Efficacy of the device combining high-frequency transcutaneous electrical nerve stimulation and thermotherapy for relieving primary dysmenorrhea: a randomized, single-blind, placebo-controlled trial

Efficacy of non-pharmacological interventions for primary dysmenorrhoea: a systematic review and Bayesian network meta-analysis

OBJECTIVES

To assess the relative benefits of various non-pharmacological interventions on treating primary dysmenorrhoea within a network meta-analysis.

STUDY DESIGN

Systematic review and Bayesian network meta-analysis.

INCLUSION CRITERIA

Randomised controlled trial involving patient with primary dysmenorrhoea and received non-pharmacological interventions.

DATA SOURCES

Four databases (Medline, Embase, Cochrane Library and Web of Science) were searched from inception to October first, 2022.

RISK-OF-BIAS ROB ASSESSMENT

RoB 2.0 assessment tools was used to assess the risk of bias in the included studies.

SYNTHESIS OF RESULTS

Conventional meta-analysis was conducted by pairwise comparison between non-pharmacological therapy and control treatment. The Bayesian network meta-analysis was conducted by the Aggregate Data Drug Information System Software based on the consistency or inconsistency model, and rank probability was used to indicate the priority of non-pharmacological therapy.

RESULTS

33 studies involving eight non-pharmacological interventions were included. With regard to conventional meta-analysis, we selected Visual Analogue Scale (VAS) as primary outcome to evaluate the pain intensity. The result showed that eight interventions (Exercise, Herb, Acupuncture, Aromatherapy, Transcutaneous Electrical Nerve Stimulation, Topical heat, Acupressure, Yoga) displayed positive effect on reduction of menstrual pain compared with placebo or no treatment. A Bayesian network meta-analysis revealed that exercise -3.20 (95% CI -4.01 to -2.34), acupuncture -2.90 (95% CI -3.97 to -2.85) and topical heat -2.97 (95% CI -4.66 to -1.29) probably resulted in a reduction in pain intensity (VAS) .

CONCLUSIONS

Non-pharmacological interventions may result in a reduction or slight reduction in pain intensity compared with no treatment or placebo. Specifically, exercise and acupuncture are considered as potentially effective non-pharmacological treatments in short-term treatment. Indeed, larger and better methodological quality research is needed.

TRIAL REGISTRATION NUMBER

CRD42022351021.

Treatment of Women With Primary Dysmenorrhea With Manual Therapy and Electrotherapy Techniques: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to evaluate the efficacy of electrotherapy and manual therapy for the treatment of women with primary dysmenorrhea.

METHODS

Systematic searches were conducted in Scopus, Web of Science, PubMed, CINAHL, and MEDLINE. The articles must have been published in the last 10 years, had a sample exclusively of women with primary dysmenorrhea, had a randomized controlled trial design, and used interventions that included some form of manual therapy and/or electrotherapy techniques. Two reviewers independently screened articles for eligibility and extracted data. Difference in mean differences and their 95% CIs were calculated as the between-group difference in means divided by the pooled standard deviation. The I2 statistic was used to determine the degree of heterogeneity.

RESULTS

Twelve selected studies evaluated interventions, with 5 evaluating electrotherapy techniques and 7 evaluating manual therapy techniques. All studies analyzed identified improvements in pain intensity and meta-analysis confirmed their strong effect.

CONCLUSIONS

Manual therapy and electrotherapy are effective for the treatment of women with primary dysmenorrhea. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage stands out for its effects on the intensity and duration of pain with the application of a few sessions and their long-term effects.

IMPACT

Manual therapy techniques and electrotherapy methods reduce the pain intensity of women with primary dysmenorrhea. Quality of life and degree of anxiety improved significantly with manual therapy interventions. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage are the interventions with which positive effects were achieved with fewer sessions.

