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. One possible treatment is spinal manipulation therapy. One hypothesis is that mechanical dysfunction in certain 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. 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 gynaecological 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
  We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 18 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1980 to March 2004), CINAHL (1982 to March 2004), AMED (1985 to March 2004), Biological Abstracts (1969 to Dec 2003), PsycINFO (1872 to March 2004) and SPORTDiscus (1830 to March 2004). The Cochrane Complementary Medicine Field's Register of controlled trials (CISCOM) was also searched. Attempts were also made to identify trials from the metaRegister of Controlled Trials 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 randomised controlled trials (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
  Four trials of high velocity, low amplitude manipulation (HVLA), and one of 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.
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; D010388:Pelvis / Q000098:blood supply; D016032:Randomized Controlled Trials as Topic