Exercise for dysmenorrhoea

Mike Armour; Carolyn C Ee; Dhevaksha Naidoo; Zahra Ayati; K Jane Chalmers; Kylie A Steel; Michael J de Manincor; Elahe Delshad

doi:10.1002/14651858.CD004142.pub4

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Figure 1

Study flow diagram

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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 4

Forest plot of comparison: 1 Exercise versus no treatment, outcome: 1.1 Menstrual pain intensity.

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Analysis 1.1

Comparison 1 Exercise versus no treatment, Outcome 1 Menstrual pain intensity.

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Analysis 1.2

Comparison 1 Exercise versus no treatment, Outcome 2 Overall menstrual symptoms.

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Analysis 1.3

Comparison 1 Exercise versus no treatment, Outcome 3 Quality of life.

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Analysis 2.1

Comparison 2 Exercise versus NSAIDs, Outcome 1 Menstrual pain intensity.

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Analysis 2.2

Comparison 2 Exercise versus NSAIDs, Outcome 2 Use of rescue analgesic medication.

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Analysis 2.3

Comparison 2 Exercise versus NSAIDs, Outcome 3 Absence from work or school.

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Summary of findings for the main comparison. Exercise compared to no treatment for dysmenorrhoea

Exercise compared to no treatment for dysmenorrhoea
Patient or population: young women with suspected primary dysmenorrhoea Setting: school, university or outpatient setting Intervention: exercise Comparison: no treatment
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with no treatment	Risk with exercise	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Menstrual pain intensity, measured by various outcome measures including VAS, MPQ and NRS at the end of the intervention Lower scores indicate less intense menstrual pain	The mean menstrual pain intensity was 6.76	SMD 1.86 lower (2.06 lower to 1.66 lower)	‐	632 (9 RCTs)	⊕⊕⊝⊝ Low^ab	Exercise may provide a large reduction in menstrual pain intensity compared to no treatment.
Adverse events	0 per 1000	0 per 1000 (0 to 0)	Not estimable	36 (1 RCT)	⊕⊝⊝⊝ Very low^cd	Due to the very low‐quality evidence, we are uncertain whether there is any difference in risk for adverse events between exercise and no treatment control.
Overall menstrual symptoms , measured by the MMDQ at the end of the intervention. Lower scores indicates lower menstrual symptom severity	The mean overall menstrual symptoms was 99	MD 33.16 lower (40.45 lower to 25.87 lower)	‐	120 (1 RCT)	⊕⊝⊝⊝ Very low^ef	Due to the very low‐quality evidence, we are uncertain whether exercise reduces overall menstrual symptoms compared to a no treatment control.
Use of rescue analgesic medication ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Restriction of daily life activities ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Absence from work or school ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Quality of life, assessed with: physical and mental component summary scores measured by the SF‐12 at the end of the intervention Higher scores indicate higher quality of life	Mean postintervention score for the mental component in the no treatment group was 37.6 Mean postintervention score for the physical component in the no treatment group was 44.4	Mental component: MD 4.40 higher (1.59 higher to 7.21 higher) Physical component: MD 3.40 higher (1.68 lower to 8.48 higher)	‐	55 (1 RCT)	⊕⊝⊝⊝ Very low^gh	Due to the very low‐quality evidence, we are uncertain whether exercise improves quality of life compared to a no treatment control.
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; MMDQ: Moos Menstrual Distress Questionnaire; MPQ: McGil Pain Questionnaire; NRS: numeric rating scale; RCT: randomised controlled trial; SF‐12: 12‐Item Short Form Health Survey; SMD: standardised mean difference; VAS: visual analogue scale
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aDowngraded one level for serious risk of bias: all included trials are at a high risk of bias for performance and detection bias. ^bDowngraded one level for serious inconsistency: while heterogeneity is very high (I²= 91%), all effects are in the same direction, favouring exercise. ^cDowngraded one level for serious risk of bias: single included trial has a high risk of performance and detection bias and this may affect the adverse event reporting. ^dDowngraded two levels for very serious imprecision: very small sample size (36 participants) and rare adverse events. ^eDowngraded two levels for very serious risk of bias: the single included study is at high risk of bias for three domains and unclear for the remainder. ^fDowngraded one level for serious imprecision: one small study. ^gDowngraded one level for serious risk of bias: the single included study is at high risk of bias for two domains. ^hDowngraded two levels for very serious imprecision: one small study (55 participants).

