{"paper_id":"00b7b6a2-b2fc-4600-9fc6-362e802ad843","body_text":"Page 1 of 4\nTherapeutic Role of Dance in the Treatment of \nEndometriosis-Related Chronic Pelvic Pain: A Proof-\nof-Concept Study\nM Rius1, L Quintas2, S Kauffmann3, A Pérez4, M Ridaura5, C Gurruchaga6 and F Carmona1*\n1Benign Pathology Unit, Women’s Health Institute, Spain\n2Pelvic Pain Unit, Women’s Health Institute, Spain\n3Physical Therapy Unit, Women’s Health Institute, Spain\n4Familial Therapy Unit, Psychiatry Service Hospital, Spain\n5Dance Studio, Doctors Trias i Pujol, Spain\n6Asociación de Afectadas de Endometriosis de Cataluña Sardenya, Spain\nIntroduction\nEndometriosis is an inflammatory disease that causes chronic \npelvic pain in around a great number of the women affected, \nwhich may not completely remit after applying a medical therapy \nor surgery in a righteous way [5]. Chronic pelvic pain is difficult \nto treat and one of the most prevalent symptoms related to \nendometriosis, together with dyspareunia; moreover, it may lead to \nother symptoms such as anxiety and stress that may contribute to \nthe decrease of these patients’ quality of life (QoL) [1]. \nPrescription of exercise as medicine and the possible mechanism \nof action by which it helps improving outcomes has been studied \nin several diseases, including psychiatric, neurological, metabolic, \ncardiovascular, pulmonary, musculoskeletal and cancer [2]; and \ngreat interest in new alternatives and complementary methods \nhas increased among physicians to address the symptoms and \nrecurrence of endometriosis. \n*Corresponding author: F Carmona, Benign Pathology Unit Women’s \nHealth Institute Via Augusta 281, 08017, Barcelona, Spain.\nReceived Date: October 03, 2018\nPublished Date: October 12, 2018\nISSN: 2641-6247                                                                                                                           DOI: 10.33552/WJGWH.2018.01.000507\nWorld Journal of \nGynecology & Women’s Health\nResearch Article Copyright © All rights are reserved by F Carmona\nAbstract \nBackground: Endometriosis causes chronic pelvic pain in many of the women affected, which may not remit after surgery or \npharmacological treatment. Physical exercise as complementary therapy has already shown to be beneficial QoL in some chronic \ndiseases, including endometriosis, but has not hitherto tested in the form of dance.\nMaterial and Methods: A prospective cohort-proof-of-concept, open-label study, was conducted during the first half of 2017 in \na private gynecologic center in Barcelona (Spain). Participants attended 12 dance sessions along eight weeks and were followed for \none month after the end of the therapy. 6 nulliparous women who had been preciously treated by one or more surgeries, without \ncurrent evidence of endometriosis but complaining of endometriosis-related chronic pelvic pain were included in this proof-of-\nconcept study. Pain, QoL and anxiety and kinesiophobia parameters were measured along the study.\nResults: Results showed a benefit for the QoL parameters, being significant for the SF-36, which improved in a 20.5% for its \nMental Component Summary and in a 16.4% for its Physical Component Summary. The other parameters did not reach clinical \nsignificance although improvement outcomes were observed for Zung scale and Tampa scale of kinesiophobia. Pain outcomes, \nmeasured with the Endometriosis Associated Pelvic Pain scale, did not show a significant improvement along the study.\nConclusion: Although studies with more ambitious design are needed in order to extrapolate the results of this proof of concept, \nphysical exercise seems to have a beneficial effect on QoL of women with endometriosis-related chronic pain\nKeywords: Endometriosis; Chronic pelvic pain; Physical exercise; Dancing; Quality of life\nThis work is licensed under Creative Commons Attribution 4.0 License  APPR.MS.ID.000507.