{"paper_id":"3648bee1-884e-46db-85ac-8beb4adb47f0","body_text":"REVIEW ARTICLE\nPhysiotherapy and physical activity as \nadjunctive  treatments in women with \nsymptomatic endometriosis – literature \nreview\nFizjoterapia i aktywność fizyczna jako leczenie wspomagające u kobiet \nz objawową endometriozą – przegląd literatury\nKateryna Shved1,A-F \n , Klaudia Antkowiak2,B-D \n , Zofia Kędzierska 3,B-C,E  \n , Urszula Żurek 3,A-C \n , \nKlaudia Dadas 3,C,E-F  \n , Aleksandra Świercz3,A,F \n , Dominika Małachowska3,E-F \n ,  \nHubert Ciecierski-Koźlarek4,C \n , Ignacy Tołwiński3,E \n1 Multidisciplinary Municipal Hospital named after J. Strusia in Poznan, Poland  \n2 Hospital of the Middle Heart of Jesus Company z o.o in Sroda Wielkopolska, Poland  \n3 Warsaw Southern Hospital, Poland  \n4 Provincial Specialist Hospital in Olsztyn, Poland  \nA – Research concept and design, B – Collection and/or assembly of data, C – Data analysis and interpretation,  \nD – Writing the article, E – Critical revision of the article, F – Final approval of the article\nShved K, Antkowiak K, Kędzierska Z, Żurek U, Dadas K, Świercz A, Małachowska D, Ciecierski-Koźlarek H, Tołwiński I. Physiotherapy and \nphysical activity as adjunctive treatments in women with symptomatic endometriosis: a review of the literature. Med Og Nauk Zdr.  \ndoi: 10.26444/monz/169984\nAbstract\nIntroduction and Objective. Endometriosis can be identified \nby the presence of endometrial tissue in an abnormal location. \nIt affects almost 10% of women of reproductive age and is \ncharacterized by persistent pelvic pain and chronic inflammation. \nThere is no effective cure for endometriosis. The purpose of \nthe study is to examine whether exercise and pelvic floor \nphysiotherapy may help symptomatic endometriosis patients. \nReview Methods. Using the PubMed database, an extensive \nexamination of the existing literature was conducted. \nKeywords served as a guide for the search strategy. Each \narticle was analyzed and assessed for eligibility for inclusion \nin the review.   \nBrief description of the state of knowledge. Due to the lack \nof targeted endometriosis therapy, non-pharmacological and \nless invasive methods are becoming increasingly prevalent. \nPelvic floor physiotherapy is a therapeutic technique that \nreduces pain while also increasing quality of life. Physical \nexercise has an anti-inflammatory effect, slowing the course \nof the condition.   \nSummary. According to a review of the articles, both treatment \nmethods can improve the biopsychophysical condition of \nendometriosis-afflicted females in a non-invasive manner, and \ncan have a number of beneficial effects on the symptoms of \nthis disease. In the light of the fact that standard treatments \nmay be ineffective and endometriosis symptoms may \nreappear following treatment, it is crucial to inform women \nof the potential benefits of physiotherapy and exercise. \nKey words\ngynaecology, endometriosis, physiotherapy, pelvic floor phy-\nsiotherapy, physical activity, deep infiltrating endometriosis\nStreszczenie\nWprowadzenie i cel pracy. Endometriozę można zdefiniować \njako obecność tkanki endometrium poza jamą macicy. Cho -\nroba dotyczy prawie 10% kobiet w wieku rozrodczym i cha -\nrakteryzuje się uporczywym bólem miednicy i przewlekłym \nprocesem zapalnym. Obecnie nie ma skutecznego leczenia \nendometriozy. Celem przeglądu jest analiza, czy ćwiczenia \ni fizjoterapia dna miednicy mogą pomóc pacjentkom z obja -\nwową endometriozą.   \nMetody przeglądu. Przeprowadzono badanie istniejącej \nliteratury, korzystając z bazy danych PubMed. W celu wyszu -\nkiwania odpowiednich artykułów wykorzystane zostały słowa \nklucze. Każdy artykuł został przeanalizowany i oceniony pod \nkątem tego, czy kwalifikuje się do włączenia do przeglądu.  \nOpis stanu wiedzy. Z powodu braku ukierunkowanej terapii \nendometriozy coraz większy nacisk kładzie się na metody nie-\nfarmakologiczne i mniej inwazyjne. Fizjoterapia dna miednicy \njest techniką terapeutyczną, która zmniejsza ból, a jedno -\ncześnie poprawia jakość życia. Ćwiczenia fizyczne wykazują \ndziałanie przeciwzapalne, spowalniając przebieg choroby.   \nPodsumowanie. Przegląd artykułów i badań w nich opi -\nsanych pokazuje, że obie metody leczenia mogą poprawić \nstan biopsychofizyczny kobiet dotkniętych endometriozą. \nSą one nieinwazyjne i mogą mieć szereg korzystnych opcji \ndla objawów tej choroby. Ponieważ standardowe leczenie \nendometriozy może być nieskuteczne, a objawy mogą pojawić \nsię ponownie po zakończeniu leczenia, niezwykle ważne jest \npoinformowanie kobiet o potencjalnych korzyściach fizjote -\nrapii i ćwiczeń fizycznych.