Summary of findings for the main comparison. Exercise compared to no treatment for dysmenorrhoea

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Summary of findings 2. Exercise compared to non‐steroidal anti‐inflammatory drugs (NSAIDs) for dysmenorrhoea

Exercise compared to non‐steroidal anti‐inflammatory drugs (NSAIDs) for dysmenorrhoea
Patient or population: young women with suspected primary dysmenorrhoea Setting: university or school Intervention: exercise Comparison: NSAIDs
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with NSAIDs	Risk with exercise	Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
Menstrual pain intensity, measured by 100 mm VAS at the end of the intervention Higher scores indicate greater reductions in pain intensity from baseline	The mean menstrual pain intensity was ‐21.3 change in VAS score from baseline	MD 7.4 lower change in VAS score from baseline (8.36 lower to 6.44 lower)	‐	122 (1 RCT)	⊕⊝⊝⊝ Very low^ab	Due to the very low‐quality evidence, we are uncertain whether exercise improves menstrual pain severity compared to NSAIDs.
Adverse events ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Overall menstrual symptoms ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Use of rescue analgesic medication assessed by: number of women who took rescue/additional analgesics during the last cycle Greater numbers indicate more women needed additional analgesics	361 per 1000	638 per 1000 (436 to 938)	RR 1.77 (1.21 to 2.60)	122 (1 RCT)	⊕⊝⊝⊝ Very low^ab	Due to the very low‐quality evidence, we are uncertain whether exercise changes the amount of additional medication needed compared to NSAIDs.
Restriction of daily life activities ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Absence from work or school	492 per 1000	492 per 1000 (322 to 663)	OR 1.00 (0.49 to 2.03)	122 (1 RCT)	⊕⊝⊝⊝ Very low^ab	Due to the very low‐quality evidence, we are uncertain whether exercise changes absenteeism compared to NSAIDs.
Quality of life ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; NSAID: non‐steroidal anti‐inflammatory drug; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; VAS: visual analogue scale
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aDowngraded two levels for very serious risk of bias: the single included study was at high risk of bias for performance and detection bias and unclear risk of bias for all other domains. ^bDowngraded one level for serious imprecision: one small study (122 participants) reported on this outcome.

Summary of findings 2. Exercise compared to non‐steroidal anti‐inflammatory drugs (NSAIDs) for dysmenorrhoea

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Comparison 1. Exercise versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Menstrual pain intensity Show forest plot	9	632	Std. Mean Difference (IV, Fixed, 95% CI)	‐1.86 [‐2.06, ‐1.66]

1.1 High‐intensity exercise	4	213	Std. Mean Difference (IV, Fixed, 95% CI)	‐2.51 [‐2.89, ‐2.13]
1.2 Low‐intensity Exercise	6	419	Std. Mean Difference (IV, Fixed, 95% CI)	‐1.62 [‐1.85, ‐1.38]
2 Overall menstrual symptoms Show forest plot	1	120	Mean Difference (IV, Fixed, 95% CI)	‐33.16 [‐40.45, ‐25.87]

3 Quality of life Show forest plot	1	110	Mean Difference (IV, Fixed, 95% CI)	4.17 [1.71, 6.62]

3.1 Mental	1	55	Mean Difference (IV, Fixed, 95% CI)	4.40 [1.59, 7.21]
3.2 Physical	1	55	Mean Difference (IV, Fixed, 95% CI)	3.40 [‐1.68, 8.48]

Comparison 1. Exercise versus no treatment

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Comparison 2. Exercise versus NSAIDs

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Menstrual pain intensity Show forest plot	1	122	Mean Difference (IV, Fixed, 95% CI)	‐7.40 [‐8.36, ‐6.44]

2 Use of rescue analgesic medication Show forest plot	1	122	Risk Ratio (M‐H, Fixed, 95% CI)	1.77 [1.21, 2.60]

3 Absence from work or school Show forest plot	1	122	Odds Ratio (M‐H, Fixed, 95% CI)	1.0 [0.49, 2.03]

Comparison 2. Exercise versus NSAIDs

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