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Disabil Rehabil, Early Online: 1–6

! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.962108

RESEARCH PAPER

Vigorous exercises in the management of primary dysmenorrhea:

a feasibility study
Priya Kannan1, Leica S. Claydon2, Dawn Miller3, and Cathy M. Chapple1
1
Centre for Health, Activity and Rehabilitation Research, University of Otago, Dunedin, New Zealand, 2Faculty of Health, Social Care and Education,
Department of Allied Health and Medicine, Anglia Ruskin University, Chelmsford, UK, and 3Department of Women and Children’s Health, Dunedin
Disabil Rehabil Downloaded from informahealthcare.com by University of Otago on 09/22/14

School of Medicine, Dunedin, New Zealand

Abstract Keywords
Purpose: To examine the feasibility of using an exercise intervention for reducing menstrual Aerobic training, exercise, menstrual pain,
pain associated with primary dysmenorrhea (PD) and to obtain preliminary results to estimate physical activity, physiotherapy, primary
the sample size for a future randomized controlled trial (RCT). Methods: A quasi-experimental dysmenorrhea
design was applied. Ten women 18–45 years with PD were included. The participants
underwent vigorous aerobic training at the School of Physiotherapy on a treadmill three times History
a week for up to 4 weeks followed by aerobic training at home for up to 4 weeks. The feasibility
measures were adherence to the intervention programme and intervention prescription, Received 12 December 2013
retention and safety. The short form McGill pain questionnaire was used to measure pain at first Revised 31 August 2014
For personal use only.

(T1), second (T2) and third (T3) menstrual cycles following trial entry. Results: Overall adherence Accepted 2 September 2014
was 98%, with 100% adherence to clinic-based intervention and intervention prescription and Published online 22 September 2014
96% for home exercise programme. Retention rate was 100%. With respect to pain a large
effect size was identified at T2 and T3. No adverse events reported. Conclusions: Results
demonstrated that the intervention is applicable and feasible. In addition, the preliminary
results show evidence of positive changes after the intervention. The intervention programme’s
effectiveness will be studied further, in a future RCT.

ä Implications for Rehabilitation

 There is a lack of available evidence from randomized controlled trials regarding the use of
exercise in alleviating the symptoms associated with primary dysmenorrhea (PD).
 The preliminary results of this study shows that exercises may be effective in reducing the
pain associated with PD indicated by a large effect size.
 The preliminary findings from this study could also contribute significantly to PD
management and introduce new practice opportunities for physiotherapists working in
women’s health.