\nStreszczenie\nendometrioza, fizjoterapia, fizjoterapia dna miednicy, gineko-\nlogia, aktywność fizyczna, głęboko naciekająca endometriozaAddress for correspondence: Kateryna Shved,  Multidisciplinary Municipal Hospital \nnamed after J. Strusia in Poznan, Szwajcarska 3, 61-285 Poznań, Poland\ne-mail: katey.shved@gmail.com\nReceived:  26.06.2023; accepted: 25.07.2023; first published: 31.07.2023\nMedycyna Ogólna i Nauki o Zdrowiu\nwww.monz.pl\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\n\nKateryna Shved, Klaudia Antkowiak, Zofia Kędzierska, Urszula Żurek, Klaudia Dadas, Aleksandra Świerc z. Physiotherapy and physical activity as adjunctive …\nINTRODUCTION AND OBJECTIVE\nEndometriosis is a prevalent disease characterized by chronic \ninflammation and associated pain. It affects approximately \n5–10% of women of reproductive age. At present, 190 million \nwomen are affected by endometriosis, according to statistics \n[1]. This disease is characterized by an increase of endometrial \nglands and stroma in areas outside the uterus, inside and \noutside the pelvic cavity [2]. In other terms, it signifies the \npresence of endometrial tissue outside of its normal location. \nClinically, endometriosis looks very diverse, and there is no \nobservable relationship between the severity of the disease \nand the occurrence of symptoms. This may indicate the role \nof other factors, more complex, in addition to basic organic \ndisease. Endometriosis is now considered to be a multimodal \netiology disease, as systems other than the gynecological \ncontribute to the development of endometriosis alterations \n[3]. The pathogenesis of endometriosis is strongly associated \nwith hormonal factors such as estrogen dependence or pro-\ngesterone resistance, as well as genetic and environmental \nfactors. Inflammatory processes, such as oxidative stress or \nan increase in inflammatory mediators, are also implicated \nin the pathogenesis of this condition [4]. The disease process \ninvolves the ectopic growth of endometrial tissue, which is \nstimulated by estrogens. Therefore, estrogen exposure ap -\npears to be necessary for the development of symptomatic \nendometriosis in the majority of women with childbearing \npotential. In addition to hormonal factors, genetic factors \nalso contribute to the development of the disease, which is \nwhy patients with affected first-degree relatives have a seven- \nto tenfold increased risk. African-Americans and Asians \nseem to be less susceptible to endometriosis than Cauca -\nsians. Endometriosis risk factors include early and frequent \nor prolonged menstruation, high growth, and low BMI, \ni.e., it occurs primarily in tall and thin women; nulliparity; \nprematurity; abnormal uterine bleeding in the first year of \nlife; and even abuse in childhood [5]. Whereas pregnancy, \nbreastfeeding, and menopause all constitute factors that \nreduce the risk of endometriosis. The most common site \nof endometriosis implants is the peritoneal cavity (ovaries, \nFallopian tubes, bladder, broad and round ligaments of the \nuterus, colon, and appendix). Disease outbreaks can also be \nfound in the scars after the episiotomy or Caesarean section, \nin the uterine muscle wall (adenomyosis), and sometimes \n(but rarely) they may occur in the liver, kidneys, pleural ca-\nvity, or even in the gluteal muscles. Regrettably, there exists \na disparity in the incidence of endometriosis across various \nresearch studies. In women with infertility, the prevalence \nranges from 20–50%, which might be because endometriosis \nis a contributing factor to infertility. Chronic pelvic pain is \npresent in a range of 71–87% of affected women. The primary \nclinical manifestation of endometriosis is the occurrence of \nintense menstrual pain, commonly referred to as dysme -\nnorrhea. Dyspareunia, or pain during sexual intercourse, \nis also a frequently reported condition, often accompanied \nby the onset of chronic pelvic pain (CPP). It is important to \nnote that progression of the disease may lead to infertility. \nFurthermore, it has been reported in numerous studies that \nthere is a correlation between pain symptoms and loss of \nfertility with anxiety and depression among patients with \nendometriosis, leading to a rate of almost 87% of women \ndeveloping some type of psychiatric disorder [6]. Despite \nbeing a common