# Exercise as it relates to Disease/Endometriosis and Exercise: Could exercise be the key to improving pelvic pain and posture?

This is a critique of the research article: Awad E, Ahmed HA, Yousef A, Abbas R. Efficacy of exercise on pelvic pain and posture associated with endometriosis: within-subject design. Journal of Physical Therapy Science. 2017;29(12):2112-5.

## What is the background to this research?

Endometriosis is a chronic disease in which endometrial tissue that would normally line the inside of the uterus, is found on other organs such as the ovaries, fallopian tubes, bladder and bowel. Common symptoms of this condition are dysmenorrhea, dyspareunia, chronic pelvic pain (CPP) and infertility. Over 50% of women affected by endometriosis suffer from CPP, with 70% of pain occurring during menstruation. Postural changes are commonly seen in women with CPP, which has been found to significantly contribute to the worsening of pain and tension in the body. Evidence suggests that symptoms of endometriosis result from a local inflammatory peritoneal reaction caused by ectopic endometrial lesions. These endometrial lesions are thought to be the primary cause of pain in women suffering from endometriosis.
While there is no cure for endometriosis, there is a range of management strategies for the treatment of pain-related symptoms.
Physical therapy and regular exercise are suggested to have protective effects against diseases with inflammatory processes. Research shows that exercise may be beneficial for managing pelvic pain associated with endometriosis as it can help the muscles to relax which may break the pain cycle. However, the effectiveness of exercise in women suffering from endometriosis is widely debated. Developing effective pain management strategies is crucial for improving the quality of life for women suffering from pelvic pain associated with endometriosis.

## Where is the research from?

This article was published in the Journal of Physical Therapy Science, a reputable peer-reviewed journal which is dedicated to accelerating physical therapy research in Asia and other areas. The research was conducted in Cairo, Egypt at a local university. The reputation of the authors is unknown, but they all work within the physical therapy or health science faculties as well as within the department of physical therapy for paediatrics and women’s health.

## What kind of research was this?

This research was conducted using a within-subject design, that is similar to a randomised control trial (RCT). This type of study design requires each participant to be exposed to the proposed treatment, while also acting as their control. The within-subject design method used in this article would be classified as level I evidence, which is considered the highest level of evidence. Within-subject designs provide reliable and valid information about the effect the treatment has on the participant's condition and they are often favoured because of their high statistical power. Like any study methodology, there can be external limitations that can influence the validity of the results. To avoid interference from external limitations study design must be carefully considered and modified if needed.

## What did the research involve?

The study involved 20 randomly selected female participants who had been diagnosed with mild to moderate endometriosis and were experiencing severe premenstrual pelvic pain. All participants were carefully screened, and extensive gynaecological and medical history was taken to ensure that participants met the criteria and to confirm that endometriosis was the only cause of pelvic pain. The intervention involved the participants performing an exercise program for over 8 weeks. During this period, pelvic pain and postural assessment measurements were taken before, after 4 weeks and after 8 weeks of performing the exercise program. Pain level was measured using a pain intensity scale ranging from 0-4 (0= no pain and 4= unbearable pain).
The exercise program was based on exercise guidelines for sedentary women by the American College of Obstetricians and Gynaecologists. Participants attended 3 supervised exercise sessions a week (24 sessions in total). Each session was 30-60 minutes and consisted of moderately hard, low impact exercises. For the rest of the week, participants were instructed to complete the same exercises at home for the duration of the study period. Compliance for the home-based portion of the intervention was monitored using self-recorded diaries.

### Limitations

* Authors did not assess the long-term effect of the exercise program or follow up after the completion of the intervention. The lack of a follow-up and the unknown long-term effects of the exercise program may reduce the internal validity of the study.
* Another limitation of this article was the absence of a separate control group which can lower the level of evidence. However, this decision was made by the authors as they did not want to leave any participants untreated during the study period.
* The final limitation of the article was the lack of an objective measure for the pain intensity scale.

