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Tsai IC, Hsu CW, Chang CH, Lei WT, Tseng PT, Chang KV. Comparative Effectiveness of Different Exercises for Reducing Pain Intensity in Primary Dysmenorrhea: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. SPORTS MEDICINE - OPEN 2024; 10:63. [PMID: 38816591 PMCID: PMC11139836 DOI: 10.1186/s40798-024-00718-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 04/20/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Studies have demonstrated that exercise can mitigate the intensity of menstrual pain in primary dysmenorrhea, but the most effective type of exercise remains unclear. The objective of this systematic review and network meta-analysis was to evaluate the effectiveness of different exercise regimens in reducing pain associated with primary dysmenorrhoea. METHODS Randomized controlled trials investigating the relationship between menstrual pain and exercise were selected from major electronic databases until February 2, 2024. The primary outcome was the effect of exercise on pain intensity measured by the mean difference on a 10-cm visual analogue scale at 4 and 8 weeks after intervention. The secondary outcome was the difference in risk of dropout at 8 weeks. The study protocol was registered as INPLASY202330050. RESULTS This systematic review and network meta-analysis included 29 randomized controlled trials, which involved 1808 participants with primary dysmenorrhea. Exercise interventions included relaxation exercise, strength training, aerobic activity, yoga, mixed exercise, and the Kegel maneuver. Relaxation exercise was the most effective in reducing menstrual pain in 4 weeks (- 3.56; 95% confidence interval: - 5.03 to - 2.08). All exercise interventions were effective in reducing menstrual pain at 8 weeks, with reductions ranging from - 3.87 (95% CI - 5.51 to - 2.22) for relaxation exercise to - 2.75 (95% CI - 4.00 to - 1.51) for yoga, compared to the control group. Relaxation exercises were found to have a significantly lower dropout risk (- 0.11; 95% CI - 0.20 to 0.02), while none of the exercise types was associated with a higher dropout risk than the control group. CONCLUSION All exercise interventions were effective in reducing menstrual pain in primary dysmenorrhea after 8 weeks of intervention. However, relaxation exercise was found to be the most effective intervention at 4 and 8 weeks and had the lowest risk of dropout.
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Affiliation(s)
- I-Chen Tsai
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Congenital Heart Disease Study Group, Asian Society of Cardiovascular Imaging, Seoul, Korea
- InnovaRad Inc., Taichung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hung Chang
- Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan
- An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Wei-Te Lei
- Section of Immunology, Rheumatology, and Allergy Department of Pediatrics, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Institute of Precision Medicine, National Sun Yat-Sen University, Kaohsiung City, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 1, Changde St., Zhongzheng Dist., Taipei City, 100229, Taiwan.
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan.
- Center for Regional Anesthesia and Pain Medicine, Taipei Medical University, Wang-Fang Hospital, Taipei, Taiwan.