Introduction
Dysmenorrhea associated with a normal ovulatory cycle and
no identifiable pelvic disease, is termed primary dysmenorrhea
(PD) [1]. The prevalence of PD is shown to be up to 90% in
women aged 18–45 years [2]. About 90% of adolescent girls and
more than 50% of adult women worldwide report suffering from
PD, with 10–20% of them describing their suffering as severe and
distressing [3]. Significant disability such as inability to sleep,
limitations in activities, and a resulting decrease of quality of life
(QoL) have been reported in women with PD [3,4]. PD leaves
women incapacitated for 1–3 d each month and is reported to be
the primary reason for recurrent absenteeism from school or work
Address for correspondence: Priya Kannan, PhD candidate, Centre for
Health, Activity and Rehabilitation Research, School of Physiotherapy,
University of Otago, Dunedin 9054, New Zealand. Tel: (+64)
0211550880. E-mail: kanpr735@student.otago.ac.nz; website: http://
physio.otago.ac.nz/University of Otago
[5–7]. One study found that 51% of women had been absent from
school or work at least once and 8% had been absent with every
menstrual period [8].
PD usually begins 6–12 months after menarche and is
characterized by spasmodic cramping pain in the lower abdomen
which can radiate to the lower back and anterior or medial thighs.
The pain is attributed to excessive production of prostaglandins
(PGs) during menstruation which is hypothesized to cause
hyper contractility of the uterus, leading to uterine hypoxia and
ischemia resulting in the pain and cramps of PD [9–11]. Non-
steroidal anti-inflammatory drugs (NSAIDs) are thought to
influence these mechanisms and are therefore frequently used to
manage PD [3,12]. However, conventional NSAIDs are associated
with the risk of significant clinical adverse effects, especially low
gastrointestinal tolerability and disruption of platelet function,
even with short-term use [13]. A systematic review currently
confirms that non-pharmacological interventions such as heat,
TENS and yoga can significantly reduce the pain associated with
 2 P. Kannan et al.
PD, but that acupuncture and acupressure and spinal manipulation
are no better than placebo [14].
Mosler in 1914 was the first to speculate that exercise relieves
pelvic congestion by shunting uterine blood flow [15]. Other
proposed mechanisms include exercise-induced release of
endogenous opiates, specifically beta endorphins; vasodilatation;
suppression of PGs; reduction in stress and elevation of mood
[11,12]. Vigorous exercises are hypothesized to stimulate the
release of beta-endorphins which act as systemic analgesics in
reducing the menstrual pain associated with PD [16]. Though
vigorous exercises are thought to be useful for PD, there is
limited empirical evidence to support their efficacy. Systematic
reviews also report that there is a lack of evidence from RCT’s
to support the use of exercise in the alleviation of symptoms
associated with PD [14,17]. Only a small, RCT has specifically
evaluated the efficacy of a 12-week aerobic training pro-
gramme on menstrual distress symptomatology [18]. The trial
reported significant reduction in the mean menstrual phase
symptomatology in the group receiving intervention compared
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with the control group but, the trial had some methodological
flaws such as lack of concealment of allocation, lack of blinding
and missing data for each main outcome. However, observational
studies evaluating the efficacy of exercise are available with
contradicting results. One prospective observational study found
that physical activity was not associated with decreased dysmen-
orrhea pain [19]. In contrast, another observational study found
that vigorous exercisers experienced less PD symptoms compared
to their sedentary counterparts [20]. Owing to limited evidence
from RCT’s and conflicting results from observational studies,
there is a need to evaluate the efficacy of exercise in managing
For personal use only.
menstrual pain in women with PD in a randomized controlled
design. Therefore, the primary objective of this study was to
examine the feasibility of using the intervention for conducting a
future RCT to evaluate the efficacy of vigorous intensity aerobic
training on menstrual pain intensity. The secondary objective was
to obtain preliminary results that will be used to estimate the
sample size for the future RCT.
Methods
Study design and recruitment
Since the aim of this study is to inform the conduct of a future
RCT, the feasibility issues were evaluated in a quasi-experimental,
one-way repeated measures design over time between March and
October 2013. Women were recruited from the Dunedin region of
New Zealand by advertising on the University of Otago campus
and in the community. The Southern Health and Disability Ethics
Committee of New Zealand (Reference No. 13/STH/12) approved
the research and all women gave informed written consent to
participate.
Participants
Study participants included 10 non-pregnant women with self-
reported dysmenorrhea in the age group of 18–45 years. Women
were considered eligible if they had regular menstrual cycles, and
menstrual pain scoring at least 4 on a 10-cm visual analogue scale
(VAS) for at least two consecutive months. Exclusion criteria
were: Women with secondary dysmenorrhea, women on a formal
exercise programme, women using intrauterine devices, women
on oral contraceptives and hormonal therapy and women with
