Comparative Evaluation of Effectiveness of Pelvic Floor Strengthening and Myokinetic Active Release of Trigger Points in Reducing Dysmenorrhea

Introduction

Dysmenorrhea is a lower midline, dull abdominal ache or cramp which is characterized by several other symptoms including dizziness, fatigue, sweating, backache, nausea, etc. It is spasmodic and cyclic pain beginning approximately two days before the onset of menstruation which is quite severe on the first day.¹ Pain may even radiate to lower back and thigh.² Prevalence ranges from 67% to 90% in young women of 17-24 years of age.³

The etiology of dysmenorrhea and its symptoms can be explained by uterine prostaglandin action, particularly PGF2-α. Increase in prostaglandin level due to withdrawal of progesterone in late luteal phase increases intrauterine contractions and pressure, causing vasoconstriction of uterine vessels, decreased blood flow, ischemia of muscles of uterus and increased sensitivity of pain receptors, thus proving ischemia as the cause of pain.⁴

The action of pelvic floor muscle (PFM) varies in accordance to hormonal fluctuations that occur during menstrual cycle.² PFMs are generally weak just before menstruation. Thus PFM has favorable effect in reducing dysmenorrhea.⁵ Kegel exercises are effective in strengthening pelvic floor muscle PFMs.

The alteration in muscle function due to hormonal imbalance can also be the cause of dysmenorrhea. Trigger points present in rectus abdominis quadratus lumborum and gluteus medius can lead to increased dysmenorrheic pain. Trigger point (TrPs) is the hypersensitive point in muscle taut band which is painful to palpation and causes referred pain.⁶

Rectus abdominis trigger points refer pain to hypogastrium that mimics pain similar to dysmenorrhea. Periumbilical part of rectus abdominis produces cramps and diffuse abdominal pain. Lower rectus abdominis deactivation relieves dysmenorrhea.⁶ Increased PGF2-α transports via blood and settles in TrPs of muscle causing its irritation and activation, resulting in development of symptoms. Falling levels of PGF2-α after menstruation may lead to latency of TrPs explaining disappearance of symptoms after menstruation.

Dysmenorrhea is connected to pain referred from various musculoskeletal structures sharing the same nerve route. Quadratus lumborum acts as a stabilizer of lumbar spine and is a frequent trigger point zone. TrPs in muscle may hamper its function. Reduction in mobility of T10-L2 segment leads to dysmenorrhea as these segments are responsible for sympathetic and parasympathetic innervations of uterus. Reduction in mobility of T10-L2 spine disturbs innervation of blood vessel within the uterus causing consequent narrowing and ischemia. Thus, restoring correct spine mobility by deactivating quadratus lumborum trigger points may improve nerve conduction and blood supply, thereby improving dysmenorrhea.⁷

Gluteus medius TrPs hypersensitivity often produces intense pain in lower back region. Gluteus medius commonly develops satellite triggers in response to active quadratus lumborum triggers because gluteus medius lies in pain preference zone of the muscle quadratus lumborum. Gluteus medius TrPs refer pain to lower back. Pain and tenderness may also extend to thigh.⁸

Various techniques can be used to deactivate trigger points. Myokinetic active release technique is a classified, multidisciplinary, advanced procedure used to treat soft tissues and can be effectively used to treat TrPs. In this technique, deep tension over the tenderness is applied while asking patient to actively move the tissues.⁹

Dysmenorrhea is one of the most frequently seen gynecological issue among females of younger age group and it has high prevalence in India. Unfortunately, very few treatment options are available for this disease. Till today, pelvic floor strengthening is used for treating dysmenorrhea but there is scanty evidence that myofascial involvement may show progressive results. Since the physiology, anatomy and dysfunction are interlinked, releasing myofascial trigger points may prove to be beneficial in influencing the recovery from the disorder. This study aimed to evaluate if myokinetic active release of trigger points of rectus abdominis, gluteus medius and quadratus lumborum is better than pelvic floor muscle PFM strengthening in reducing dysmenorrhea.