Transcutaneous Tibial Nerve Stimulation for Primary Dysmenorrhea: A Protocol for a Randomized Controlled Trial

Primary dysmenorrhea (PD) is a painful menstruation that can persist for the duration of a woman's fertile life. Non-steroidal anti-inflammatory drugs, hormonal therapy, physiotherapy techniques, etc., are the main treatments. The main objective of this study is to evaluate the effectiveness of transcutaneous posterior tibial nerve stimulation (TTNS) in PD patients. The study will consist of a single-blind randomized clinical trial, parallel-assigned with two arms. Women with PD (18-43 years) with regular menstrual cycles and at least 4 points in VAS will be randomly divided into experimental (TTNS) and placebo (simulated stimulation) groups during 12 treatment sessions (1 session/week) and several follow-ups: monthly during treatment and 1, 3 and 6 months after. Maximum and mean pain intensity, pain duration, pain severity, number of anti-inflammatory drugs, quality of life, sleep quality, overall improvement, treatment satisfaction and secondary effects will be measured once a month every 6 months and at 3 and 6 months. The Student's t-test for independent samples or the Mann-Whitney U test will be used. The literature shows effective physiotherapeutic techniques for PD in the short term, which do not act on causes and have limitations. The TTNS technique can be used in transcutaneous and percutaneous modalities, with similar effectiveness, but the transcutaneous causes less discomfort. TTNS modulates pain, and long-term benefits could be achieved at low cost and without patient discomfort.

Exercise Therapy and Electrotherapy as an Intervention for Primary Dysmenorrhea: A Systematic Review and Meta-Analysis

Primary Dysmenorrhea (PD) is characterized by painful cramps before or during menstruation. It is generally treated with nonpharmacological methods. However, with the advancement of research and the passage of time, physiotherapy plays an increasingly important role in treating patients with PD. Electrotherapy and exercise therapy are conservative methods to treat PD. Alternative methods to minimize reliance on medicinal-based treatments are the need of the hour. This review aims to determine the efficacy of exercise-based therapies and electrotherapy modalities in treating PD. Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards have been used in the present systematic review and meta-analysis. Cochrane, PubMed, and Google Scholar were searched to facilitate the same. The articles from 2011 to 2021 were included in this review. The quality of the review was assessed using the Cochrane risk of bias tool. The visual analog scale was taken as a measure of pain intensity in the meta-analysis, and other outcomes have been included in the systematic review discussed. A total of 15 publications have been included, with a meta-analysis of 7. All included studies were of high quality (PEDro ≥ 5), and demonstrated the efficacy of exercise-based therapies and electrotherapy modalities in treating pain in females with PD. This review aims to check the impact of exercise and electrotherapy in females suffering from PD.

Neuromodulation in Chronic Pelvic Pain: A Narrative Review

Chronic primary pelvic pain syndrome (CPPPS) is a heterogeneous disease with unknown pathogenesis and a lack of distinct pathological features, which complicates diagnosis and therapy and has a significant impact on patients' daily life. Because pharmacological management is ineffective and long-term use may result in additional system damage, developing a more effective treatment is critical. Neuromodulation has advanced rapidly over the last few decades, and various types of neuromodulations have demonstrated efficacy in the treatment of CPPPS. In this article we discuss the evolution of neuromodulation technology in the treatment of chronic pelvic pain, its application to various subtypes of chronic pelvic pain, and the comparison of relevant efficacy and parameter differences, as well as assess the relative advantages and disadvantages of sacral neuromodulation, percutaneous tibial nerve stimulation , transcutaneous electrical nerve stimulation, electroacupuncture, and pudendal neuromodulation. Furthermore, it was noted that chronic pelvic pain should be evaluated in terms of pain, associated symptoms, psychological problems, and quality of life. Although neuromodulation approaches have been shown to be effective in treating chronic pelvic pain, more extensive multicenter trials are required to confirm this.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Effectiveness of self-myofascial release combined with biofeedback and electrical stimulation for the management of myofascial pelvic pain: A randomized controlled trial

BACKGROUND

Myofascial pelvic pain (MFPP) caused by myofascial trigger points (MTrPs) is a major contributor to chronic pelvic pain in women. However, the effect of the patient's self-myofascial release (SMFR) is unclear. This study aimed to investigate the effect of SMFR combined with biofeedback and electrical stimulation (BES) therapy in comparison with BES alone in patients with MFPP.

