{"paper_id":"95563273-06b9-4eb6-83a7-ed3d471ae0ea","body_text":"Endometriosis is a chronic condition in which endometrial tissue that normally lines the\ninside of the uterus migrates outside of the uterus and attaches to the lining of the\nabdominal cavity and the internal organs inside the pelvis, including the ovaries, Fallopian\ntubes, bladder, and bowel. The condition occurs in 6–10% of reproductive-age women. This\ndisease is an estrogen-dependent chronic inflammatory condition that is associated with\npelvic pain and infertility. Some women with endometriosis have no symptoms, but for those\nthat do, pain can range from mild to severe 1 ) . For most of these women, pain is a consequence resulting in chronic\npelvic pain (CPP). Nearly half of those affected with endometriosis have CPP, while in 70%\npain occurs during menstruation 2 ) . In\nclinical practice, postural changes are frequently observed among women with CPP. Postural\nassessment can lead to early detection of uneven positions, shortenings, antalgic postures\nand tensions. Although these changes may not be the primary cause of the clinical condition,\nthey can contribute significantly to the worsening of pain and tension 3 ) . Endometriosis can be associated with pelvic floor\ndysfunction (PFD). The pelvic floor consists of muscles, connective tissue and supporting\nligaments, which form a sling from the pubic bone to the tailbone. The pelvic floor\nstructures support the abdominal and pelvic organs as well as assisting with sphincter and\nsexual functions. PFD refers to problems that occur when these muscles are weak, in spasm or\ntoo tight 4 ) . Secondary musculoskeletal\nimpairments may occur in the region of endometrial implantation. For instance, endometrial\nimplants on the psoas or lumbar musculature may reproduce musculoskeletal symptoms during\nexamination 5 ) . It is likely that if gone\nuntreated, symptoms will progress and worsen over time 6 ) . While there is no cure for endometriosis, there are two types of\ninterventions; treatment of pain and treatment of endometriosis-associated infertility 7 ) . Physical therapy techniques have been\nproven to reduce pain and improve quality of life in endometriosis. The overall goal of\ntreatment is for the patient to learn how to relax the muscles, which in turn helps break\nthe pain cycle 8 ) . Evidence suggested that\nsymptoms of endometriosis result of a local inflammatory peritoneal reaction caused by the\nectopic endometrial implant, which undergo cyclic bleeding 9 ) . On the other hand, regular physical exercise seems to have\nprotective effects against diseases that involve inflammatory processes since it induces an\nincrease in the systemic levels of cytokines with anti-inflammatory properties 10 ) . Regular physical exercise has been\nclaimed to foster the reduction of menstrual flow, of ovarian stimulation, and of the action\nof estrogen 11 ) . Analysis of available\nliterature data shows that there are no controlled and randomized studies identifying\nwhether, or to what extent physical exercise could be beneficial for women with\nendometriosis. Thus, until now researchers only have speculations about this topic 12 ) . This study was therefore conducted to\ndetermine the effect of an exercise program on pelvic pain and posture associated with\nendometriosis.\n\nThis study was designed as within subject design that compared one group of patients\ndiagnosed with mild or moderate endometriosis before, after 4 weeks, and after 8 weeks\nperforming an exercise program. The study design and sampling were carried out after\nobtaining approval from the hospital’s ethical committee to carry out the study at the\nPhysical Therapy Department of Bab El-Sharia University Hospital and an informed consent\nform was signed by each patient before participating in the study. Ethical approval was\nobtained from the institutional review board at Faculty of Physical Therapy, Cairo\nUniversity before study commencement (No: P.T.REC/012/001488). The study was followed the\nGuidelines of Declaration of Helsinki on the conduct of human research.\nThere were twenty patients suffering from severe premenstrual pelvic pain and diagnosed by\nlaparoscope as having mild or moderate endometriosis 13 ) . Patients were selected randomly from the Gynecology Outpatient\nClinic at Bab El-Sharia University Hospital and recruited according to the inclusion and\nexclusion criteria of the study. The main exclusion criterion was the presence of diabetes\nmellitus, gynecological hemorrhage, impaired sensation, tubo-ovarian abscess, chest\ndiseases, scoliosis or previous trauma or fractures in the spine, pelvis, and lower limbs.