disease, misdiagnosis is still observed and \nthe diagnosis is frequently delayed by a few years, and the \nadministration of effective therapy often prolonged. On \naverage, it can take anywhere from 8–10 years to diagnose \nendometriosis, depending on the study. During this time, \nit is possible for both musculoskeletal and mental disorders \nto develop as secondary changes [2]. Even after receiving \nproper treatment, many patients still feel pain, which wor -\nsens the quality of life [7]. Nowadays, the primary approach \nto managing endometriosis involves surgical intervention, \nhormonal therapy, and reduction of pain, which is the most \ndifficult and disturbing symptom experienced by women. In \nthe absence of effective endometriosis treatment at present, \nthere is an increasing interest in other options for treating this \ncondition that are non-pharmacological and less invasive. \nPhysiotherapy and exercises can be such an ‘other option’. \nThe purpose of this review is to check the literature and \nassess whether exercise and pelvic floor physiotherapy can \nbe used as supportive treatments for women suffering from \nsymptomatic endometriosis.\nMATERIALS AND METHOD\nA comprehensive review of the literature was carried out by \nsearching the PubMed database. The search strategy was gu-\nided by the following keywords: ‘endometriosis’, ‘physiothe-\nrapy’, ‘gynecology,’, ‘pelvic floor physiotherapy, ‘physical \nactivity’ and ‘deep infiltrating endometriosis’. Each article \nwas analyzed and assessed for eligibility for inclusion in the \nreview. Eligibility criteria were: English or Polish language, \narticles published after 2015, full-text articles, articles on \nphysiotherapy and exercises in women with laparoscopically \nconfirmed endometriosis, and articles on the inclusion of all \ntypes of physical exercises. First, each article was checked by \ntitle and abstract, then downloaded and analyzed by qualifi-\ncation criteria. This analysis did not take into account articles \npublished before 2015, articles on physiotherapy for women \nwithout diagnosed endometriosis, or articles without the \npossibility of downloading the full text. No effort was made \nto find studies that had not been published.\nCURRENT STATE OF KNOWLEDGE\nEndometriosis is a widespread gynecological disease that can \ninterfere with everyday life due to chronic pain and reduced \nquality of life. This particular pathological state results in \na systemic inflammatory response and induces changes in \ngenetic transcription within the central nervous system, \nleading to heightened pain perception (pain sensitization) \nand affective disturbances, which are often mood disorders. \nCharacterized by persistent pelvic and peritoneal inflamma-\ntion and pain, this is the most commonly notified symptom. \nFemales experience an ache during sexual intercourse, as \nwell as during urination and defecation. During menstrual \ncycles, pain may be intensified through hormonal changes [8]. \nPatients presenting with endometriosis symptoms, such as \ninfertility or pain, can pose a challenge in terms of treatment.\nEndometriosis appears to be a systemic disease with vario-\nus manifestations beyond the signs of classic gynecological \ndisease, thereby necessitating a multidisciplinary approach \nfor diagnosis and treatment. Given the chronic nature of \nendometriosis, it would be most advantageous to use agents \nMONZ Medycyna Ogólna i Nauki o Zdrowiu\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\n\nKateryna Shved, Klaudia Antkowiak, Zofia Kędzierska, Urszula Żurek, Klaudia Dadas, Aleksandra Świerc z. Physiotherapy and physical activity as adjunctive …\nthat are safe for long-term application. At present, the most \neffective modality of imaging to identify endometriosis im -\nplants is magnetic resonance imaging (MRI), but laparoscopy \nwith direct visualization of lesions is still considered the \ngold standard for its diagnosis. A definitive diagnosis of \nendometriosis can only be made with a biopsy of the lesion.\nTreatment. There is no target cure for endometriosis. With \na view to the most prevalent symptoms reported by patients, \nnamely chronic pain and infertility, the treatment concen -\ntrates on hormone therapy and surgery, both of which are \ndirected against ectopic endometrial lesions. Such therapies \ndo not allow the cure of endometriosis, although in the \ncase of chronic pain they give the opportunity to control \nthe progression of the disease but, unfortunately, have their \nlimitations and adverse effects [9]. Hormonal treatment can \nbecome inefficient with time, whereas the efficacy of surgery \nis typically short-lasting. Chronic pelvic pain (CPP) is an an-\nnoying symptom in patients with endometriosis. In addition, \nit is often resistant to both hormonal and surgical treatments. \nInfertility, which is the second most common symptom of \nsymptomatic endometriosis, affects up to 50% of women.