Materials and Methods

This experimental study was conducted in the Department of Physiotherapy of Sardar Bhagwan Singh Biomedical Sciences and Research (SBSPGI), Balawala, Dehradun. It included 40 subjects selected based on inclusion and exclusion criteria. Exclusion criteria of the study were, patients with inflammatory disease, adenomycosis, polyps, fibroids, postnatal dysmenorrhea, endometriosis, malignancy, oral contraceptives, ovarian cysts, intrauterine device, cervical stenosis, fever or any other gynecological disease. Inclusion criteria of the study were, females in the age range of 20 to 30 years experiencing dysmenorrhea, subjects willing to volunteer for few days of physiotherapy and subjects having trigger points in rectus abdominis, quadratus lumborum and gluteus medius. Informed consent was obtained from the subjects after explaining objective of the study and the procedure in detail. The subjects were divided into two groups using random sampling method - Group 1 (PFM strengthening group) and Group 2 (Myokinetic active release group). Each group comprised of 20 subjects. All the subjects were screened for pain using visual analogue scale (VAS) (pre-treatment reading) and presence of trigger points using flat palpation and jump sign test. For subjects in Group 1, PFM strengthening using Kegel exercise was prescribed with three repetitions, three times a day² for seven days before the speculated next menstruation date. For subjects in Group 2, myokinetic active release of trigger points in rectus abdominis, quadratus lumborum and gluteus medius with five strokes each side was prescribed for seven days before the next speculated date of menstruation. Pain after the next menstruation was measured using VAS (post treatment reading). Data were collected and subjected to statistical analysis.

Results

According to the objective of study, value of VAS after the treatment was compared between the two groups statistically using Statistical Package For The Social Sciences (SPSS) software. Paired t test was applied for comparison of pre-and post-treatment VAS score within the two groups. The mean and standard deviation of the pre-and post-treatment data were calculated (Table 1). Unpaired t test was applied to compare the post treatment VAS scores between the groups i.e. post treatment VAS of Group 1 and post treatment VAS score of Group 2. The results showed a significant (p <0.05) improvement in VAS score of both the groups (Table 2). However, improvement in VAS score of Group 2 was higher than Group 1 (Table 3). The pre-and post-treatment mean and standard deviation within the group (Figure 1 and 2) and post treatment mean and standard deviation between the groups (Figure 3) is plotted in the graph. The graph depicts the significant effect of pelvic floor muscle strengthening and myokinetic active release of trigger points of rectus abdominis, gluteus medius and quadratus lumborum in treating dysmenorrhea. However, myokinetic active release of trigger points was found to be more effective compared to pelvic floor strengthening in reducing dysmenorrhea.

Discussion

Dysmenorrhea is the most frequent gynecological complaint of recent times. Menstrual pain with its distinctive cramping tends to tense women’s muscle and that in turn can significantly restrict muscles of abdomen and pelvic floor. Carrie M Hall added that pelvic floor muscles are likely to be weak at end of the day when sick and just before menstruation.¹⁰ Priya Kumari et al., hypothesized that PFM exercise has significant effect in reducing pain. Literature suggests that PFM strengthening when done regularly improves PFM functions and dysmenorrhea.² Joseph E. Muscolino stated myofascial is positioned as a component in generating both musculoskeletal and visceral pain.¹¹ The trigger points present in rectus abdominis, gluteus medius and quadratus lumborum contribute to increased pain during menstruation. Robb et al., found that the sympathetic and parasympathetic pelvic nerve pathway closely associates with spinal vertebras, particularly 2^nd to 4^th sacral segments and 10^th thoracic to 2^nd lumbar segments.¹² A hypothesis suggests that mechanical dysfunction in these vertebras cause decrease in spinal mobility. This could hamper sympathetic nerve supply of the blood vessel that supplies the pelvic viscera (internal organ), causing dysmenorrhea due to vasoconstriction. Manipulation of vertebral segments will increase mobility of spine and enhance blood supply of pelvis by influencing the autonomic nerve supply of the blood vessel. Barcikowska et al., stated when pelvis is stable, quadrates lumborum act as lateral flexor of lumbar spine.⁷ Reduction in mobility of T10 to L2 segment responsible for parasympathetic and sympathetic supply of the uterus disturbs blood vessel innervation of the uterus causing consequent uterine narrowing as well as ischemia. Dysmenorrhea is connected to pain referred from musculoskeletal structure having same nerve routes as uterus. Therefore, restoration of the correct spinal mobility shall lead to improved nerve conduction as well as uterine blood supply.⁷

Gaubeca et al., stated rectus abdominis trigger points refer pain to hypogastrium that mimics symptoms of dysmenorrhea pain.⁶ Increase in uterine prostaglandins F2α production in weeks just before menstruation can be transported in the blood. This prostaglandin settles in rectus abdominis taut band, causing irritation and activation of trigger points of the muscle. After menstruation, with the fall in concentration of prostaglandins, the trigger points return to latency (asymptomatic) causing the symptoms to decrease or disappear for some time.

Conclusion

The results of the study concluded that there is a significant effect of pelvic floor muscle strengthening and myokinetic active release of trigger points of rectus abdominis, gluteus medius and quadratus lumborum in treating dysmenorrhea. However, myokinetic active release of trigger points was found to be more effective than pelvic floor strengthening.

Funding

Nil

Conflict of Interest

Nil