\n\n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 2 \nCitation:  F Carmona , M Rius, L Quintas, S Kauffmann, A Pérez, et al. Therapeutic Role of Dance in the Treatment of Endometriosis-Related \nChronic Pelvic Pain: A Proof-of-Concept Study. W J Gynecol Women’s Health. 1(2): 2018. WJGWH.MS.ID.000507. \nDOI: 10.33552/WJGWH.2018.01.000507.\nPage 2 of 4\nDancing, a special form of movement and physical exercise, \nhas shown to be beneficial as additional therapy in some affections \nsuch as Parkinson’s disease and chronic pain [3-6]. However, no \ndata have been published on the effect of dancing as therapy for \nwomen who suffer endometriosis-related pelvic pain.\nAlthough the therapeutic role of physical exercise in \nendometriosis has been proved to improve pain outcomes, it has \nnot been yet studied whether dance can have this beneficial effect. \nDancing may contribute to diminish endometriosis-related chronic \npelvic pain refractory to other treatments [7]. Secondarily, the \nreduction of pain may be associated to a reduction in the levels of \ndepression and anxiety. In this proof-of-concept study, we analyses \nthe evolution of QoL parameters in women using dancing exercises \nas therapy.\nMaterials and Methods\nThis open-label, single-center, non-controlled study was \ndesigned as a proof of concept to measure the change in pain and \nquality of life parameters before starting dance sessions and after.\nSelection of patients\nSix patients were included, accounting for an ideal size for a \ndancing therapy group. Demographic characteristics of the patients \nare displayed in Table 1. Patients included had previous histologic \ndiagnosis of endometriosis and did not show any evidence of \ncurrent active disease in the moment of inclusion. All of them \ncomplained of chronic pelvic pain considered as an endometriosis \nsequel their level of pain was severe (VAS≥7); they should not be \nattending pelvic physiotherapy or related treatments currently or \nthree months prior to inclusion, and they had signed the informed \nconsent. Patients were not included in the study if they experienced \nimpossibility or difficulty of movement which makes unable to \nperform the provided dancing movements or if they present other \nmedical conditions which contraindicates the performance of those \nmovements. Before inclusion, patients were clinically evaluated at \nWomen’s Health Institute in Barcelona, with the collaboration of the \nAsociación de Afectadas de Endometriosis de Cataluña (Endo&Cat).\nStudy objectives\nAll the patients were evaluated from clinical, physical, \npsychological and QoL’s perspectives. The evaluation of \nendometriosis patient’s status included the anamnesis, medical \nhistory, physical exploration and ultrasound study to assess the \nextent of the disease. Physical (ability of the patients to perform the \ndancing movements) and psychologic status were also assessed.\nThe primary endpoints were to compare the levels of pain \nand QoL before and after the dance sessions: Level of pain was \nmeasured using the endometriosis-associated pelvic pain (EAPP) \nwith the use of an 11-point numeric rating scale (NRS), with 0 \nindicating absence of pain and 10 pain as bad as it could be for the \nsymptoms of dysmenorrhea, dyspareunia, dyschezia, ovulatory \npain and non-cyclic pelvic pain. Patients were considered eligible if \nthey complained of at least one moderate-to-severe pain symptom \n(points 6–8, moderate pain; point 9 or 10, severe pain). QoL was \nevaluated with the 36-item short form survey (SF-36). Secondary \nendpoints were to assess the evolution of anxiety and stress \nlevels using the Zung self-rating scale and the Tampa scale of \nkinesiophobia (TSK)-11. All the questionnaires performed where \naccording to validated Spanish versions.\nStudy design\nThe program consisted in 12 dance sessions performed in the \nDance studio in Barcelona. At weeks 1, 2, 3 and 4, women attended \ntwo sessions per week (Tuesday and Thursday); at weeks 5, 6, 7 \nand 8, women attended one session per weeks (Tuesday). Each \nsession lasted 50 minutes, starting at 1pm. \nFigure 1: Study design.