title: Spinal manipulation for primary and secondary dysmenorrhoea.
abstract: BACKGROUND
  Dysmenorrhoea refers to the occurrence of painful menstrual cramps of uterine origin and is a common gynaecological condition. The efficacy of medical treatments such as nonsteroidal anti-inflammatories (NSAIDs) or oral contraceptive pills (OCPs) is considerable, however the failure rate can still be as high as 20-25% and there are also a number of associated adverse effects. Many women are thus seeking alternatives to conventional medicine. One popular treatment modality is spinal manipulation therapy. There are several rationales for the use of musculoskeletal manipulation to treat dysmenorrhoea. The parasympathetic and sympathetic pelvic nerve pathways are closely associated with the spinal vertebrae, in particular the 2nd-4th sacral segments and the 10th thoracic to the 2nd lumbar segments. One hypothesis is that mechanical dysfunction in these vertebrae causes decreased spinal mobility. This could affect the sympathetic nerve supply to the blood vessels supplying the pelvic viscera, leading to dysmenorrhoea as a result of vasoconstriction. Manipulation of these vertebrae increases spinal mobility and may improve pelvic blood supply through an influence on the autonomic nerve supply to the blood vessels. Another hypothesis is that dysmenorrhoea is referred pain arising from musculoskeletal structures that share the same pelvic nerve pathways. The character of pain from musculoskeletal dysfunction can be very similar to gynecological pain and can present as cyclic pain as it can also be altered by hormonal influences associated with menstruation.
  
  
  OBJECTIVE
  To determine the safety and efficacy of spinal manipulative interventions for the treatment of primary or secondary dysmenorrhoea when compared to each other, placebo, no treatment, or other medical treatment.
  
  
  METHODS
  Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, CCTR, MEDLINE, EMBASE, CINAHL, Bio extracts, Psyclit and SPORTDiscus were performed to identify relevant randomised controlled trials (RCTs). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the National Research Register, the Clinical Trial Register and the citation lists of review articles and included trials. In most cases, the first or corresponding author of each included trial was contacted for additional information.
  
  
  METHODS
  Any RCTs including spinal manipulative interventions (e.g. chiropractic, osteopathy or manipulative physiotherapy) vs each other, placebo, no treatment, or other medical treatment were considered. Exclusion criteria were: mild or infrequent dysmenorrhoea or dysmenorrhoea from an IUD.
  
  
  METHODS
  Five RCTs were identified that fulfilled the inclusion criteria for this review. Four trials involving high velocity, low amplitude manipulation (HVLA), and one involving the Toftness manipulation technique were included. Quality assessment and data extraction were performed independently by two reviewers. Meta analysis was performed using odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes. Data unsuitable for meta-analysis were reported as descriptive data and were also included for discussion. The outcome measures were pain relief or pain intensity (dichotomous, visual analogue scales, descriptive) and adverse effects.
  
  
  RESULTS
  Results from the four trials of high velocity, low amplitude manipulation suggest that the technique was no more effective than sham manipulation for the treatment of dysmenorrhoea, although it was possibly more effective than no treatment. Three of the smaller trials indicated a difference in favour of HVLA, however the one trial with an adequate sample size found no difference between HVLA and sham treatment. There was no difference in adverse effects experienced by participants in the HVLA or sham treatment. The Toftness technique was shown to be more effective than sham treatment by one small trial, but no strong conclusions could be made due to the small size of the trial and other methodological considerations.
  
  
  CONCLUSIONS
  Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.
authors.affiliation: Department of Obstetrics and Gynaecology, National Women's Hospital, Claude Road, Epsom, Auckland, New Zealand, 1003. m.proctor@auckland.ac.nz
authors.forename: M L
authors.initials: ML
authors.lastname: Proctor
authors.forename: W
authors.initials: W
authors.lastname: Hing
authors.forename: T C
authors.initials: TC
authors.lastname: Johnson
authors.forename: P A
authors.initials: PA
authors.lastname: Murphy
mesh_terms: D004412:Dysmenorrhea / Q000628:therapy*; D005260:Female; D006801:Humans; D020393:Manipulation, Spinal; D016032:Randomized Controlled Trials as Topic