## What were the basic results?

After the completion of an 8-week exercise program, there was a significant decrease in pelvic pain and thoracic kyphosis angle related to postural kyphosis.
Dependent variables in patients with endometriosis in pre, post 4 weeks and post 8 weeks of an exercise 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 (IRQ)) | 4 (1) | 1.5 (1.75)* | 1 (1)$^{#¥}$ |
Significant (p<0.025) difference between pre and post 4 weeks, #Significant (p<0.025) difference between pre and post 8 weeks, ¥Significant (p<0.025) difference between post 4 weeks and post 8 weeks, IQR: Interquartile Range; SD: standard deviation.

## What conclusions can we take from this research?

Overall, this research provides women who are suffering from endometriosis with evidence that a regular exercise program is an effective pain management strategy. By including low impact moderately hard exercises at least 3 times a week into their daily routine, women suffering from moderate to severe premenstrual pelvic pain should see a reduction in their level of pain as well as an improved posture.
There are limited studies on the association between endometriosis and physical activity. However, recent research on the effect of physical activity on endometriosis shows that regular low impact exercise can be beneficial for treating pelvic pain and other associated symptoms. It’s important to note that there is no evidence in the literature that regular exercise plays a role in the prevention and progression of endometriosis.

## Practical advice

* No conclusions have been made on the total effectiveness of an exercise program on endometriosis. For some women with severe pelvic pain, the discomfort they experience can prevent them from participating in exercise. Before participating in any exercise, a health professional, gynaecologist and or pelvic floor physiotherapist should be consulted.
* Progressive muscle relaxation exercises can help relax pelvic muscles and the rest of the body which has been found to help decrease pain, anxiety and depression
* Engage in low impact exercises such as diaphragmatic breathing, stretching and exercises to strengthen the pelvic floor. Aerobic exercise such as walking for 20 minutes or swimming is beneficial for circulation, toning and relaxing muscles and mood-boosting.

## Further information/resources

If you a seeking further information or need support see the links below.
* https://www.endometriosisaustralia.org/
* https://www.pelvicpain.org.au/?v=ef10366317f4
* https://www.health.gov.au/health-topics/chronic-conditions/what-were-doing-about-chronic-conditions/what-were-doing-about-endometriosis
* https://www.qendo.org.au/

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Awad E, Ahmed HA, Yousef A, Abbas R. Efficacy of exercise on pelvic pain and posture associated with endometriosis: within subject design. Journal of Physical Therapy Science. 2017;29(12):2112-5.
* 1 2 3 4 5 Montenegro ML, Bonocher CM, Meola J, Portella RL, Ribeiro-Silva A, Brunaldi MO, Ferriani RA, Rosa-e-Silva JC. Effect of Physical Exercise on Endometriosis Experimentally Induced in Rats. Reproductive Sciences. 2019 Jun;26(6):785-93.
* 1 2 3 Bonocher CM, Montenegro ML, e Silva JC, Ferriani RA, Meola J. Endometriosis and physical exercises: a systematic review. Reproductive biology and endocrinology. 2014 Dec 1;12(1):4.
* 1 2 Logan LR, Hickman RR, Harris SR, Heriza CB. Single‐subject research design: recommendations for levels of evidence and quality rating. Developmental medicine & child neurology. 2008 Feb;50(2):99-103.).
* ↑ Steingrimsdottir HS, Arntzen E. On the utility of within-participant research design when working with patients with neurocognitive disorders. Clinical interventions in aging. 2015;10:1189.
* ↑ Altermatt B. Threats to internal validity for within-subjects designs. Retrieved from. 2014.
* ↑ Zhao L, Wu H, Zhou X, Wang Q, Zhu W, Chen J. Effects of progressive muscular relaxation training on anxiety, depression and quality of life of endometriosis patients under gonadotrophin-releasing hormone agonist therapy. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2012 Jun 1;162(2):211-5.
* ↑ Pelvic Floor Foundation. Easy Stretches to Relax the Pelvis - Women. Available from http://pelvicpain.org.au/easy-stretches-to-relax-the-pelvis-women/?v=ef10366317f4 Stretches for Pelvic Pain. Accessed 14.09.20