\nAll patients participated in a supervised exercise program for 8 weeks (24 sessions) and\nreceived the same regimen of hormonal treatment (Medroxyprogesterone Acetate 100 mg\nonce/month for 6 months) without administering any analgesic drugs all through the exercise\nperiod (8 weeks). Their age ranged from 26 to 32 years and their body mass index (BMI) did\nnot exceed 29 kg/m 2 . The duration of this study was 6 months from December 2015\ntill April 2016.\nFurther screening for inclusion and exclusion criterion and demographic details were\nrecorded for each patient to confirm that the only cause of pelvic pain was endometriosis.\nAll data and information of the patients were recorded in a recording data sheet. A detailed\nmedical and gynecological history was taken for each patient before starting the study,\naccording to the items of the recording data sheet. Diagnostic ultrasonography (Sonoace\n3200) was used by the gynecologist before laparoscopy to locate endometriosis cysts and to\nexclude any pelvic pathology in each patient. Laparoscopic machine (Gemetex XL-300A) was\nused by the same gynecologist to confirm the diagnosis of endometriosis in patients. Before\nintervention, intensity of pain was measured by mean of the present pain intensity scale to\nhelp patients to determine the intensity of pain on a scale from 0 to 4 in which pain\nintensity was scored as follows: no pain=0, mild pain=1, moderate pain=2, severe pain=3, and\nunbearable pain=4. The Present Pain Intensity scale is reported to be a reliable outcome\nmeasure for pain evaluation 14 ) .\nReevaluation for intensity of pain was repeated after 4 weeks (12 sessions) and 8 weeks (24\nsessions) of performing the exercise program. Postural assessment revealed that patients\nsuffered from postural kyphosis due to chronic pelvic pain and this diagnosis was confirmed\nby measuring the thoracic kyphosis angle by Formetric II instrument in the spinal shape\nanalysis laboratory at the Faculty of Physical Therapy, Cairo University, before and after 4\nand 8 weeks of performing the exercise program. Formetric II instrument was an optical\n3D-spine, posture and measurement system, which was reliable, valid and safe to be used on\npatients 15 ) .\nThe exercise program parameters were based on the American College of Obstetricians and\nGynecologists guidelines for exercise for sedentary women, according to the FITT principle\n(frequency, intensity, time, and type), which included frequency=minimum of three\ntimes/week, intensity=moderately hard perceived exertion, time=30–60 min/day, and type=low\nimpact 16 ) . Class size was limited to\nfive patients to ensure their close supervision. All classes were conducted by the same\nphysiotherapist. Each patient was supervised carefully during the exercise program. The\nexercise program included posture correction exercises from crock lying, supine, and sitting\nand standing positions (each exercise was maintained for 5 s and then the woman relaxed for\n10 s and repeated this 10 times), diaphragmatic and lateral costal breathing exercises (the\nwoman took a deep breath for 5 s and relaxed for 10 s and repeated this five times), general\nrelaxation and teaching muscle sense (for 10 min), Diversion drill training (for 3 min),\npositional education on cross-sitting and squatting positions (for 6 min), stretching\nexercises for lower back muscles, adductors muscles, hamstrings muscles and pelvic floor\nmuscles each stretch was maintained for 45 s and repeated 3 times at the start and the end\nof each session. Each exercise session was terminated by walking on treadmill for 20 min.\nPatients attended exercise sessions 3 times/week, and for the rest of the week they were\ninstructed to perform the same exercises regularly at home throughout the study period.\nCompliance with home-based exercise was monitored by a self-recorded diary. The total number\nof sessions that were conducted during 8 weeks was 24 sessions. Attendance of at least 20\nout of 24 sessions was required to be defined as completion of the intervention.\nData analysis was performed using (SPSS, Inc. Chicago, IL, USA) program version 20 for\nWindows. The sample size (20 patients) was calculated to yield an 90% power and α=0.05.\nPrior to final analysis, data were screened for normality assumption and presence of extreme\nscores. This exploration was done as a pre-requisite for parametric calculation of the\nanalysis of differences and of relationship measures. Normality test of data using\nShapiro-Wilk test was used, this ensures that the data is normally distributed for kyphosis\nangle and not normally distributed for present pain intensity scale. Therefore, repeated\nmeasure ANOVA was used to compare the kyphosis angle at different measuring periods. Also,\nFriedman (nonparametric alternative to the repeated measure ANOVA) was used to compare the\npresent pain intensity scale at different measuring periods and “Wilcoxon signed rank tests”\nwas used as post hoc tests if Friedman test among three measuring periods is significant. As\ntwo statistical analysis tests (repeated measures ANOVA and Friedman tests) were performed\non the examined sample, the alpha level was adjusted to 0.025 (0.05/2) for each of the two\nconducted statistical tests. Adjustment was performed to avoid alpha inflation and\ncommitting type I error.