METHODS

A prospective randomized controlled study was conducted. Sixty-eight patients were randomly allocated into BES-SMFR group (n = 34) and BES group (n = 34). Every patient received 4 weeks of treatment, evaluated at baseline (T0), 4 weeks post-intervention (T4) and 12-week follow-up (T12). The primary outcome was pain intensity. The secondary outcomes were degree of activation of MTrPs, surface electromyography (sEMG) levels and Patient Global Impression of Improvement (PGI-I).

RESULTS

Compared with the effect of BES, BES-SMFR treatment significantly decreased pain intensity and the degree of activation of MTrPs in the levator ani (p = 0.02) and obturator internus (p = 0.03), as well as the sEMG levels of the pre-test resting baseline and post-test resting baseline (all p < 0.01). The degree of activation of MTrPs in the piriformis and coccygeus (all p > 0.05) and the sEMG levels of the quick flicks and endurance contraction were not significantly different. The BES-SMFR treatment improved the PGI-I scale at T4 (p = 0.02) but not at T12 (p = 0.40).

CONCLUSIONS

This study confirmed that the addition of SMFR to BES treatment resulted in superior outcomes compared with those with BES alone in patients with MFPP.

SIGNIFICANCE STATEMENT

Myofascial pelvic pain (MFPP) is a major contributor of female chronic pelvic pain. Myofascial release has been used commonly for better pain release; however, poor therapeutic effect due to poor patient compliance is common in clinical practice. Therefore, in future research, there is a need to investigate the effect of patient's self-myofascial release (SMFR) technique, which can eliminate the need for frequent office visits and improve patient compliance to some extent, in patients with MFPP.

Transcutaneous electrical nerve stimulation for women with primary dysmenorrhea: Study protocol for a randomized controlled clinical trial with economic evaluation

Primary dysmenorrhea (PD) is a common gynecological disorder characterized by cramping pain in the lower abdomen during menstruation, in the absence of identifiable pathology. While Transcutaneous Electrical Nerve Stimulation (TENS) is used to promote PD pain relief, there is still a need to understand the parameters and cost-effectiveness of this intervention. As such, this study aims to disclose a study that will evaluate the effectiveness and cost-effectiveness of TENS on pain intensity in women with PD. This is a protocol for an assessor-blinded randomized controlled trial that includes 174 women with PD, >18 years old, with menstrual pain greater than or equal to four points in the Numerical Rating Scale. Participants will be randomized into three groups (active TENS, placebo TENS, and educational booklet). Participants allocated to the active TENS group will receive electrical stimulation (F = 100 Hz, pulse duration = 200 μs, for 30 min). In contrast, the placebo TENS group will receive placebo stimulation (same parameters, but for only 30 s, and then the current will be ramped off over a 15-s time frame) for three consecutive months during menstruation. Participants allocated to the educational booklet group will receive instructions about health promotion and education actions related to PD. A blinded assessor will evaluate the pain intensity (Numerical Rating Scale), presenteeism (Stanford Presenteeism Scale), Health-Related Quality of Life (Short-Form 6 dimensions and SF-36), and health costs of menstrual pain. This is the first study to propose a health economic evaluation while assessing the benefits of using TENS to treat PD symptoms. It is hypothesized that active TENS will be more effective than placebo TENS or the educational booklet in improving clinical outcomes in the short-, medium- and long-term. The study will also provide information about the cost-effectiveness of TENS, which can be used by policy makers to improve PD care in public and private health systems.