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Kannan P, Cheung KK, Lau BWM, Li L, Chen H, Sun F. A mixed-methods study to evaluate the effectiveness and cost-effectiveness of aerobic exercise for primary dysmenorrhea: A study protocol. PLoS One 2021; 16:e0256263. [PMID: 34398930 PMCID: PMC8366973 DOI: 10.1371/journal.pone.0256263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/23/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Several studies have evaluated the effects of high-intensity aerobic training (HIAT) on pain severity and quality of life (QoL) among women with primary dysmenorrhea. However, to date, no studies have evaluated the effectiveness of HIAT on academic performance or absenteeism or examined the cost-effectiveness of HIAT relative to other treatments in women with primary dysmenorrhea. Furthermore, the mechanisms underlying aerobic exercise-induced analgesia in primary dysmenorrhea remain unclear. The objectives of this study are to: (1) evaluate the effects of HIAT on absenteeism and academic performance among university students, (2) identify the underlying mechanisms associated with aerobic exercise-induced analgesia in primary dysmenorrhea, and (3) determine the cost-effectiveness of HIAT compared with a wait-list control (WLC) group receiving usual care. METHODS A sequential, embedded, mixed-methods study design, including a crossover, randomised controlled trial (RCT) and semi-structured focus groups, will be conducted alongside an economic evaluation. A total of 130 women aged 18-24 years will be randomised into either HIAT (n = 65) or wait-list control (n = 65) groups. Primary outcomes will include average pain intensity, absenteeism from university, and academic performance. Primary mediators will include salivary progesterone and prostaglandin F2α levels. Outcome and meditator variables will be assessed at baseline and post-treatment, at 12 and 28 weeks. An economic analysis will be conducted from the societal and healthcare perspective of Hong Kong. Semi-structured focus groups will be conducted at 32 weeks. Of the 130 participants included in the RCT, 70 will be included in the focus groups. STATISTICAL ANALYSIS All statistical analyses will be performed on an intention-to-treat basis, using SPSS (version 24). Preliminary analysis using an independent samples t-test and a two-sided, unpaired Student's t-test will be performed to exclude carryover effects and identify within-participant differences in outcome variables between the study periods, respectively. Treatment effects will be evaluated using analysis of variance via a mixed-effects model with fixed effects for intervention, period, and sequence. In all models, random effects will include the participants nested within the sequence as a sampling cluster. The mediation effects will be assessed using the Sobel test. The EQ-5D responses will be converted into utility scores to estimate the gain or loss of quality-adjusted life-years. Seemingly unrelated regression analyses will be used to estimate the total cost differences and effect differences. Qualitative data will be analysed using the process of thematic analysis.
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Affiliation(s)
- Priya Kannan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Kwok-Kuen Cheung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Benson Wui-Man Lau
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Lin Li
- Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Huijun Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Fenghua Sun
- Department of Health and Physical Education, Education University of Hong Kong, Hung Hom, Hong Kong
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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. [PMID: 32415471 DOI: 10.1007/s00404-020-05579-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/30/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Primary dysmenorrhea is the most common gynecological problem in young women and adolescents. Exercise therapy provides positive effects on women with primary dysmenorrhea. The aim of the study was to investigate the effects of a combined exercise program on pain, sleep and menstrual symptoms in patients with primary dysmenorrhea. METHODS The study is a randomized controlled study. The study included 28 sedentary individuals. The participants were assigned to two groups as the exercise (mean age 22.9 ± 2.0 years) and the control (mean age 23.1 ± 1.8 years) groups. The exercise protocol was carried out with the exercise group three times a week for eight weeks. The Visual Analog Scale (VAS) was used for assessing the intensity of pain. The Menstrual Symptom Questionnaire (MSQ) and Pittsburgh Sleep Quality Index (PSQI) were used for evaluating menstrual symptoms and sleep quality, respectively. The study was registered on the Clinical Trials website by the number NCT03625375. RESULTS The comparisons between the groups revealed statistically significant differences in abdominal pain severity, MSQ total score and the subscale scores of negative outcomes and management methods (p < 0.05). The intragroup comparisons of the exercise group demonstrated that the scores of the low back pain and abdominal pain and the MSQ and PSQI scores were found to be significantly different after the 8-week program (p < 0.05). CONCLUSION The combined exercise therapy is an effective way to manage symptoms associated with primary dysmenorrhea.
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Affiliation(s)
- Berkiye Kirmizigil
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Eastern Mediterranean University, Famagusta, North Cyprus, via Mersin-10, Turkey.
