{"paper_id":"3d777408-48c5-403a-b5df-c80849d0bd86","body_text":"1\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nInternational \nJournal of\nHealth \nScience\nv. 4, n. 10, 2024\nAll content in this magazine is \nlicensed under a Creative Com-\nmons Attribution License. Attri-\nbution-Non-Commercial-Non-\nDerivatives 4.0 International (CC \nBY-NC-ND 4.0).\nEFFECT OF THIELE \nMASSAGE AND \nTRANSCUTANEOUS \nELECTRICAL \nSTIMULATION ON \nQUALITY OF LIFE AND \nPHYSICAL SYMPTOMS \nIN WOMEN WITH \nENDOMETRIOSIS: A \nRANDOMIZED CLINICAL \nTRIAL\nBruna Silva Oliveira\nPhysiotherapist, postgraduate student \nin Urogynecology and Obstetrics - \nINTERFISIO/RJ\nLuliane Bressan de Oliveira\nPhysiotherapist, postgraduate student in \nTrauma-orthopedics - FUPAC/UBÁ\nGeovane Elias Guidini Lima\nMaster in Bioengineering by: Universidade \nBrasil\nPhysiotherapy teacher of the course - \nFUPAC/Ubá\nKarina Oliveira Martinho\nPost-doctorate in Public Health and \nNutrition by UFV\nPhysiotherapy teacher of the course - \nFUPAC/Ubá\nCarla Marinho Carias\nPostgraduated in Neurofunctional \nPhysiotherapy\nPhysiotherapy teacher of the course - \nFUPAC/Ubá\n\n \n2\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nAdelton Andrade Barbosa\nMaster in Biology by: Universidade Federal \nde Viçosa\nPhysiotherapy teacher of the course - \nFUPAC/Ubá\nPriscila Almeida Barbosa\nMaster in Public Health by UFJF , Teacher of \nthe physiotherapy course - UniAcademia/ JF\nAbstract: Introduction: Endometriosis \nis a chronic disease capable of drastically \ninterfering with women’s quality of life. \nAvailable treatments fail to manage pain and \nimprove patients’ quality of life. Despite being \na growing variable in studies, there is a shortage \nof alternative techniques for managing pain \nand improving quality of life. Objective: To \nevaluate the effect of Thiele massage and \ntranscutaneous electrical stimulation on \nquality of life and physical symptoms in women \nwith endometriosis through a randomized \nclinical trial. Methodology: a total of 21 \nvolunteers participated in 3 intervention \ngroups. In G1 there was application of \nThiele massage, in G2 there was application \nof transcutaneous electrical stimulation \nand in G3 there was a combination of both \ntechniques. Assessments were measured \nusing the Visual Analogue Pain Scale and the \nquestionnaire: Endometriosis Health Profile \nQuestionnaire-30. Results: For quality of \nlife there was a significant improvement (p \n≤ 0.05) in the 3 intervention groups; diffuse \nabdominal pain, pain on vaginal palpation \nand the presence of trigger points, a statistical \nimprovement was found only in G1 and G3; \npain during sexual intercourse achieved a \nstatistical improvement of 100% in G1 and G2. \nConclusion: Electrical stimulation and Thiele \nmassage resulted in a better assessment of \nquality of life in patients with endometriosis, \nwith no difference between the techniques. \nThiele’s massage improved physical symptoms \nrelated to endometriosis. Electrostimulation \nwas not able to obtain statistical improvement \nin physical symptoms, only in pain during \nsexual intercourse. The combination of the \ntwo techniques improved abdominal and \nvaginal pain, but did not improve strength or \npain during sexual intercourse.\nKeywords: Endometriosis, Chronic pelvic \npain, Physiotherapy, Thiele massage, \nElectrostimulation.\n\n \n3\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nINTRODUCTION\nEndometriosis is characterized by a chronic \ninflammatory disease 1, and presents as a \npainful disorder 2 accompanied by adhesions \nand anatomical deformities which are related \nto chronic pelvic pain (CPP) and infertility. 1 \nIt affects approximately 10% of women, who \nare diagnosed at reproductive age. 2 The main \nmanifestations are dysmenorrhea, chronic \npelvic pain, profound dyspareunia, dyschezia \nand dysuria.3,4 \nCPP is characterized by non-cyclical and \nnon-menstrual pain, located in the lower \nportion of the abdomen and lasting at least \n6 months, with continuous or intermittent \nsymptoms, which is not related to sexual pain.5 \nIn addition to the clinical manifestations \nalready mentioned, psychological symptoms \nsuch as anxiety and depression are prevalent \nin women with endometriosis. Problems \nrelated to relationships are also recurrent, \nsince, due to pelvic pain, there is a decrease \nin the frequency of sexual intercourse, which \nin many cases ends up leading to divorce due \nto the partner’s misunderstanding. Given the \ncountless repercussions in the life context \nof this population, there has been a growing \ninterest in discovering new tools to combine \nwith the medical treatment of this condition.3 \nIn addition to clinical diagnosis, \nlaparoscopy is indicated as the gold standard \nfor diagnosing Endometriosis, however it \nis known that around 60% of women with \nCPP have never received a correct diagnosis, \nand around 20% are even subjected to an \ninvestigation for the pain picture presented 5.  \nIn this context, women experience a delay of 7 \nto 12 years from the onset of pain symptoms to \nsurgical diagnosis and this delay is even greater \nfor patients seeking concomitant treatment \nfor infertility and CPP . All this difficulty in \naccessing the correct diagnosis not only leads \nto ineffective treatments for this condition, but \nalso affects the quality of life of these women \nin their social and personal aspects. Partially, \nthis is due to the requirement for a surgical \nlaparoscopy exam to confirm the diagnosis \n5 and untrained health professionals, who \nin many cases trivialize and normalize self-\nreported pain and severity in women. 6\nThere are currently no curative treatments \nfor DPC 6, therefore, first-line treatment \noptions are restricted to surgical incisions and \nhormonal therapies, which can offer positive \nresults in controlling the extent of the disease, \nbut are still ineffective in controlling pain.4 \nAll of these approaches focus on the treatment \nof ectopic lesions of the endometrium, in turn \nnot intervening in the mechanisms of central \nsensitization and myofascial pain secondary \nto active myofascial trigger points (i.e., \nspontaneously painful) which are probably \na source of initiation, amplification and \nperpetuation of the pain even after surgery. 7 \nFurthermore, it is important to highlight \nthat endometriosis itself is also refractory to \nthese conventional treatments, causing many \nfrustrations for patients who resort to these \nresources in an attempt to minimize their \npain. It is noteworthy that the rate of recurrent \npain after surgical intervention reaches \n30%, corresponding to a total of 2 million \nwomen worldwide who do not have access \nto specialized treatment centers, highlighting \nthe urgent need for new methods, techniques \nand alternative practices that help control and \nreduce pain.\nAlthough endometriosis is a relevant and \nextremely current topic in the women’s health \nscenario, we know that the literature is still \nvery scarce regarding the physiotherapeutic \napproach to this condition, which makes \nit necessary and urgent to expand our \nknowledge regarding the applicability of non-\ninvasive resources, such as Thiele massage and \ntranscutaneous electrical stimulation as allies \nin the treatment of this condition.\nThus, the present study aimed to \n\n \n4\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nevaluate the effect of Thiele massage and \ntranscutaneous electrical stimulation on \nquality of life and physical symptoms in \nwomen with endometriosis. \nMATERIALS AND METHODS\nThis is a randomized, experimental, \nexplanatory, prospective longitudinal clinical \ntrial, approved by the local institutional Ethics \nCommittee.\nFirst, an invitation to women to respond \nto an online questionnaire (Appendix 1) was \nwidely publicized on social media, which \ncollected data on age, body mass index, history \nof pathologies and medical diagnosis, current \nhormonal therapies, previous surgeries, \nfrequency and satisfaction. of sexual activity. \nBased on the responses, women with an \nactive menstrual period between 18 and 50 \nyears of age, with a confirmed diagnosis of \nendometriosis and symptoms of chronic pelvic \npain were included, for convenience. Those \nwho had undergone previous physiotherapy \ntreatment for the same purpose, those who \nhad a history of genital malignancy, a history \nof pelvic organ prolapses, a history of previous \nsurgery in the abdominopelvic region and \nthose who did not agree to sign the Informed \nConsent form were excluded. according to \nresolution 466/2012 of the National Health \nCouncil (Annex 2).