\nPain parameters for EAPP VAS, Zung scale and TSK-11SV were \nevaluated previous to inclusion, after sessions 6 and 12 and in \nthe one-month follow-up visit. Quality of life (SF-36) and physical \nparameters were evaluated previous to inclusion and in the one-\nmonth follow-up visit. A scheme of the study design is displayed in \nFigure 1.\nSessions methodology\nEach session was scheduled in 15 minutes of warming up, \n20 minutes of choreography, 10 minutes of improvisation and 5 \nminutes of relaxation and cooling down.\nThe sessions included specific movements. A description \n\nCitation:  F Carmona , M Rius, L Quintas, S Kauffmann, A Pérez, et al. Therapeutic Role of Dance in the Treatment of Endometriosis-Related \nChronic Pelvic Pain: A Proof-of-Concept Study. W J Gynecol Women’s Health. 1(2): 2018. WJGWH.MS.ID.000507. \nDOI: 10.33552/WJGWH.2018.01.000507.\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 2 \nPage 3 of 4\nof performed dance movements is included in Supplementary \ninformation.\nStatistical analysis \nSince this study was a proof of concept, a small sample size was \nenough to cover the statistical objectives. This size was also suitable \nfor a dancing group and allowed a close and thorough analysis of \nthe outcomes. Data were collected ad-hoc and analyzed by the \nFisher’s exact and non-parametric tests.\nResults\nAll participants had had at least one endometriosis-related \nsurgery and the six of them were on hormonal treatment at the \ninclusion; none of them had previous births (Table 1).\nTable 1: Demographic characteristics of the patients at the moment of \ninclusion.\nVariable  \nAge, years  Mean (range)  37.2 (35-42)\nParity, nr of births Mean (range) 0\nTime from first symptom to diagnostic, years-\nMean (range) Number of previous surgeries*  10.2 (1-20)\nTotal mean (range) 3.1 (1-5)\nExploratory laparoscopy 2\nEndometrioma excision 4\nUnilateral adnexectomy 1\nDeep nodule excision 6\nAdenomyoma excision 1\nHysterectomy + bilateral adnexectomy 1\nNumber of current endometriosis treatment  \nOral progestin 2\nMirena® (intrauterine device) 1\nCombined oral contraceptives 3\n*A patient may have more than one previous surgical procedure\nTable 2: Evolution of analyzed parameters\nParameter Base-\nline Session 6 Session \n12\n1-month \nfol-\nlow-up\np \nvalue\nMaximum \nEAPP \n8.7 (7-\n10) 8.2 (7-10) 9.3 (7-\n10)\n9.0 (7-\n10) 0.8\nZung scale  \nDepression 57.5 \n(43-68)\n55.4 (41-\n64)\n52.3 \n(40-62)\n51.9 (39-\n61) 0.3\nAnxiety 61.3 \n(42-69)\n58.4 (44-\n65)\n55.5 \n(40-63)\n56.4 (39-\n65) 0.2\nTSK 25.2 \n(21-36)\n24.6 (21-\n32)\n23.1 \n(19-28)\n20.7 (16-\n29) 0.06\nSF-36\nMCS 64.1 \n(49-84) - - 80.6 (59-\n87) <0.05\nPCS 68.9 \n(53-81) - - 82.4 (59-\n89) <0.05\nNo women discontinued the therapy. N=6 for all the timepoints as-\nsessed.\nMCS: mental component summary; PCS: physical component summary.\nValues are mean (range).\nTable 2 summarizes the more important study findings. Zung \nanxiety and pain parameters did not show a clear tendency towards \nimprovement during the study period. However, a clear (although \nnot statistically significant) trend to improvement in patient’s \nmobility was observed with a 20% decrease in the TSK-11 scale. \nImprovements for all the measured QoL parameters were \nobserved from baseline to the end of the study Statistical \nsignificance was reached for improvements in the SF-36 global QoL \nscores measured at baseline and at the end of the study for both \nits mental (MCS) and physical (PCS) components, with a slightly \nbetter performance for the MCS: 16.5 points (20.5%) vs. 13.5 points \n(16.4%) for PCS.\nDiscussion\nThis is the first study analyzing the effect of dancing \nin endometriosis-related chronic pelvic pain. Significant \nimprovements in SF-36 scale seem to indicate a better performance \nin QoL after the dance therapy. Improvement in parameters such as \nTSK and Zung, although non-significant, sum to the fact that dance \nas complementary therapy may represent a good tool to address \nendometriosis-related complications. Although the reported \nendometriosis-related pain scores did not improve during the \nstudy, it is worth to notice that the main objective of this proof of \nconcept was to assess QoL, which improved for all the parameters \nmeasured: SF-36, Zung and TSK.