Benefits and Harms of Electrical Neuromodulation for Chronic Pelvic Pain: A Systematic Review

CONTEXT

Patients with chronic pelvic pain (CPP) may have pain refractory to conventional pain management strategies. Neuromodulation could provide relief of pain.

OBJECTIVE

To evaluate the benefits and harms of neuromodulation for CPP.

EVIDENCE ACQUISITION

A comprehensive search of EMBASE, PUBMED, and SCOPUS was performed for the entire database to January 2018. Studies were selected, data were extracted, and quality was assessed by two independent reviewers. A meta-analysis was used to combine randomized controlled trials (RCTs); otherwise, a narrative analysis was used.

EVIDENCE SYNTHESIS

After screening 1311 abstracts, 36 studies including eight RCTs were identified, enrolling 1099 patients. Studies covered a broad range in terms of phenotypes of CPP and methods of neuromodulation. A meta-analysis was possible for percutaneous tibial nerve stimulation and transcutaneous electrical nerve stimulation, which showed improvement in pain. Only narrative synthesis was possible for other modalities (sacral nerve stimulation, spinal cord stimulation, intravaginal electrical stimulation, and pudendal nerve stimulation) which appeared to reduce pain in patients with CPP. Treatments generally improved quality of life but with variable reporting of adverse events. Many studies showed high risks of bias and confounding.

CONCLUSIONS

While electrical neuromodulation may improve symptoms in CPP, further work is needed with high-quality studies to confirm it.

PATIENT SUMMARY

Neuromodulation may be useful in reducing pain and improving quality of life in patients with chronic pelvic pain, but more research is needed.

Analgesia by Sacral Surface Electrical Stimulation for Primary Dysmenorrhoea

Objective

To evaluate the effects of analgesia by sacral surface electrical stimulation on lower abdominal pain in women with primary dysmenorrhoea.

Design

Explorative study.

Participants

Eleven female university students, who regularly experience difficulty in their university work due to menstrual pain, or who use analgesics for more than one day each month, were recruited.

Methods

Sacral surface electrical stimulation, 5 Hz for 15 min, was performed after the onset of menstruation. Electrodes were placed on the skin, directly above the second and fourth sacral foramina. Visual analogue scale and degree of pain (calculated by using a low current to assess pain) were determined before and after electrical stimulation.

Results

Visual analogue scale score and degree of pain decreased significantly immediately after electrical stimulation (p < 0.001). A correlation was observed between visual analogue scale score and degree of pain before and after electrical stimulation (r=0.516, p <0.001). No side-effects were observed in any participant.

Conclusion

Sacral surface electrical stimulation may provide immediate pain relief in women with dysmenorrhoea and lower abdominal pain.

Effects of thermotherapy and transcutaneous electrical nerve stimulation on patients with primary dysmenorrhea: A randomized, placebo-controlled, double-blind clinical trial

OBJECTIVES

To evaluate the effects of thermotherapy and transcutaneous electrical nerve stimulation (TENS) on pain intensity, pressure pain threshold (PPT) and conditioned pain modulation (CPM) in patients with primary dysmenorrhea (PD).

DESIGN

A randomized, placebo-controlled, double-blind clinical trial.

SETTING

Physiotherapy Department of the Universidade Cidade de São Paulo, São Paulo (Brazil).

INTERVENTIONS

Eighty-eight dysmenorrheic women were randomly allocated into four groups: Thermotherapy + TENS(n = 22), Thermotherapy(n = 22), TENS(n = 22) and Placebo(n = 22). Thermotherapy was applied by microwave diathermy (20 min), and TENS (200 μs, 100 Hz, 30 min), into the lower abdomen both.

MAIN OUTCOME MEASURES

Pain intensity was measured using the numeric rating scale (NRS) and the McGill Pain Questionnaire (Br-MPQ). PPT and CPM were recorded from women's abdominal and lumbar. The evaluation was done in 5 times: baseline, after 20, 50, 110 min and 24 h from intervention.