| | - Cisel Demiralp
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Eastern Mediterranean University, Famagusta, North Cyprus, via Mersin-10, Turkey
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Carroquino-Garcia P, Jiménez-Rejano JJ, 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. [PMID: 31665789 DOI: 10.1093/ptj/pzz101] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 02/08/2019] [Accepted: 02/25/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dysmenorrhea is a health problem with a high impact on health and society. Some drugs have been shown to be effective at treating dysmenorrhea. Therapeutic exercise is another option for reducing the symptomatology of this health problem, with a low cost and the absence of side effects. PURPOSE The purposes of this review were to study the efficacy of physical exercise for pain intensity in primary dysmenorrhea and to assess its effectiveness in decreasing the duration of pain and improving quality of life. DATA SOURCES Searches were conducted between February 2017 and May 2017 in the databases Web of Science, Physiotherapy Evidence Database (PEDro), PubMed, Scopus, CINAHL, and Dialnet, using the terms dysmenorrhea, exercise therapy, exercise movement technique, exercise, physical therapy, physical therapy speciality, treatment, primary dysmenorrhea, prevention, etiology, epidemiology, and pain. STUDY SELECTION We included randomized controlled trial studies conducted on women who were 16 to 25 years old and had primary dysmenorrhea, studies that included exercise as a type of therapy, studies that assessed the intensity and duration of pain and quality of life, and studies published in English or Spanish. Studies that included women with irregular cycles, women diagnosed with a gynecological disease, women who had had surgery, women with serious diseases, or women who used intracavitary or oral contraceptives were excluded. We started with 455 studies; 16 were included in the systematic review, and 11 were included in the 3 meta-analyses that were carried out. DATA EXTRACTION Two authors selected the studies and extracted their characteristics (participants, intervention, comparators, and outcomes) and results. The evaluation of the methodological quality of the studies was carried out by PEDro scale. DATA SYNTHESIS There was moderate evidence that therapeutic exercise can be considered a useful tool in the treatment of primary dysmenorrhea in terms of a reduction in pain intensity. Regarding the duration of pain and quality of life, there was low evidence and very low evidence, respectively. In the 3 meta-analyses, the results were significantly positive in favor of exercise for decreases in both the intensity and the duration of pain. LIMITATIONS Limitations of this study include the great heterogeneity of the interventions applied in the studies in terms of type of exercise, in combination or alone, and dosage. This review includes a small number of studies with risk of bias, so the present findings must be interpreted with caution. CONCLUSIONS Therapeutic exercise reduces pain intensity in patients with primary dysmenorrhea.
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Affiliation(s)
| | | | | | | | - Esther Diaz-Mohedo
- Department of Psychiatrics and Physiotherapy, University of Malaga, Malaga, Spain
| | - Carmen Suarez-Serrano
- Department of Physiotherapy, University of Seville, c/Avicena s/n. 41009, Seville, Spain
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Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad E. Exercise for dysmenorrhoea. Cochrane Database Syst Rev 2019; 9:CD004142. [PMID: 31538328 PMCID: PMC6753056 DOI: 10.1002/14651858.cd004142.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Exercise has a number of health benefits and has been recommended as a treatment for primary dysmenorrhoea (period pain), but the evidence for its effectiveness on primary dysmenorrhoea is unclear. This review examined the available evidence supporting the use of exercise to treat primary dysmenorrhoea. OBJECTIVES To evaluate the effectiveness and safety of exercise for women with primary dysmenorrhoea. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED and CINAHL (from inception to July 2019). We searched two clinical trial databases (inception to March 2019) and handsearched reference lists and previous systematic reviews. SELECTION CRITERIA We included studies if they randomised women with moderate-to-severe primary dysmenorrhoea to receive exercise versus no treatment, attention control, non-steroidal anti-inflammatory drugs (NSAIDs) or the oral contraceptive pill. Cross-over studies and cluster-randomised trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies, assessed eligible studies for risk of bias, and extracted data from each study. We contacted study authors for missing information. We assessed the quality of the evidence using GRADE. Our primary outcomes were menstrual pain intensity and adverse events. Secondary outcomes included overall menstrual symptoms, usage of rescue analgesic medication, restriction of daily life activities, absence from work or school and quality of life. MAIN RESULTS We included a total of 12 trials with 854 women in the review, with 10 trials and 754 women in the meta-analysis. Nine of the 10 studies compared exercise with no treatment, and one study compared exercise with NSAIDs. No studies compared exercise with attention control or with the oral contraceptive pill. Studies used low-intensity exercise (stretching, core strengthening or yoga) or high-intensity exercise (Zumba or aerobic training); none of the included studies used resistance training.Exercise versus no treatmentExercise may have a large effect on reducing menstrual pain intensity compared to no exercise (standard mean difference (SMD) -1.86, 95% confidence interval (CI) -2.06 to -1.66; 9 randomised controlled trials (RCTs), n = 632; I2= 91%; low-quality evidence). This SMD corresponds to a 25 mm reduction on a 100 mm visual analogue scale (VAS) and is likely to be clinically significant. We are uncertain if there is any difference in adverse event rates between exercise and no treatment.We are uncertain if exercise reduces overall menstrual symptoms (as measured by the Moos Menstrual Distress Questionnaire (MMDQ)), such as back pain or fatigue compared to no treatment (mean difference (MD) -33.16, 95% CI -40.45 to -25.87; 1 RCT, n = 120; very low-quality evidence), or improves mental quality of life (MD 4.40, 95% CI 1.59 to 7.21; 1 RCT, n = 55; very low-quality evidence) or physical quality of life (as measured by the 12-Item Short Form Health Survey (SF-12)) compared to no exercise (MD 3.40, 95% CI -1.68 to 8.48; 1 RCT, n = 55; very low-quality evidence) when compared to no treatment. No studies reported on any changes in restriction of daily life activities or on absence from work or school.Exercise versus NSAIDsWe are uncertain if exercise, when compared with mefenamic acid, reduced menstrual pain intensity (MD -7.40, 95% CI -8.36 to -6.44; 1 RCT, n = 122; very low-quality evidence), use of rescue analgesic medication (risk ratio (RR) 1.77, 95% CI 1.21 to 2.60; 1 RCT, n = 122; very low-quality evidence) or absence from work or school (RR 1.00, 95% CI 0.49 to 2.03; 1 RCT, n = 122; very low-quality evidence). None of the included studies reported on adverse events, overall menstrual symptoms, restriction of daily life activities or quality of life. AUTHORS' CONCLUSIONS The current low-quality evidence suggests that exercise, performed for about 45 to 60 minutes each time, three times per week or more, regardless of intensity, may provide a clinically significant reduction in menstrual pain intensity of around 25 mm on a 100 mm VAS. All studies used exercise regularly throughout the month, with some studies asking women not to exercise during menstruation. Given the overall health benefits of exercise, and the relatively low risk of side effects reported in the general population, women may consider using exercise, either alone or in conjunction with other modalities, such as NSAIDs, to manage menstrual pain. It is unclear if the benefits of exercise persist after regular exercise has stopped or if they are similar in women over the age of 25. Further research is required, using validated outcome measures, adequate blinding and suitable comparator groups reflecting current best practice or accounting for the extra attention given during exercise.
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Affiliation(s)
- Mike Armour
- Western Sydney UniversityNICM Health Research InstituteBuilding J, Westmead CampusPenrithNSWAustralia2751
| | - Carolyn C Ee
- Western Sydney UniversityNICM Health Research InstituteBuilding J, Westmead CampusPenrithNSWAustralia2751
| | - Dhevaksha Naidoo
- Western Sydney UniversityNICM Health Research InstituteBuilding J, Westmead CampusPenrithNSWAustralia2751
| | - Zahra Ayati
- Mashhad University of Medical SciencesSchool of PharmacyVakil Abad Blv, Ferdowsi UniversityMashhadIran
| | - K Jane Chalmers
- Western Sydney UniversitySchool of Science and HealthBuilding 24, Campbelltown CampusPenrithNSWAustralia2751
| | - Kylie A Steel
- Western Sydney UniversitySchool of Science and HealthBuilding 24, Campbelltown CampusPenrithNSWAustralia2751
| | - Michael J de Manincor
- Western Sydney UniversityNICM Health Research InstituteBuilding J, Westmead CampusPenrithNSWAustralia2751
| | - Elahe Delshad
- Mashhad University of Medical SciencesSchool of Persian and Complementary MedicineVakil Abad Blv, Ferdowsi University, Medial SchoolMashhadIran