menstrual cycle interval exceeding 34 d. Participants continued
taking pain medication (analgesics or NSAIDs) if required, and
were requested to record the type and the amount of pain
medication taken during the menstrual cycle after entering into
the study.
Disabil Rehabil, Early Online: 1–6
Intervention
Participants underwent vigorous intensity aerobic training on a
treadmill at the School of Physiotherapy (SoP), Dunedin for
30 min at 70–85% of their maximum heart rate (MHR). MHR was
calculated from an estimate of peak heart rate healthy women
should attain during exercise [21,22]. Treadmill exercise was
preceded by warm-up exercises for 10 min and followed by cool
down exercises for 10 min, including stretching for mid- and
lower- back muscles and abdominal strengthening. The interven-
tion at SoP was for 3 weeks for participants with 28 d cycle length
and 4 weeks for participants with cycle lengths more than 28 d
and less than 35 d. The intervention at SoP started after
completion of the first menstrual cycle, and ending before the
start of the second menstrual cycle. On completion of the
intervention at SoP, participants were then asked to complete a
home exercise programme, for up to 4 weeks between their
second and third menstrual cycles. They were provided with a
booklet containing the stretching and strengthening exercises and
an exercise adherence diary.
The intervention for the participants was provided by the
primary investigator, a New Zealand registered physiotherapist,
with 3 years of specialist experience in the area of pain and
women’s health. She has an undergraduate qualification in
physiotherapy and is now undertaking a PhD at the School of
Physiotherapy, University of Otago, New Zealand. The exercises
and aerobic training were taught and supervised on a one-to-one
basis.
Procedures
Volunteers were given an appointment for screening for eligibility.
Screening involves completing a self-reported questionnaire on
demographic details, pain history, general medical history,
gynaecological and menstrual history, obstetric history and
participation in exercise. All eligible participants were provided
with an information sheet and consent forms. Those women who
gave written informed consent to participate were provided with
pain questionnaires and return envelopes and asked to complete
the questionnaires on the day of maximum pain during their
first (T1) menstrual cycle before the start of intervention, second
(T2) menstrual cycle following intervention at SoP and third
(T3) menstrual cycle following home exercise programme.
Feasibility measures
The primary feasibility measures were (1) adherence to the
clinic-based intervention programme recorded as percentage
attendance, (2) adherence to home-based intervention programme
monitored with the use of exercise diaries, (3) adherence to clinic-
based intervention prescription, calculated as the percentage of
total minutes of walking/jogging within the target heart rate zone
and total minutes of walking on treadmill, respectively [23],
(4) safety was measured by number of adverse events either
during the intervention at SoP and or during the home exercise
programme. This included changes in the menstrual cycle or
symptoms, in addition to sprains or strains from exercising,
(5) retention rates, calculated as the percentage of participants
who completed the feasibility study, and (6) acceptability of
intervention obtained as feedback from participants.
Outcomes
The outcomes were pain quality and intensity measured with
short form of McGill pain questionnaire (SF-MPQ) and pain
medications. The time-points of measurements were at first
menstrual cycle before the start of intervention (T1), second
 DOI: 10.3109/09638288.2014.962108
menstrual cycle following intervention at SoP (T2) and third
menstrual cycle following home exercise programme (T3).
(1) SF-MPQ is a self-reported measure of pain quality and
intensity. It is a multi-dimensional measure of perceived pain
that evaluates the sensory, affective-emotional, evaluative and
temporal aspects of chronic pain and has three parts: the pain
rating index (PRI), VAS and the present pain index (PPI) [24].
The SF-MPQ is reported to have adequate content validity
and reliability coefficient of 0.87 and good internal consistency
(Cronbach’s a ¼ 0.92–0.93) on women with PD [25,26]. (2) Pain
medications: The participants were asked to record type
and amount of pain medication taken during their participation
in the study.
Data analysis
Statistical analysis was done using the Statistical Package for the
Social Sciences (SPSS) version 20. A one-way repeated measure
analysis of variance (ANOVA) was used to compare the scores
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Exercise for primary dysmenorrhea 3
The flow of participants through the study is summarized
in Figure 1. Most participants were NZ European (5/10), and
were recruited from the University (8/10). The baseline charac-
teristics of the participants are presented in Table 1.
Adherence to the intervention programme
(clinic-based + home-based)
Seven of the 10 (70%) had 18 sessions prescribed and 3/10 (30%)
participants had 24 sessions prescribed each over the study
period. The mean number of intervention sessions prescribed over
the study period was 19.8 SD 2.8, and the mean number of
sessions attended by the participants was 19.4 SD 3.2. The mean
percentage of adherence to intervention sessions are summarized
in Table 2.
Adherence to clinic-based and home-based intervention
programme