\nA total of 21 women with endometriosis \nwere eligible for the study and were evaluated \nand treated at ``Clínica Escola Doutor \nCícero Brandão`` in Ubá – MG or at the \npatient’s home, preserving the guarantee of no \nchanges in the results in any of the research \nenvironments. \nIn the first consultation, the Endometriosis \nHealth Profile Questionnaire-30 (EHP-30)8 \nquestionnaire (Appendix 3) was administered \nto assess quality of life. The questionnaire \nconsists of two parts, the first of which is \ndivided into 5 domains (pain, control and \nimpotence, emotional well-being, social \nsupport and self-image) containing 30 \nquestions applied to all women. The second \npart is modular and contains 6 domains \n(work, relationship with children, sexual \nrelations, medical relationship, treatment and \ninfertility), made up of 23 questions which \ndo not necessarily apply to all women. Each \nquestion ranges from 0 (never) to 4 (always), so \nthat the minimum number of points achieved \nwould be zero (indicating the best state of \nhealth) to 212 (indicating the worst state of \nhealth). Next, there was a physical assessment \n(Appendix 4) through vaginal and abdominal \npalpation to quantify pain, trigger points and \nmuscle strength. Palpation was performed \nby dividing the abdomen into 4 quadrants \nand palpating the regions to identify painful \ndiscomfort. During vaginal palpation, we \ndivide the 4 quadrants by viewing the clock \nand applying pressure to the vaginal wall to \nidentify pain points. To quantify pain, we \nuse the Visual Analogue Scale (V AS), which \nvaries from 0 to 10, where 0 means no pain \nand 10 refers to maximum pain; The trigger \npoints were evaluated using the deep sliding \ntechnique during vaginal palpation and \nquantified according to their presence in the \nvaginal wall (0-10), and finally the muscular \nstrength of the pelvic floor using the Modified \nOxford Scale, which ranges from 0 to 5, where \n0 means no contraction and 5 means strong \ncontraction. The evaluations were carried out \nby a single evaluator to avoid bias in the work.\nAfter the evaluation, the patients were \nrandomly divided into three groups: In G1, \nthey underwent Thiele massage, lasting 10 \nminutes, which consists of posterior digital \npressure with stretching of the muscles \n1. In G2, they underwent transcutaneous \nelectrical stimulation in the sacral region \n(S4-S5), frequency of 85Hz, pulse duration \nof 75μs, intensity adjustable to “comfortable \nstrong” and duration of 30 min 1. In G3, \n\n \n5\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nthey underwent a combination of the two \ninterventions simultaneously. All participants \nunderwent 15 consultations, twice a week. At \nthe end, the participants were re-evaluated by \nthe same initial evaluator.\nFor statistical analysis, data were entered \ninto Microsoft Excel (2010) and analyzed \nusing STATA software (version 13.0). Initially, \nall variables were tested for normality using \nthe Shapiro Wilk test and homogeneity using \nthe Levene test. For data analysis, descriptive \nanalysis was used with mean and standard \ndeviation for quantitative variables and \nabsolute and relative frequency for qualitative \nvariables. \nTo compare proportions between \nqualitative variables, Fisher’s Exact Test \nwas used. The Kruskall Wallis test was used \nto compare means between groups and \nthe Wilcoxon test was used to evaluate the \neffectiveness of the protocol, before and after \ntreatment. The level of significance adopted \nwas α = 0,05. \nRESULTS\nWhen characterizing the sample, most \nparticipants were married, used a hormonal \ncontraceptive method to control symptoms, \ndid not have nutritional monitoring, were not \ndiagnosed with infertility and the symptoms \nbegan more than 18 months ago. There \nwas no statistical difference in the sample \ncharacterization between the groups. (Table \n1)\nWhen we assessed quality of life according \nto the EHP-30 questionnaire, we observed \nthat there was a significant improvement (p ≤ \n0.05) in the 3 intervention groups, but with no \ndifference between them. (Table 2) \nIn table 3, when evaluating the physical \nsymptoms related to diffuse abdominal pain, \npain on vaginal palpation and the presence \nof trigger points, there was a statistical \nimprovement only in G1 and G3 with the \ntreatment; muscle strength statistically \nimproved only in G1 and pain during sexual \nintercourse achieved a statistical improvement \nof 100% in G1 and G2. However, there was no \nstatistically significant difference between the \ngroups.\nDISCUSSION\nThe present study aimed to evaluate the \neffect of Thiele massage and transcutaneous \nelectrical stimulation on quality of life \nand physical symptoms in women with \nendometriosis.