\nSeveral studies have been published recently analyzing the role \nof physical therapies and moderate exercise in improving pain and \nQoL outcomes of women affected. Carpenter, et al. [8] reported \na reduction in the number of androgenic side effects in women \nwith endometriosis treated with danazol and physical exercise \ncompared with women receiving only danazol. More recently, \nZhao L et al. [9] probed an improvement of anxiety, depression \nand QoL outcomes in Chinese women with endometriosis under \ngonadotropin-releasing hormone agonist therapy who practiced \nprogressive muscular relaxation training for 12 weeks. Similar data \nwere obtained by Friggi K, et al. [4] [10] A review from Bonocher \nCM, et al. [11] claimed that regular exercise has protective effect \nagainst inflammatory diseases and reduces estrogen levels. Yoga \nhas been also used with positive results in Brazilian patients as a \nform of exercise integrating body and mind [1,12]. \nThe results of this study confirm those obtained by Gonçalves \nmind [1,12], showing the beneficial effect of physical exercise in \nQoL and pain parameters among women who suffer endometriosis. \nThey also add a first glimpse of the role of dancing as complementary \ntherapy for the treatment in this disease.\nEndometriosis-related complications still represent a \nchallenge in clinical practice mind [1]. Severe pain is associated \nwith endometriosis at a high rate and caused by an interaction of \nfactors such as mechanical interactions, inflammation, immune \nsystem and nerve fibers [1]. The connection of these nerve fibers \nto the central nervous system (CNS) has been shown to create a \npermanent stimulus which may persist even after the removal \nof the endometrial lesion [13]. Since pharmacological treatment \naddressing the physical pathways of pain seem not to control \n\nWorld Journal of Gynecology & Women’s Health                                                                                                             Volume 1-Issue 2 \nCitation:  F Carmona , M Rius, L Quintas, S Kauffmann, A Pérez, et al. Therapeutic Role of Dance in the Treatment of Endometriosis-Related \nChronic Pelvic Pain: A Proof-of-Concept Study. W J Gynecol Women’s Health. 1(2): 2018. WJGWH.MS.ID.000507. \nDOI: 10.33552/WJGWH.2018.01.000507.\nPage 4 of 4\nefficiently enough this complication, several researches try to \nimprove women´s QoL by addressing the psychological side of pain \n[1]. \nSince severe pain seems to have a complex building into \nthe CNS [13], the slower change in EAPP scores and the slightly \nbetter improvement in the MCS- over the PCS-SF-36 scale may be \nexplained by its characteristic persistency. A long-term design is \nneeded in order to analyses the influence that improving of QoL has \nin reversing the neurological stimuli leading to chronic pain. It is \nworth to notice that last assessments were performed one month \nafter finishing the therapy and the improvements were registered \neven though no more dance sessions were performed (physical \nactivity of each women outside of the study was not recorded).\nEndometriotic pelvic pain has been also associated with \nadenomyosis [14]. Being the myometrium involved, it can be \nhypothesized that movements such as the employed in dance \nsessions, which help to gain muscular elasticity and strength \naround the uterine area, may provide a benefit in women’s pain and \nQoL outcomes.