within the group at each time-point. As an index of post-
intervention change, effect sizes were computed based on the
difference between T1 and T2 and T1 and T3 means and the
pooled variance.
Results
Participant characteristics and baseline data
There were 14 women who volunteered to be in the study;
four women were excluded as they did not meet the inclusion
criteria. The remaining 10 women were included in the study.
For personal use only.
All of the participants attended all of the clinic-based intervention
sessions prescribed and therefore the mean percentage of clinic-
based intervention sessions completed was 100% (Table 2). The
mean percentage of home-based intervention sessions completed
was 96% (Table 2).
Adherence to clinic-based intervention prescription
The adherence to intensity and duration of the intervention at the
SoP was 100%. All the participants were able to complete the
aerobic training for the entire duration of 30 min within the target
heart rate zone.

Figure 1. Flow diagram of the participants Assessed for eligibility (n=14)

through the study.

Excluded (n=4):
Age criteria not met (n=2) Enrolled (n=10)
Had irregular periods (n=2)

Baseline measurement (T1) First menstrual cycle

Intervention for up to 4 weeks at SoP

Measurement of outcomes (n=10)

Second menstrual cycle
(T2)

Home exercise for up to 4 weeks

Measurement of outcomes (n=10)

Third menstrual cycle
(T3)

Analyzed (n=10)
 4 P. Kannan et al. Disabil Rehabil, Early Online: 1–6

Safety wrote ‘‘I intend to continue exercising as it is a good health

regime and I felt a difference in fitness levels and wellbeing’’.
No adverse events occurred during the intervention training at
SoP. No participant reported an adverse event to have occurred
Pain quality and intensity
while exercising at home.
With respect to quality of pain on PRI, and intensity of pain on
Retention of participants VAS and PPI there was a positive change in scores at T2 and T3.
The effect size for PRI, VAS and PPI between T1 and T2, and T1
All the participants who entered the study completed the study.
and T3 reflects a large difference. The effects of the intervention
There were no dropouts or loss to follow-up at any time-point.
are summarized in Table 3.
This represents a 100% retention rate.
Pain medications
Acceptability of intervention
Five participants reported they never took pain medications even
The intervention was acceptable to all the 10 participants and no
if the pain was unbearable, for the fear of the side effects
negative comments were made when feedback on the intervention
associated with NSAIDs. Of the remaining five participants who
and intensity of training was elicited. All 10 of them reported that
took pain medications, four participants took less pain medication
exercises were do-able in terms of intensity and duration. In
at T2 and/or T3 compared to T1 while one increased her pain
particular, one participant wrote ‘‘intensity and duration of the
medication at T3. The type and amount of pain medication
treadmill training was a good balance – pushed me but not too
consumed by five participants on the day of maximum pain are
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exhausting’’. Another participant wrote ‘‘the treadmill training

was do-able, not too much per week, and well-spaced out’’.
Regarding the commitment to home exercise programme all
participants wrote that the home exercises were easy to keep up.
Three of the participants said they made it a point to walk back
home from work instead of taking a bus or using their private
vehicle. For the question on their intention to exercise regularly
even after the study ends, five participants wrote that they would
continue to do the exercises. In particular one participant wrote
‘‘the difference in my pain was so noticeable and therefore I will
keep up to the exercise programme’’. Three participants wrote
For personal use only.
summarised in Table 4.
Sample size for future trial
A two-sample normal approximation formula was used to
determine the total sample size for a future RCT [27]. The
sample size was estimated to be 70 (35 in each group), using the
variance for VAS scores between T1-T2 (Table 3), assuming 90%
power, two-tailed 0.05 level of significance, to detect a difference
of 15 mm on the VAS for pain.

they will start going to the gym for exercises. One participant Discussion
The results from this study were encouraging with regard
Table 1. Baseline characteristics of participants. to adherence, safety and acceptability of the intervention tested.
This study focused on a heterogeneous sample of participants
Mean (SD, range) with regard to age (18–45), pain level, menstrual cycle length, and
(n ¼ 10) n (%) ethnicity.
Characteristics
Age (years) 33.0 (8.8, 21–44) Adherence, acceptability and safety
Mean pain on 0–10 cm 7.7 (1.4, 5–10)
VAS (SD, range) The study found high adherence rate to the clinic-based and
Mean age at menarche in 12.6 (0.5, 12–13) home-based exercise sessions, with a mean percentage of 98% of
years (SD, range) prescribed sessions attended by participants. These results support
Mean menstrual flow in days 4.7 (0.8, 3–6) the implementation of the programme on a larger scale.
(SD, range)
Mean interval between cycles in 28.6 (2.2, 25–32)
days (SD, range)
Marital status, married 5 (50) Table 2. The summary of adherence to intervention sessions.
Employed
Yes 5 (50) Mean number Mean number
No, student 4 (40) of sessions of sessions Mean
No, not student 1 (10) prescribed attended percentage
Pregnancies
0 2 (20) Over the study period 19.8 19.4 98%
1 2 (20) (n ¼ 10)
2 1 (10) Clinic-based (n ¼ 10) 9.9 9.9 100%
2+ 5 (50) Home-based (n ¼ 10) 9.9 9.5 96%

SD, standard deviation; %, percentage Min, minimum; Max, maximum.