\nThe general characterization of the sample \nproved to be homogeneous since the majority \nof participants had an average age of 32.1 years, \nwere married, used hormonal contraceptives \nto control symptoms and diagnose infertility, \nwere sedentary, did not have nutritional \nsupport and they had a prolonged period \nof time between the onset of symptoms and \npain. Although not the subject of our research, \nthe profile of women with endometriosis in \nthis study portrays the social barriers to be \novercome, as many of them tend to endure the \npain for more or less 2 years before seeking \ntreatment, plus there is still the barriers related \nto the lack of training of health professionals \nin diagnosis and therapy, thus perpetuating \nthe patient’s painful symptoms for a long time \nthrough ineffective treatments. \nWhen we evaluate quality of life, we see \nimprovements in all groups. \nMira et al .4 in a study with 22 women \nwith endometriosis showed a significant \nimprovement in general symptoms and \nquality of life through the application of \ntranscutaneous electrical nerve stimulation \nalone, corroborating our findings. Nonetheless, \nDel Forno et al .1 in a study carried out with \n10 women diagnosed with endometriosis and \nmonitored by Transperineal ultrasound, they \ndid not observe any improvement in quality \nof life with Thiele’s massage. This finding \n\n \n6\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nVariables Group 1 Group 2 Group 3 p-value\nAge (years), Average (DP) 37,4 (± 5,3) 29,1 (± 6,9) 29,8 (± 6,2) 0,79*\nMarital status, N (%)\n Single 1 (14,3%) 2 (28,6%) 3 (42,8%) 0,67#\n Married 6 (85,7%) 5 (71,4%) 4 (57, 2%)\nHormonal method, N (%)\nThe patient does not use it 3 (42,8%) 1 (14,3%) 1 (14,3%) 0,37#\nThe patient uses it 4 (57,2%) 6 (85,7%) 6 (85,7%)\nNutrition, N (%)\nNo 6 (85,7%) 5 (71,4%) 4 (57,2%) 0,19#\nYe s 1 (14,3%) 2 (28,6%) 3 (42,8%)\nPhysical exercise, N (%)\nNo 4 (57,2%) 3 (42,8%) 5 (71,4%) 0,22#\nYe s 3 (42,8%) 4 (57,2%) 2 (28,6%)\nInfertility, N (%)\nNo 4 (57,2%) 6 (85,7%) 6 (85,7%) 0,13#\nYe s 3 (42,8%) 1 (14,3%) 1 (14,3%)\nPain realized, Average (DP) 7,4 (± 2,7) 6,7 (± 2,7) 7,3 (±3,1) 0,59*\nPeriod of pain (months), Average (DP) 89,4 (±104,3) 89,7 (±116,0) 134,6 (±92,8) 0,09*\nOnset of symptoms, N (%)\n0 – 6 months -- 1 (14,3%) -- 0,27#\n6 – 18 months 1 (14,3%) -- --\n18 – 24 months 6 (85,7%) 6 (85,7%) 7 (100%)\nTable 1: Characterization of the sample profile of women with endometriosis, according to treatment \ngroups. Ubá, 2022.\n# It means p-value in Fisher’s Exact test; * means p-value in the Wilcoxon test; SD: Standard deviation; N: \nsample number\nVariables Group 1 Group 2 Group 3\nQuality of life, average (DP)\nBefore 96,6 (± 50,4) 102,4 (± 30,4) 99 (± 50,1)\nAfter 19,4 (± 20,1) * 39,8 (± 25,3) * 23,1 (± 22,5) *\nTable 2: Quality of life assessment according to the EHP-30 questionnaire before and after treatment. \nUbá, 2022.\n* it means p-value ≤ 0.05, in the Wilcoxon test | SD: Standard deviation\nVariables Group 1 Group 2 Group 3\nDiffuse abdominal pain, Average (DP)\nBefore 12,1 (±10,3) 10,7 (± 11,8) 12 (± 7,0)\nAfter 2,0 (± 2,1) * 2,6 (± 2,6) 3,7 (± 2,9) *\nPain on vaginal palpation, average (DP)\nBefore 16,8 (± 10,7) 7,3 (± 8,2) 17,7 (± 10,8)\nAfter 1,3 (± 1,9) * 0,7 (± 1,2) 2,7 (± 1,9) *\nPresence of trigger point, average (DP)\nBefore 1,0 (± 0,8) 0,8 (± 0,9) 1,8 (± 1,7)\n\n \n7\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nAfter 0,0* 0,4 (± 0,8) 0,5 (± 1,1) *\nMuscle strength, average (DP)\nBefore 2,1 (± 1,8) 1,7 (± 0,7) 2,7 (± 1,1)\nAfter 2,8 (± 1,7) * 2,1 (± 0,9) 3,1 (± 0,9)\nPain during sexual intercourse, N (%)\nBefore 6 (85,7%) 4 (57,2%) 2 (28,6%)\nAfter -- -- 1 (14,3%)\nTable 3: Assessment of physical symptoms of endometriosis before and after treatment. Ubá, 2022.\n* it means p-value ≤ 0.05, in the Wilcoxon test; SD: Standard deviation; N: sample number\ncan be justified by the use of a self-reported \nquestionnaire to assess QoL in this population, \nunlike our study, which chose to apply a \nvalidated instrument for this condition, the \nEHP-30.8\nWhen analyzing the physical symptoms \nreported by patients in the study results, we \nnoticed a statistical improvement in diffuse \nabdominal pain and vaginal pain only in the \ngroups that received Thiele’s massage and \nno difference in the group that underwent \nonly transcutaneous electrical stimulation. \nAlthough Mira et al.4 pointed out a significant \nimprovement in pain after the application of \nelectrical stimulation in endometriosis, our \nstudy did not observe an improvement in the \nsymptoms evaluated. Klotz et al.9 and Aredo \net al.7 concluded that trigger point therapy \nand Thiele massage showed superior results \nto other techniques by demonstrating positive \nresults in the patient’s painful myofascial \nsyndrome. These data support our findings in \nthat myofascial syndrome may not necessarily \ncause latent pain, but may limit movement \nand develop muscle weakness. Therefore, \ninhibiting this painful reflex resulting from \nmyofascial syndrome is important to obtain \nsignificant improvement in pain symptoms \nand trigger points in the abdominopelvic \nmuscles.5\nWhen we evaluate the variable muscle \nstrength, we observed an improvement only \nin the Thiele massage group, a fact that can be \njustified by the indirect effect of the massage \nthat acts on myofascial dysfunctions, by \nreducing muscle tension and promoting the \nrelease of trigger points, in turn normalizing \nthe length. and stretching the fiber, thus \nfavoring better contractile capacity. Based on \nthis assumption, the improvement in strength \nin group 1 is justified, in which the recovery \nof myofascial function corresponded to the \nrecovery of tissue contractility and consequent \nimprovement in muscle strength.7\nPain during sexual intercourse can be present \nbefore, during or after sexual intercourse, \nnegatively influencing women’s physical and \nmental health, with important repercussions \non their personal and interpersonal \nrelationships. In our study, we obtained a 100% \nimprovement in pain in groups 1 and 2. The \nstudy by Del Forno et al.1 mentioned above \nshows that Thiele’s massage improved sexual \nfunction and dyspareunia after 5 sessions of \n30 minutes each. In a systematic review of \ncomplementary interventions to treat pain \nin women with endometriosis, acupuncture \nwas identified as an effective method for \nimproving pain. However, the review presents \na set of approaches that showed a tendency \nto improve pain during sexual intercourse, \nincluding Thiele’s massage.3 A narrative review \ndemonstrated satisfactory results for female \npainful sexual disorders with the application \nof various methods, including transcutaneous \nelectrical stimulation. The analgesic effects \nof electrical stimulation are related to a \nmechanism of “closing the entrance” in the \n\n \n8\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\ndorsal columns of the spinal cord and may also \nbe associated with the release of endogenous \nopioids, since when using a strong intensity \nlevel of electrical stimulation, there will be \ninduction of the release of these substances \nat the brain and spinal level determined the \nsedative effect on peripheral nerves, data that \nconfirm and support the effect of this resource \nas an adjuvant in the treatment of pain.10\nGroup 3, despite having been subjected to \nboth resources, did not show an improvement \nin strength and pain during sexual intercourse \nas expected, just as Group 2, in turn, only \nimproved pain during sexual intercourse, \nthese inconsistencies in the findings suggest \na limitation of the study with regard not only \nto the sample size, but the heterogeneity of \nthe groups and the lack of control for the \npain time variable in the assessment between \ngroups for greater reliability of the results.\nCONCLUSION\nElectrostimulation and perineal massage \nresulted in a better assessment of quality of \nlife in patients with endometriosis, with no \ndifference between the techniques. Thiele’s \nmassage improved physical symptoms related \nto endometriosis. Electrostimulation was \nnot able to obtain statistical improvement \nin physical symptoms, only in pain during \nsexual intercourse. The combination of the \ntwo techniques improved abdominal and \nvaginal pain, but did not improve strength or \npain during sexual intercourse.\nIt is hoped that this preliminary study can \nguide new future research on endometriosis \nin the area of Pelvic Physiotherapy, based \non the premise of a more significant sample \nvalue and greater rigor regarding the control \nvariable, time of pain in this condition, in \norder to offer the possibility of an effective \nand safe that results in effective control of \nsymptoms and improvements in the quality of \nlife of this population.\n\n \n9\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1594102422016\nREFERENCES\n1. 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Physiotherapy management of patients with chronic pelvic pain \n(CPP): A systematic review. Physiother Theory and Pract. 2019; 35(6): 516-532.\n10. Lima RGR, Silva SLS, Freire AB, Barbosa LMA. Tratamento Fisioterapêutico nos Transtornos Sexuais Dolorosos Femininos: \nRevisão Narrativa. Rev. Ele. Estacio Rec. 2016; 2(1):02-10.","source_license":"CC0","license_restricted":false}