RESULTS

There was a significant decrease in the NRS for Thermotherapy + TENS vs. TENS, for Thermotherapy vs. TENS and for Placebo, after 20 min; for Thermotherapy vs. TENS and for Placebo, after 110 min and 24 h. Abdome PPT increased in the Thermotherapy + TENS vs. TENS and Placebo, after 50 min; for Thermotherapy + TENS vs. Placebo and for Thermotherapy vs. Placebo, after 110 min. No changes in lumbar PPT and CPM were observed.

CONCLUSIONS

The use of thermotherapy reduced NRS compared to the TENS and Placebo after 20, 110 min and 24 h. Thermotherapy demonstrated an increase in the PPT in the abdomen after 50 and 110 min and decreased the Br-MPQ scores after 110 min in patients with PD.

No. 345-Primary Dysmenorrhea Consensus Guideline

OBJECTIVE

This guideline reviews the investigation and treatment of primary dysmenorrhea.

INTENDED USERS

Health care providers.

TARGET POPULATION

Women and adolescents experiencing menstrual pain for which no underlying cause has been identified.

EVIDENCE

Published clinical trials, population studies, and review articles cited in PubMed or the Cochrane database from January 2005 to March 2016.

VALIDATION METHODS

Seven clinical questions were generated by the authors and reviewed by the SOGC Clinical Practice-Gynaecology Committee. The available literature was searched. Guideline No. 169 was reviewed and rewritten in order to incorporate current evidence. Recommendations addressing the identified clinical questions were formulated and evaluated using the ranking of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Primary dysmenorrhea is common and frequently undertreated. Effective therapy is widely available at minimal cost. Treatment has the potential to improve quality of life and to decrease time lost from school or work.

GUIDELINE UPDATE

This guideline is a revision and update of No. 169, December 2005.

SPONSORS

SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Microwave diathermy and transcutaneous electrical nerve stimulation effects in primary dysmenorrhea: clinical trial protocol

The aim of this study will be to analyze the effects of microwave diathermy (MWD) and transcutaneous electrical nerve stimulation (TENS) on primary dysmenorrhea. Eighty eight women, age range 18-44 years, with no previous pregnancy, no practice physical activities, a BMI of ≤29.9 kg/m², a regular menstrual cycle and a diagnosis of primary dysmenorrhea, with menstrual pain ranging from mild to severe, will be selected. The participants will be randomized into four groups: MWD and TENS, MWD and placebo TENS, placebo MWD and TENS, and placebo MWD and placebo TENS. Pain will be measured using the visual numeric scale and the McGill Pain Questionnaire; the pressure pain threshold using a digital algometer and conditioned pain modulation using the cold pressor test. Brazilian Clinical Trials Registry (RBR-5QKCK4. Registered on 16 March 2016).

Effect of transcutaneous electrical nerve stimulation therapy for the treatment of primary dysmenorrheal

BACKGROUND

This study aimed to investigate the effect and safety of transcutaneous electrical nerve stimulation (TENS) therapy for relieving pain in women with primary dysmenorrhea (PD).

METHODS

In this study, 134 participants with PD were randomly divided into the intervention group and the sham group, with 67 participants in each group. Participants in the intervention group received TENS, whereas those in the sham group received sham TENS. The primary outcome was measured by the Numeric Rating Scale (NRS). The secondary outcomes were measured by the duration of relief from dysmenorrheal pain, number of ibuprofen tablets taken, and the World Health Organization quality of life (WHOQOL)-BREF score, as well as the adverse events.

RESULTS

A total of 122 participants completed the study. Compared to sham TENS, TENS showed a greater effect in pain relief with regard to the NRS (P < .01), duration of relief from dysmenorrheal pain (P < .01), and number of ibuprofen tablets taken (P < .01). However, no significant differences in the quality of life, measured by the WHOQOL-BREF score, were found between 2 groups. The adverse event profiles were also similar between 2 groups.

CONCLUSION

TENS was efficacious and safe in relieving pain in participants with PD.