\nPrior to commencing treatment, it is necessary to ask the \npatient if she intends to conceive in the immediate future, \ngiven the limited treatment options available for those se -\neking both pelvic pain treatment and fertility. However, on \ncertain occasions, gestation provides temporary relief from \nendometriosis-related pain. Furthermore, numerous studies \nhave demonstrated a correlation between depression and \nmanifestations of pain and infertility. It has been observed \nthat nearly 87% of women diagnosed with endometriosis tend \nto develop a certain type of mental disorder [6]. The obvious \nfact is that medical interventions alone are not sufficient to \ntreat and control the symptoms of endometriosis. Presently, \nthere is an increased emphasis on non-pharmacologic and \nminimally invasive interventions; thus, physiotherapy and \nphysical activity may be suggested as alternative or comple-\nmentary treatments.\nRelationship between pelvic floor physiotherapy and en -\ndometriosis – review of the literature. Based on a review \nof the 2021 article, it can be inferred that pelvic floor phy -\nsiotherapy (PFP) can be a promising possibility for treating \nsuperficial dyspareunia and chronic pelvic pain (CPP) caused \nby chronic inflammation in women with deep infiltrating \nendometriosis (DIE) [10]. Deep infiltrating endometriosis \nis a condition when endometriosis implants occur below \nthe peritoneum with access to the rectum, ureters, bladder, \nor uterine ligaments. There is a strong correlation between \nDIE and severe pelvic pain [11]. The article first highlights \nthe occurrence of deep and superficial dyspareunia, while \nother studies focused on dyspareunia only as a symptom of \naching sexual intercourse [12]. Women frequently report the \nsuperficial form of dyspareunia to their doctors as a manife-\nstation of pain symptomatology [13]. Superficial dyspareunia \nis characterized by pain occurring in or around the vaginal \nentrance. Deep dyspareunia is characterized by discomfort \nduring sexual activity [14].\nA randomized study was conducted and described, invol-\nving 34 nulliparous females who reported the symptom \nof superficial dyspareunia and were diagnosed with deep \ninfiltrating endometriosis (DIE). Female participants were \nassigned to 2 cohorts, the control and study groups, in a 1:1 \nratio. The study cohort underwent a series of 5 sessions of \npelvic floor physiotherapy. The requirement was attendan -\nce at all 5 sessions. The results of the study postulate that \nthere was a notable reduction in the intensity of pain for \nthe surface dyspareunia in the study group in relation to \nthe control group. In addition, an identical outcome was \nachieved for chronic pelvic discomfort (CPP). Unfortunately, \nthere was no statistically significant disparity between the \ntwo cohorts for deep dyspareunia or for other symptoms of \nendometriosis, such as dysuria, dyschezia, or painful periods. \nStudies performed with transperineal ultrasound in 3D and \n4D show that women with superficial dyspareunia may have \npelvic floor hypertonia [10, 13]. This also affirms the result of \nthe previously described randomized study. The reduction \nin pain intensity for superficial dyspareunia in the study \ngroup, i.e., women who have completed all 5 physiotherapy \nsessions, suggests that this condition is caused by the lack or \ninadequate relaxation of the pelvic floor muscles. However, \nthe lack of a PFP effect on deep dyspareunia suggests that this \ntype of pain may be caused by the presence of endometriosis \nimplants, and the effect of mass exerted by endometrial tissue \nduring sexual intercourse [15].