Table 3. Means (SD) and effect sizes (Cohen’s d) for PRI, VAS, and PPI (n ¼ 10).

Mean (SD) Mean difference (SD) Effect size

T1 T2 T3 T1–T2 T1–T3 T1–T2 T1–T3
PRI 16.5 (3.4) 10.4 (5.0) 8.4 (5.4) 6.1 (4.9) 8.1 (4.9) 1.2 1.6
VAS 71.7 (16.4) 51.5 (18.1) 35.8 (19.3) 20.2 (13.7) 35.9 (19.7) 1.5 1.8
PPI 3.3 (1.1) 2.1 (1.1) 1.7 (0.9) 1.2 (1.2) 1.6 (1.0) 1.0 1.6

PRI, pain rating index; VAS, visual analogue scale; PPI, present pain index.
 DOI: 10.3109/09638288.2014.962108 Exercise for primary dysmenorrhea 5
Table 4. Summary of analgesics used on the day of maximum pain. attributed to the intervention because this is an underpowered
non-randomized trial and some reduction in pain could have been
Time- Number of due to regression to the mean (RTM) and therefore the true
Participant point Medication pills (per day) efficacy of the interventions remains unknown. RTM is a
1 T1 Codeine (15 mg) 8 statistical phenomenon that can make natural variation in repeated
T2 Paracetamol (500 mg) 4 measurements look like real change [29]. It is suggested that the
T3 Paracetamol (500 mg) 4 problem of RTM could be minimized by random allocation to
2 T1 Ibuprofen (200 mg) 12 comparison groups and any difference in response between
T2 Ibuprofen (200 mg) 12
T3 Ibuprofen (200 mg) 8
the two groups will exclude RTM [30]. This indicates the need
3 T1 Aspirin (325 mg) 8 for an RCT.
T2 Aspirin (325 mg) 8
T3 Aspirin (325 mg) 4 Changes to the future RCT
4 T1 Naproxen sodium (275 mg) 3
T2 Naproxen sodium (275 mg) 3 Age criteria and baseline characteristics
T3 Naproxen sodium (275 mg) 2
5 T1 Paracetamol (500 mg) 4 The age criteria for inclusion will be reduced to 43 from 45
T2 Paracetamol (500 mg) 4 in order to exclude women in perimenopause transition stage.
T3 Paracetamol (500 mg) 8 The average age of menopause is reported to be 51 and the
perimenopause phase can begin 4–8 years prior to this [31].
NSAID, non-steroidal anti-inflammatory drug.
As smoking is considered to be a significant risk factor for
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PD [3] participants will be asked to report on their smoking

Environmental factors such as the exercise setting and its
proximity to the workplace or home is generally accepted as a
positive indicator of good adherence [28]. High adherence rates
in the current study could be attributed to the fact that the study
was conducted at the University campus, and the majority (8/10)
of the study participants were from the University. An RCT by
Israel et al. [18] to evaluate the efficacy of a 12-week aerobic
training programme found 80% adherence to the intervention
programme. The possible reasons for the difference in adherence
For personal use only.
history for establishing baseline levels between groups for the
future RCT. We will also be using the international physical
activity questionnaire for establishing baseline physical activity
levels which was not done for the current study. In this study,
we included participants with baseline pain scoring 4 or more on
a 10-cm VAS but the Initiative on Methods, Measurement,
and Pain Assessment in Clinical Trials (IMMPACT) 2010 [32]
recommends all chronic pain clinical trials to include participants
with self-reported baseline pain intensity levels of 4 on a 0–10