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Kannan P, Chapple CM, Miller D, Claydon-Mueller L, Baxter GD. Effectiveness of a treadmill-based aerobic exercise intervention on pain, daily functioning, and quality of life in women with primary dysmenorrhea: A randomized controlled trial. Contemp Clin Trials 2019; 81:80-86. [PMID: 31071464 DOI: 10.1016/j.cct.2019.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a treadmill-based aerobic exercise intervention on pain and associated symptoms of primary dysmenorrhea. METHODS Seventy women with primary dysmenorrhea were included in the study. The experimental group underwent supervised aerobic training for 4 weeks followed by unsupervised home exercise for the next 6 months. The control group continued usual care. The primary outcome was pain. Secondary outcomes included quality of life (QoL), daily functioning, and sleep. RESULTS After the 4-week training, compared to the control group exercise significantly improved primary outcomes pain quality (mean difference (MD) -1.9, 95% CI 3.8 to -0.04, p < .05), and intensity (MD -4.7, 95% CI -9.3 to -0.09, p < .05), but not present pain. Significant effects were also reported for pain interference (MD -1.7, 95% CI -3.4 to -0.02, p < .05) at 4 weeks; the other outcomes did not significantly differ between groups at this time. During the follow-up period of 7-months, the effect on pain improved to 22 mm (95% CI 18 to 25). Significant benefits of exercise were maintained up to 7-months for present pain, QoL and daily functioning. CONCLUSION Exercise has significant effects on primary dysmenorrhea-related pain, QoL and function. TRIAL REGISTRATION ACTRN12613001195741.
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Affiliation(s)
- Priya Kannan
- School of Physiotherapy, University of Otago, Dunedin, New Zealand.
| | - Cathy M Chapple
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Dawn Miller
- Department of Women's and Children's Health, Dunedin School of Medicine, Dunedin, New Zealand
| | | | - G David Baxter
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Behbahani BM, Ansaripour L, Akbarzadeh M, Zare N, Hadianfard MJ. Comparison of the effects of acupressure and self-care behaviors training on the intensity of primary dysmenorrhea based on McGill pain questionnaire among Shiraz University students. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:104. [PMID: 28250781 PMCID: PMC5322691 DOI: 10.4103/1735-1995.193176] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/13/2016] [Accepted: 07/27/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dysmenorrhea is one of the common problems during reproductive ages, with prevalence rate of 60-90%. This study aimed to compare the effects of acupressure at Guan yuan (RN-4) and Qu gu (RN-2) acupoints, self-care behaviors training, and ibuprofen on the intensity of primary dysmenorrhea based on McGill pain questionnaire. MATERIALS AND METHODS In the randomized clinical trial, 120 females, aged between 18 and 25 years, with primary dysmenorrhea, randomly selected from five dormitories of Shiraz University, Shiraz, Iran were screened and randomized into acupressure group, in that pressure was applied for 20 min over the 1st 2 days of menstruation for two cycles. In the second group, the training group took part in four educational sessions each lasting for 60-90 min and control group received ibuprofen 400 mg. The intensity of pain before and after the intervention was measured using short-form McGill pain questionnaire. The data were entered into the SPSS statistical software (version 16) and analyzed using Kruskal-Wallis test, paired t-test, and Chi-square test. RESULTS A significant difference was found in the mean intensity of pain before and after the intervention in all the three study groups. The mean score of pain intensity was 10.65 ± 5.71 in the training group, 19 ± 5.41 in the control group, and 14.40 ± 6.87 in the acupressure group after the intervention. The results of Kruskal-Wallis test revealed that both interventions were more effective compared to consumption of ibuprofen. CONCLUSION Training and acupressure were more effective than ibuprofen in the reduction of dysmenorrhea. Thus, they can be considered as trainable methods without side effects in adolescent girls.
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Affiliation(s)
- Bahar Morshed Behbahani
- Department of Midwifery, Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Lala Ansaripour
- Department of Midwifery, Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marzieh Akbarzadeh
- Department of Midwifery, Maternal-Fetal Medicine Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Najaf Zare
- Department of Biostatistics, Infertility Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Javad Hadianfard
- Department of Physical Medicine and Rehabilitation, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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