\n\nAs indicated by the repeated measures ANOVA, there was a statistically significant\ndifference in kyphosis angle among the three measuring periods (pre and post 12 sessions of\ntreatment, and post 24 sessions) (p<0.025). A Tukey multiple comparison tests (Post hoc\ntests) revealed that there was a statistically significant reduction in the kyphosis angle\nin the post 24 sessions of treatment compared with the pre treatment and post 12 sessions of\ntreatment (p<0.025). While, there was no statistically significant difference in the pre\ntreatment compared with the post 12 sessions of treatment (p>0.025) ( Table 1 Table 1. Dependent variables in patients with endometriosis in pre, post four weeks and\npost eight weeks of exercises program Measuring periods Pre exercises Post 4 weeks Post 8 weeks Kyphosis angle (mean ± SD) 43.1 ± 1.4 43.0 ± 1.4 39.6 ± 2.1 #¥ Pain intensity level (median (IQR)) 4 (1) 1.5 (1.75) * 1 (1) #¥ * Significant (p<0.025) difference between pre and post 4 weeks,\n # Significant (p<0.025) difference between pre and post 8 weeks,\n ¥ Significant (p<0.025) difference between post 4 weeks and post 8\nweeks, IQR: Interquartile Range; SD: standard deviation. ).\n* Significant (p<0.025) difference between pre and post 4 weeks,\n # Significant (p<0.025) difference between pre and post 8 weeks,\n ¥ Significant (p<0.025) difference between post 4 weeks and post 8\nweeks, IQR: Interquartile Range; SD: standard deviation.\nThe Friedman test revealed that there was a statistically significant difference in pain\nlevel among the three measuring periods (pre and post 12 sessions of treatment, and post 24\nsessions) (p<0.025). A Wilcoxon signed rank tests (Post hoc tests) revealed that there\nwas a statistically significant reduction in the pain level in the post 24 sessions of\ntreatment compared with the pre treatment and post 12 sessions of treatment (p<0.025). In\naddition, there was a statistically significant reduction in the pain level in the post 12\nsessions of treatment compared with the pre-treatment (p<0.025).\n\nThis study was conducted to determine the effect of exercise on pain and posture associated\nwith endometriosis in 20 patients diagnosed with mild or moderate forms of the disease. The\nresults of this study showed a statistically significant decrease in the intensity of\nendometriosis pain after performing the exercise program as well as, a statistically\nsignificant decrease in thoracic kyphosis angle related to postural kyphosis deformity,\nwhile, there was no significant correlation between patients’ physical characteristics and\nintensity of endometriosis pain. The results of this study come in agreement with the review\nof Bergström et al. 17 ) , who found that\nphysical exercise has beneficial effects on relaxing the muscles of patients’ suffering from\nendometriosis which in turn helps to break their pain cycle. In addition, the results of\nthis study agree with those of another recent RCT which reported that progressive muscular\nrelaxation training was more effective in improving pain, anxiety and depression in\nendometriosis women under hormonal therapy 18 ) . Cardiovascular activity helps endometriosis patients to maintain a\ngood level of energy. Exercise is one of the most effective strategies for boosting\nserotonin levels; physical activity and deep breathing exercises may increase the firing\nrate of serotonin neurons in the brain, which may stimulate the production of mood-elevating\nchemicals. Aerobic exercises such as walking and swimming may have a more significant effect\non serotonin levels, toning the muscles of the entire body, and improving the general\ncirculation 19 ) . While, the results of\nthis study were not in agreement with the literature data which proved that physical\nexercise plays no role in the prevention of the occurrence or progression of endometriosis\nin preventing the occurrence or progression of the endometriosis. These studies also draw\nattention to the possibility of conclusions about non-protective effect of exercise in women\nwith endometriosis that can be due the discomfort experienced, which prevents the practice\nof physical exercise. There are several limitations of our study. First, the lack of an\nobjective outcome measure of pain intensity scale. Second, the authors did not assess the\nlong-term effect and follow up of the exercise program. A third limitation was the absence\nof control group of patients with endometriosis who received no treatment as the authors did\nnot want to leave patients untreated through this period of time.","source_license":"CC0","license_restricted":false}