rates could have been the access to the study setting or the
duration of the intervention programme.
The study also found that participants had good acceptance
towards the intervention and intensity of training. Lack of
motivation is the most commonly identified personal character-
istic directly related to decreased adherence to and increased
dropout from exercise programmes [28]. All our 10 participants
were very motivated and were able to complete 30 min of
walking/jogging on the treadmill at an intensity calculated for
their age and this indicates that the intervention protocol is
achievable. This suggests adherence rates to intervention pre-
scription should be high in the future RCT. In terms of safety, we
noticed that no participant experienced adverse events to the
intervention programme. This provides support for the assertion
that vigorous physical activity is safe for women with PD.
Recruitment and retention
There was a good response to advertisement flyers and the
required number of participants was recruited in less than 4
weeks. We hope to recruit three participants each week for the
future RCT which makes it 6 months for the estimated sample
size. The University was a good source for recruiting participants
and will be targeted for recruitment in the future RCT. With
regards to retention, there were no dropouts or lost to follow-up in
the study. A previous RCT [18] on 12-week aerobic training for
PD had a lost to follow-up of 39% in the experimental group and
17% in the control group. The authors of that trial report, the
dropouts were due to illness and injuries which were not caused
by trial intervention. Though this study had no dropouts, to
accommodate for any such reasons we plan to keep the drop-out
rate at 15% for the future RCT.
Changes in pain quality and intensity
The preliminary results of our feasibility study showed large
effect size in PRI, VAS and PPI scores between T1 and T2, and T1
and T3. This improvement in pain levels cannot be completely
numeric rating scale (NRS). Therefore, for our future RCT we will
be using the NRS instead of the VAS.
Intervention and outcomes measures
In this study, there was an inequality in the frequency of
intervention for participants with different menstrual cycle
lengths provided at SoP. Therefore, to make the frequency of
intervention homogeneous for all participants in the future RCT
we decided to keep the intervention frequency as 3 weeks for all
participants in the experimental group, irrespective of their
menstrual cycle length.
Women with PD experience cyclic pelvic pain that nega-
tively impacts their QoL [33]. It is recommended that women’s
health care providers should not discount the possibility of
improving a woman’s quality of life by reducing or relieving
menstrual discomfort [7]. As measurement of QoL is considered
a vital part of assessing the effect of treatment in clinical trials,
we therefore will include health-related quality of life (HRQoL)
as an outcome measure in our future trial. Several intervention
studies have used generic SF-36 health survey to evaluate the
outcomes of treatment on women with PD [34–36]. For our
future RCT, we will therefore be using the SF-12 health survey
which is a validated alternative to the SF36 [37,38]. Apart from
negatively affecting QoL, PD can cause significant activity
limitation and can leave women incapacitated for 1–3 d every
month. [7,39]. This indicates a need to evaluate physical
functioning in women with PD. An instrument for measuring
physical functioning will therefore be included for our future
RCT. There is also a need to measure quality of sleep because
sleep and chronic pain are interrelated [40]. Disturbed sleep is a
consequence of pain, and sleep disruption may also contribute
directly to hyperalgesia [41]. Baker et al. reported that women
with the pain of PD have more disturbed sleep and less efficient
sleep during menstruation compared with the controls [4].
Additionally the IMMPACT 2005 [42] guidelines recommend
that clinical trials studying chronic pain should measure sleep.
 6 P. Kannan et al.
Conclusion
The results of the current study have demonstrated that aer-
obic training combined with exercises in the management of PD is
feasible and no safety concerns were evident. The intensity and
duration of the intervention tested are achievable and tolerated
well by women with PD and preliminary results suggest some
improvement in PD after the intervention. These preliminary
findings justify the need for a future RCT to establish the efficacy
of aerobic training and exercises in the management of PD. This
will contribute to the literature on the potential use of exercise
and physical activity for the management menstrual pain. This
low-cost intervention, if shown to be effective, has the potential to
impact significantly upon the lives of women with PD.
Acknowledgements
The authors would like to thank the research team of School
of Physiotherapy and Women’s and Children’s Health for their
assistance with the project.
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Declaration of interest
Funding for the study was obtained as a grant from the
Department of Women’s and Children’s Health, Dunedin School
of Medicine, University of Otago, Dunedin, New Zealand. The
authors report no conflicts of interest. This study has been
registered in the Australia New Zealand Clinical Trials Registry
(Ref: ANZCTR12613000073707).
For personal use only.
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