\nAnother article published in 2022, postulated that any type \nof physiotherapy can be used as an adjunctive treatment for \nendometriosis [5]. The most common forms of this therapy in \nendometriosis are physical therapy and kinesiotherapy. The \narticle indicates that a crucial element in pain relief is women’s \nphysical activity as well as learning to relax and stretch the \nmuscle. However, it does not specify the type and amount of \nphysical activity that should be undertaken. It is noteworthy \nthat physiotherapy can be used in both the physiotherapist’s \noffice and spa treatments. Based on the information provided \nin the article, it is evident that kinesiotherapy constitutes an \nimportant element of treatment for females who have been \ndiagnosed with endometriosis. It is suggested that women \nshould select an appropriate genital exercise regimen with \nthe correct load and targeted massage techniques for the area. \nAttention should be paid to the fact that kinesiotherapy may \nbe a treatment option for people who are ineligible for surgery \nand hormonal treatment [16]. Physicotherapy is also used in \nwomen with endometriosis, mainly phototherapy, electrothe-\nrapy, especially TENS, and laser therapy. Phototherapy and \nlaser therapy are treatment modalities employed to accelerate \nand improve wound healing and tissue regeneration in the \npost-operative period. Phototherapy is utilized to enhance \ncirculation in post-operative areas, whereas laser biostimu -\nlation promotes the proliferation of collagen and nerve fibres \nat wound sites. The main advantage of electrotherapy is its \nanalgesic impact on the pelvic region. The effect of percuta-\nneous electrical nerve stimulation (TENS) has been proven \nin cases in which there was noticeable reduction in pain \nintensity, resulting in an overall enhancement in the quality \nof life among women with deeply infiltrating endometriosis, \nand suffering from deep dyspareunia.\nThere are two different varieties of TENS therapy: low -\n-frequency and high-frequency TENS. Regardless of the \nfrequency distribution, this therapy is effective for reducing \npain intensity.\nRelationship between physical activity and endometriosis \n– a review of the literature. Physical activity works through \nan anti-inflammatory mechanism, impeding the progression \nof the disease.\nMONZMedycyna Ogólna i Nauki o Zdrowiu\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\n\nKateryna Shved, Klaudia Antkowiak, Zofia Kędzierska, Urszula Żurek, Klaudia Dadas, Aleksandra Świerc z. Physiotherapy and physical activity as adjunctive …\nUpon assessing the 2016 article regarding the impact of \nphysical exercise, it can be posited that physical activity \ncan reduce the likelihood of endometriosis development in \nwomen who have not yet developed the condition [17]. On \nthe other hand, it is difficult to clearly determine whether \nphysical activity reduces pain perception in women already \ndiagnosed with endometriosis.\nThe following article assesses 3 studies, 2 of which were \nrandomized. The research included a variety of exercises, ran-\nging from strength training to yoga and varying in frequency \nof training [18]. The studies were conducted on a cohort of \n109 female patients with varying degrees of symptomatic \nendometriosis, validated by surgical or imaging diagnostics. \nThe findings were ambiguous. In Goncalves et al., women \npracticed 120 minutes of yoga twice a week for 8 weeks or \n2 months [19]. The study was randomized, with the women \nassigned to 2 groups: study and control. The effects were eva-\nluated using the visual VAS scale and the EHP-30 Scale (30-\nitem Endometriosis Health Profile) specific to endometriosis. \nFriggi Sebe Petrelluzzi et al. included 30 women diagnosed \nwith endometriosis and chronic pelvic pain lasting 7 years \nor longer [20]. Randomized, Carpenter et al. studied 39 wo-\nmen using Danazol, or hormonal endometriosis treatment \n[20]. Description and results are included in the Table below.\nReferences Type of study Number \n of participants Outcome\nGoncalves et al. [19] Randomized \nstudy 40\nDegree of daily pain \nwas much lower in \nthe study group, \ni.e., in exercising \nwomen, than in the \ncontrol group.\nFriggi Sebe Petrelluzzi \net al. [20]\nNon-randomized \nstudy.\nPre-post study\n30\nNo significant im-\nprovement in pain \nintensity.\nCarpenter et al. [20] Randomized \nstudy 39\nBoth groups, exam-\nined and controlled, \ndemonstrated im-\nprovement in pain-\nful menstruation \nand dyspareunia.