Primary Dysmenorrhea (PD)
Conditions
Keywords
Graded Motor Imagery, Primary Dysmenorrhea, Primary dysmenorrhea and pressure pain threshold, Primary dysmenorrhea and altered pain sensitivity, Non-pharmacological intervention for primary dysmenorrhea
Brief summary
The goal of this clinical trial is to learn if graded motor imagery can reduce pain sensitivity and period pain in women with primary dysmenorrhea (painful periods with no medical cause). The main questions it aims to answer are: 1. Is there a decrease in pressure pain threshold (increased pain sensitivity) with graded motor imagery? 2. Is the intensity of menstrual pain reduced by graded motor imagery? 3. Is GMI helpful to reduce menstrual symptoms and pain catastrophizing (negative thinking about pain)? Researchers will compare full GMI (active intervention), a sham GMI(inactive intervention), and a wait-list (no intervention) to see if GMI works better than the alternatives. Participants will: 1. Take part in a 6-week graded motor imagery program, sham program, or no intervention control. 2. Do laterality recognition, motor imagery, and mirror therapy exercises in the graded motor imagery group. 3. Complete pain and symptom assessments before and after the program, and again at follow-up.
Detailed description
Women with primary dysmenorrhea have decreased pressure pain threshold (PPT) at local abdominal and lumbar sites and at remote sites (tibialis anterior). This is indicative of central sensitization, rather than just peripheral, prostaglandin-driven pain. This sensitization extends out of the menstrual window and is associated with increased pain catastrophizing (a cognitive-affective amplifier of central pain processing). All of these factors contribute to primary dysmenorrhea being an appropriate target for brain-directed intervention. Graded Motor Imagery (GMI) is a three-phase physiotherapy program aimed at restoring the normal representation of pain in the cortex and reducing movement-related threat appraisal. Phases progress from implicit motor imagery using left/right body-part recognition tasks, followed by explicit mental rehearsal of pain-free movement. The third phase involves mirror therapy with visual feedback of normal movement. This sequenced approach targets the two measurable mechanisms underlying central sensitization in dysmenorrhea: altered pressure pain sensitivity and elevated pain catastrophizing. GMI has proven to be effective in complex regional pain syndrome, phantom limb pain, and genito-pelvic pain. However, it has not been specifically tested in primary dysmenorrhea. This three-arm randomized controlled trial compares full GMI, sham GMI, and a wait-list control over six weeks of online-delivered sessions. The sham program is identical to GMI in terms of therapist contact time and structure of sessions, but employs non-pelvic imagery content (to control for non-specific effects of attention and engagement). The outcome is measured at baseline, 6 and 10 weeks by a blinded assessor.
Interventions
BEHAVIORALGraded Motor Imagery (GMI)
The intervention will be a structured 6-week graded motor imagery program focused on the modulation of pain processing and sensorimotor representation in women with primary dysmenorrhea. It will consist of three sequential steps. Firstly, laterality recognition training with pelvic and abdominal body images. Secondly, explicit motor imagery with pain-free abdominal and pelvic movements. Finally, mirror therapy/visual feedback for normal pain-free movement. The program will be delivered online by a trained physiotherapist with two supervised sessions per week as well as daily home practice. This intervention is different from usual exercise or education because it mainly focuses on the cortical and sensorimotor mechanisms rather than only physical conditioning.
BEHAVIORALSham Graded Motor Imagery
The intervention will be a sham 6-week graded motor imagery program in which the participants will undergo a program of the same amount of contact time as well as duration over 6 weeks with the same number of sessions. The sham intervention will consist of three phases. Sham laterality discrimination tasks will be performed with distal body parts only (e.g., hands and feet) and without pelvic content. Moreover, the sham general relaxation imagery will have peaceful scenes rather than body movement. Lastly, sham mirror exposure will be done by looking at a mirror showing the contralateral hand but not at the pelvic area. The sham protocol aims to control non-specific effects of therapist contact, attention, and imagery engagement, and to remove the pelvic-specific cortical engagement as occurred in the active component of GMI.
Sponsors
Dr. Mehak Naeem
University of Health Sciences Lahore
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Outcomes Assessor)
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 30 Years
Healthy volunteers
No
Inclusion criteria
1. Female sex (aged 18-30 years) 2. Diagnosis of primary dysmenorrhea confirmed by a physician (painful menstruation for ≥6 consecutive cycles, in the absence of identifiable pelvic pathology on clinical and/or ultrasound evaluation) 3. Pain ≥4/10 NRS experienced during the last period. 4. Confirmed altered pressure pain threshold: PPT ≥2 standard deviations below published norms for age-matched healthy women, measured at baseline assessment 5. Regular menstrual cycle (21-35 days) 6. Capable of engaging in virtual video sessions and taking online tests. 7. Consent to withhold new analgesic or hormonal treatments during the study period.
Exclusion criteria
1. Secondary dysmenorrhea (endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, ovarian cysts ≥3 cm confirmed on imaging) 2. Current use of hormonal contraceptives (which alter prostaglandin levels and pain processing) 3. Pregnancy or lactation 4. Concurrent chronic pain condition (fibromyalgia, CRPS, chronic low back pain, chronic pelvic pain unrelated to menstruation) 5. Neurological or psychiatric disorder that would impair motor imagery ability (stroke, schizophrenia, active psychosis) 6. Cognitive impairment affecting informed consent capacity 7. Participation in another clinical trial within 4 weeks before enrollment 8. Previous exposure to graded motor imagery or mirror therapy 9. Regular use of NSAIDs or opioids for non-menstrual indications
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Pain Pressure Threshold | Baseline, post-intervention at 6 weeks, and 4-week follow-up. | Pressure pain threshold will be measured at local abdominal and lumbar sites, and at a remote site over the tibialis anterior muscle by using a handheld algometer. Three readings will be taken at each site and averaged. Higher values will indicate lower pain sensitivity. |
| Menstrual pain intensity | Baseline, 6 weeks post-intervention, and 4-week follow-up. | Menstrual pain intensity will be assessed using a Numeric Rating Scale during active menstruation. Participants will rate their pain on the days of menstrual pain, and the scores will be recorded for comparison over time. Higher scores will indicate greater pain intensity. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Menstrual symptom severity | Baseline, 6 weeks post-intervention, and 4-week follow-up. | Menstrual symptom severity will be measured using the Moos Menstrual Distress Questionnaire. This questionnaire assesses the severity of physical and emotional symptoms related to menstruation. Higher scores indicate more severe menstrual symptoms. |
| Pain Catastrophizing | Baseline, 6 weeks post-intervention, and 4-week follow-up. | Pain catastrophizing will be measured using the Pain Catastrophizing Scale. This scale assesses exaggerated negative thoughts and feelings about pain. Higher scores indicate greater catastrophizing. |
Countries
Pakistan
Outcome results
None listed