\nOne of the most noticeable limitations of this study was its size, \nsince the number of patients recruited depended on the optimal \nsample size of a dance session. Due to the novelty of a study with \nthese characteristics, an optimal sample size cannot be determined \nbased on previous studies, and it was decided based on the most \nbeneficial number for performance. The lack of control group and \nthe open character may compromise the strength of the results. \nBesides, movements performed by each patient may be biased by \ntheir own capacities, mood and physical abilities. On the other hand, \na small number of patients allowed for proximity and enough time \nfor exploration and measurements, which benefits the outcomes \naccuracy.\nSince few patients were recruited, the study is only exploratory, \nand our results need to be confirmed in larger and more \nheterogeneous population studies. More studies on dance and \nendometriosis are required to support our results and give a clearer \nidea of the benefits dance can offer as complementary therapy \nfor women who suffer endometriosis-related pelvic pain despite \nrighteous surgical and/or pharmacological treatment.\nAcknowledgement\nThe authors thank staff members from our institutions for their \nassistance with data collection and patients care. The authors also \ngratefully acknowledge Dr. Izaskun Muruzábal-Lecumberri for her \ncollaboration in writing this paper.\nReferences\n1. Gonçalves AV, Barros NF, Bahamondes L (2017) The Practice of hatha \nyoga for the treatment of pain associated with endometriosis. J Altern \nComplement Med 23(1): 45-52. \n2. Pedersen BK, Saltin B (2015) Exercise as medicine - evidence for \nprescribing exercise as therapy in 26 different chronic diseases. Scand J \nMed Sci Sports 25 Suppl 3: 1-72. \n3. Butt CA (2017) “Move your arm like a swan”: dance for pd demedicalizes \nparkinson disease. JAMA 317(4): 342-343.\n4. Hulbert S, Ashburn A, Roberts L, Verheyden G (2017) Dance for \nparkinson’s-the effects on whole body co-ordination during turning \naround. Complement Ther Med 32: 91-97. \n5. Shanahan J, Morris ME, Bhriain ON, Volpe D, Lynch T , et al. (2017) \nDancing for parkinson disease: a randomized trial of irish set dancing \ncompared with Usual Care. Arch Phys Med Rehabil 98(9): 1744-1751. \n6. Ventura MI, Barnes DE, Ross JM, Lanni KE, Sigvardt KA, et al. (2016) A \npilot study to evaluate multi-dimensional effects of dance for people \nwith Parkinson’s disease. Contemp Clin Trials 51: 50-55. \n7. Krampe J, Wagner JM, Hawthorne K, Sanazaro D, Wong-Anuchit C, et al. \n(2014) Does dance-based therapy increase gait speed in older adults \nwith chronic lower extremity pain: a feasibility study. Geriatr Nurs \n35(5): 339-344. \n8. Carpenter SE, Tjaden B, Rock JA, Kimball A (1995) The effect of regular \nexercise on women receiving danazol for treatment of endometriosis. \nInt J Gynaecol Obstet 49(3): 299-304. \n9. Zhao L, Wu H, Zhou X, Wang Q, Zhu W, et al. (2012) Effects of progressive \nmuscular relaxation training on anxiety, depression and quality of life \nof endometriosis patients under gonadotrophin-releasing hormone \nagonist therapy. Eur J Obstet Gynecol Reprod Biol 162(2): 211-215.\n10. Friggi K, Garcia MC, Petta CA, Ribeiro DA, de Oliveira Monteiro NR, et \nal. (2012) Physical therapy and psychological intervention normalize \ncortisol levels and improve vitality in women with endometriosis. J \nPsychosom Obstet Gynaecol 33(4): 191-198. \n11. Bonocher CM, Montenegro ML, Rosa E Silva JC, Ferriani RA, Meola J \n(2014) Endometriosis and physical exercises: a systematic review. \nReprod Biol Endocrinol 12: 4. \n12. Gonçalves AV, Makuch MY, Setubal MS, Barros NF, Bahamondes L \n(2016) A Qualitative study on the practice of yoga for women with pain-\nassociated endometriosis. J Altern Complement Med 22(12): 977-982. \n13. Stratton P , Khachikyan I, Sinaii N, Ortiz R, Shah J (2015) Association of \nchronic pelvic pain and endometriosis with signs of sensitization and \nmyofascial pain. Obstet Gynecol 125(3): 719-728. \n14. Perelló MF, Martínez-Zamora MÁ, Torres X, Munrós J, Balasch Cortina J \n(2017) Endometriotic pain Is associated with adenomyosis but not with \nthe compartments affected by deep Infiltrating endometriosis. Gynecol \nObstet Invest 82(3): 240-246.","source_license":"CC0","license_restricted":false}