\nThe article, assessing 6 other studies about physical exercise \nin endometriosis, presents the results of Koppan et al., Awad \net al., and Armor et al. [20, 21, 22]. Although not randomized, \nKoppan et al. presented interesting results [20]. Eighty-one \nwomen with intraoperatively confirmed endometriosis par-\nticipated in the study. The patients who utilized analgesics \nwhile engaging in physical activity exhibited a decrease in \nthe frequency of their consumption in comparison to those \nwho refrained from exercising. The study by Awad et al. \nincluded a group of 20 female patients with laparoscopically \nconfirmed endometriosis [21]. A variety of physical activities \nwere employed over the course of 24 sessions. The findings \nindicate a positive outcome with a significant reduction in \npain perception. However, according to the negative results \nof a newer study published in 2019 by Armor et al., women \nexperienced an increase in pain sensation during physical \nexercise [22].\nSumming-up the research findings, it can be inferred \nthat due to the significant diversity in the studies (different \nmethods, different durations, different numbers of women, \nand different research projects), it is challenging to determine \ndefinitive conclusions regarding the efficacy of physical trai-\nning in alleviating symptoms of endometriosis, or its impact \non women›s pain levels. Such a variety of studies indicate the \nnecessity to perform high-quality randomized tests and utili-\nzing appropriate pain measurement scales, such as the EHP-\n30, specifically developed for women with endometriosis.\nCONCLUSIONS\nEndometriosis remains a challenging health issue for the \nfemale population. The condition is being recognized not \nonly as a gynaecological disease but also as an internal me -\ndicine concern. It is being emphasized that a multidiscipli -\nnary approach to treatment is needed. There is still a lack of \neffective treatment options, and only symptomatic therapy \nis available: painkillers, predominantly non-steroidal anti -\n-inflammatory drugs (NSAIDs), hormonal medications, and \nsurgical interventions. Physiotherapy and physical training, \nwhich are non-invasive and well-tolerated by women, appear \nto be viable options for supportive care. Furthermore, it can \nbe an alternative treatment option for women who are not \neligible for surgery.\nUpon reviewing the literature on physiotherapy in the \ntreatment of endometriosis, it is clear that this modality, in its \nvarious forms, can be a viable and efficacious complementary \nintervention for females suffering from this disorder. The the-\nrapeutic intervention of pelvic floor physiotherapy is known \nto effectively reduce pain, ipso facto improving the quality \nof life, although it cannot solve the issue of infertility. Re -\ngrettably, owing to the limited quantity of accessible articles \nand studies conducted, it is difficult to clearly determine the \neffectiveness of physical activity in endometriosis treatment. \nIn order to improve research outcomes, it is imperative to \nconduct randomized studies with meticulous attention to \nhigh-quality methods, well-defined research groups, and \nclearly delineated physical training regimens. Test results \nshould be measured using proven pain assessment scales \ndedicated to women with endometriosis. Despite this, this \nreview of the articles and studies clearly indicates that both \nmethods can enhance the biopsychophysical condition of \nfemales afflicted with endometriosis in a non-invasive man-\nner and can have several advantageous outcomes for symp-\ntoms associated with this disease. Considering the fact that \nstandard treatments may be ineffective and endometriosis \nsymptoms may return after treatment, it is essential to convey \nto women the potentially beneficial effects of physiotherapy \nand exercise.\nREFERENCES\n1. Rasheed HAM, Hamid P. Inflammation to Infertility: Panoramic View \non Endometriosis. Cureus. 2020;12:e11516. https://doi.org/10.7759/\ncureus.11516\n2. França PRC, Lontra ACP, Fernandes PD. Endometriosis: A Disease with \nFew Direct Treatment Options. Molecules. 2022;27(13):4034. https://\ndoi.org/doi:10.3390/molecules27134034\n3. Zondervan KT, Becker CM, Missmer SA. Endometriosis. 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Efficacy of exercise on pelvic \npain and posture associated with endometriosis: within subject design. \nJ Phys Ther Sci. 2017;29:2112–2115. https://doi.org/10.1589/jpts.29.2112\n22. Armour M, Sinclair J, Chalmers KJ, et al. Self-management strate -\ngies amongst Australian women with endometriosis: a national on -\nline survey. BMC Complement Altern Med. 2019;19:17. https://doi.\norg/10.1186/s12906-019-2431-x\nMONZMedycyna Ogólna i Nauki o Zdrowiu\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST\nONLINE FIRST","source_license":"CC0","license_restricted":false}