0.5 (−2.0–1.0) 0.624 0.446 0.669 0.633
MAQ-III 17.5 (15.2–19.7) 19.0 (17.0–20.7) 2.0 (0.2–3.7) 18.0 (14.2–20.0) 18.0 (15.0–20.7) 0.5 (−1.7–1.0) 0.744 0.047* 0.875 0.029∗
MAQ-IV 27.0 (26.0–30.0) 26.5 (25.0–30.0) 0 (−2.0–2.7) 26.5 (25.0–28.0) 27.0 (26.0–28.0) −0.5 (−2.0–2.5) 0.263 0.856 0.830 0.673
MAQ-V 12.0 (11.0–12.7) 12.0 (10.0–13.7) 1.0 (−2.0–2.0) 10.5 (9.0–13.5) 11.0 (10.0–13.0) 0 (−1.0–1.0) 0.238 0.424 0.563 0.538

PIS: Pain Intensity Score, PCS: Pain Catastrophizing Score, MSS: Menstrual Symptom Score, MAQ: Menstrual Attitude Questionnaire ass.: assessment, Δ1 and Δ2:
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 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.

4. Discussion in the present study, no subjects were cured. This finding is similar to
the results of the study of Demirtürk et al. [23], which also performed a
This is the first randomized controlled trial investigating the effects one-cycle CTM. Reis et al. [22] reported a total pain remission in 23%
of CTM in PD. Our results demonstrated that a combination of one-cycle of the subjects after three cycles of CTM. Based on this result, the cure
of CTM with lifestyle advising is more effective than lifestyle advising of menstrual pain with CTM seems possible. Therefore, further placebo-
alone for relieving menstrual pain and symptoms in dysmenorrheic controlled studies are needed to determine or confirm if longer therapy
women. Except for some aspects of menstrual attitude, the superiority will improve the cure rate.
of CTM was noted in all outcome parameters including menstrual pain In treatment follow-ups, one study [23] reported that the im-
and symptoms, pain medication and pain catastrophizing. provement in outcome parameters was maintained after the first men-
Physiotherapy for PD has been mainly focused on heat therapy, struation following treatment. Another study [21] presented relatively
electrotherapy, spinal manipulation, and exercises [41]. On the other small increase in average pain and medication use after the cessation of
hand, although CTM has been used for the treatment of broad range of the three cycles of therapy. Since the results are contradictory, further
health conditions including painful conditions, such as fibromyalgia, studies with long-term follow-up are needed.
migraine, or mechanical neck pain [15,17,19,20,42], vascular problems In the present study, the lack of differences in some subscales of
[21], or bowel dysfunction [16,43], the evidence for its use in PD is MAQ may also be attributed to the study duration. Therefore, long-term
very limited. follow-up will also clarify the effect of CTM on other aspects of the
There are only two studies reporting the effects of CTM in PD menstrual attitude of dysmenorrheic patients.
[22,23]. One of them is a pilot observational cohort study [22] and the On the other hand, the deterioration in some parameters (pain, pain
other one is a comparative study comparing the CTM and foot reflex- catastrophizing and menstrual symptoms) in the control group of the
ology [23]. Both studies have no control group and reported significant present study may be related to increased perception of the patient's
improvement in menstrual pain and symptoms as well as in medication own situation and the expectation of other therapeutic approaches from
use with CTM. therapist by aggregating their present situation. However, these para-
In the study of Reis et al. [22], sacral, lumbar, last thoracic vertebra meters showed statistically significant improvement in CTM group.
and subcostal regions were manipulated twice a week during three Despite the effectiveness of NSAIDs, which is reported to be first line
menstrual cycles following admission while the patients were not of treatment for PD, they are associated with many adverse reactions,
menstruating. In this study, the number of massage sessions varied such as neurological and gastrointestinal reactions, which become more
between 16 and 39 (mean: 23). In the other study by Demirtürk et al. apparent and severe with long-term use [44]. The women in our study
[23], whole back region (sacral, lumbar, lower thoracic, scapular, in- reported no adverse effects and also reduced pain medication use,
terscapular, cervical, and occipital) were manipulated five days a week suggesting less drug-related side effects. These results emphasize once
from the third or fourth day of menstruation till the first day of the again that the further studies should particularly focus on such con-
following menstruation. In this study, there is no information about the servative options.
number of CTM sessions. Although there is no definition for regular The strengths of our study were the randomized controlled design
menstrual cycle length in this study, when we calculate the number of and the use of reliable and valid specific tools for pain and symptom
sessions for this study based on 28 ± 7 days cycle length, it equals to assessment. Given the limited effectiveness of the current pharmaco-
16–32 sessions of CTM therapy. logical agents and the increasing demand for non-pharmacological/
In the present study, we manipulated only menstrual pain zones conservative alternatives for dysmenorrhea, using CTM as a non-phar-
from the estimated day of ovulation till the next period begins [27]. The macological option in this common gynecological pain condition may
number of sessions varied between 10 and 15. Therefore, compared be another strength of our study.
with other studies, improvement in outcome parameters was achieved This study has some limitations. First is the lack of a sham massage/
with fewer sessions in a shorter time period and narrower application. therapy group to eliminate the placebo effect of CTM. However, com-
Based on these findings, necessity of manipulating the areas beyond pared with sham treatments, massage was found superior in common
menstrual zones and optimal intensity and duration of CTM should be chronic pain syndromes including low back pain and fibromiyalgia
questioned in further studies. Additionally, we reported less pain cat- [45–47] and in vascular problems [21]. Secondly, due to the nature of
astrophizing, better perception of menstruation as a natural event, and interventions used in both groups and patient reported outcomes,
higher satisfaction scores with CTM in the present study. blinding the patient and/or assessor, thus a double-blind design, was
Although all participants reported improvement in menstrual pain not possible.

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