TITLE: The effect of balance taping for prevention of menstrual pain in female
middle school students

  ABSTRACT:
[Purpose] The age at menarche in Korean women has been declining sharply. However, for
the students who are just beginning to menstruate, taking pain medication might become a
long-term habit continuing until adulthood. Therefore, this study investigated whether
balance taping would be more helpful than medication in relieving the pain. [Subjects and
Methods] Subjects of this study included 125 female students. The participants were
assigned to the balance taping group, the control group, and the medication group. The
medication group was given 1 dose of Tylenol (acetaminophen 500 mg) and the balance-taping
group had taping applied, and the changes in pain were measured before the taping, as well
as1 hour, 4 hours, 8 hours, and 24 hours after. The measurement was done two times for the
repeatability of the result. [Results] The balance-taping group showed a difference in
pain from 1 hour after the taping compared with the control group, and the pain was
significantly reduced until 24 hours after the taping. The balance taping group showed a
statistically significant difference in pain compared with the medication group from 4
hours after the taping, and it lasted until 24 hours after the taping. The results were
similar in the second measurement as well. [Conclusion] Balance taping was shown to be
effective in relieving menstrual pain. Balance taping could be an effective alternative to
medication in relieving menstrual pain and distress.

BODY.INTRODUCTION:
The age at menarche in South Korean women has been declining. According to the 2008 Korean
National Health and Nutrition Survey, the average age of menarche among women born in 1920's
was 16.0 years old, while women born after 1995 had it at about 11.39 years old. Thus, it is
concluded that the average age at menarche in South Korean women has been declining by about
0.731 years per decade1).  Unlike secondary dysmenorrhea caused by organic pelvic pathology, primary dysmenorrhea
occurs due to the prostaglandins. Prostaglandins make the uterine muscles contract, helping
the uterus shed the lining that has built up for embryo implantation; the contraction
decreases the blood flow to the uterus, depriving oxygen2, 3). In case of primary
dysmenorrhea, high levels of prostaglandins (PGE2 and PGF2) with endometrial tissues are
found in menstrual fluid.  Menstrual pain is most commonly felt in the lower abdomen (80.6%) or the back (59.1%),
being accompanied by other symptoms such as headaches (38%), muscle aches, nausea, or
diarrhea4, 5). The pain is usually more severe in the first 1–2 days (87.5%), but
it rarely lasts longer than 72 hours6).  According to some research, menstrual pain was reported in 81.9% to 89% of female college
students, 83% of high school students, and 79% of middle school students7, 8). Of
these, 8.0% of the middle school students and 16.6% of the high school students reported
difficulty in performing everyday activities. The severe menstrual pain is a common cause of
school absenteeism, and in 10% of cases, the pain was so severe that they couldn't do any
normal activity for 1 to 3 days9, 10).  In general, to relieve menstrual pain, pain medication or alternative therapies are used.
According to Hewison & Olga's research11), only one-third of the female college students were medicated after
consulting with doctors, and rest of the students took medicine without prescription.
However, long-term use of pain medications may lead to physical dependency.  Another choice of medication is estrogen, as it suppresses ovulation, resulting in very
effective pain reduction. However, it requires taking the pills for 21 days to relieve pain
in only a 24–48 hour period. Furthermore, women with contraindication to estrogen can't use
this method.  As for alternative therapies, there have been a variety of studies to assess the effects of
alternative methods on menstrual pain including aroma therapy12, 13), taping therapy14), and biofeedback therapy15).  Balance taping therapy involves applying elastic tape without any medicine to the skin to
cure diseases. This gives balance to muscles and internal organs and maximizes the body's
natural healing ability, controlling electromagnetic currents on the skin. Balance taping
differs from sports taping, in that it allows normal movements as well as pain reduction,
improving blood circulation and lymphatic circulation in the area. As normal movement
improves circulation, it restores natural healing power through solidifying soft
tissues.  In female students, menstrual pain interferes with their school activities, preventing them
from going to school, making them late for classes, or forcing them to leave school early.
Furthermore, for the students who are just beginning to menstruate, taking pain medication
might become a long-term habit continuing until adulthood. Therefore, there was a need to
study whether balance taping, which is easy to use and a non-pharmacological pain management
method, would be more effective than medication in relieving menstrual pain.

BODY.SUBJECTS AND METHODS:
A total of 500 female students (13–15 years old) attending a middle school located in Seoul
were surveyed using a questionnaire to select the girls who suffer from severe menstrual
pain. The visual analogue scale (VAS) was used to rate their pain. Of students who scored
5.0 points or higher on the scale, those who submitted parental informed consents
participated in the study.  Students who hadn't been diagnosed with internal, gynecological, or psychological disorders
that might cause pain in the pelvic area were included. Study participants were not taking
medication or other alternative therapies for menstrual pain. And they didn't have a history
of Tylenol side effects and allergic reactions to the tape. Students who were taking any
other medications containing acetaminophen and who had a history of asthma, allergic
rhinitis, or other allergies were excluded. A total of 125 participants were assigned to the
balance taping group, the control group, and the medication group.  Prior to the experiment, detailed explanation with precautions related to the experiment
was given, and the participants were instructed not to receive any pain treatment except the
experimental treatment during the experiment.  All participants were measured for their changes in pain intensity right before the taping,
as well as 1 hour, 4 hours, 8 hours, and 24 hours after, twice per each measurement. The
medication group took only 1 dose of Tylenol 500 mg, but midterm and final exam periods were
made an exception.  The Visual Analogue Scale16), which is
the most widely used pain intensity scale with high repeatability, was used to assess the
participants' pain severity. Students themselves marked their perceived pain, and then the
distance from the start point to mark point along the scale was converted into a numeric
pain score.  There are two types of tape available for the treatment; elastic tape and non-elastic tape.
Elastic tape can be applied in I shape, X shape, Y shape, or finger shape. While non-elastic
tape can be applied in lattice shape (to the muscle motor points), spiral shape (to the
response points in the same direction of the electromagnetic current on the muscles and
skin) etc., there's also a colored tape (methyl processed to deliver color wavelength to the
skin, used mostly in meridian massage).  As a preliminary test, general characteristics of participants were obtained through a
questionnaire, and the participants were instructed to visit the school nurse's office to
take the taping treatment as soon as they arrived at school on the morning following when
they started their period.  Collected data was processed using the SPSS/WIN 12.0 (Statistical Package for social
Sciences for windows 12.0 version, Chicago, USA). Differences in the VAS scores among the
groups were evaluated by using χ2-test and ANOVA, and the effects of treatments
and the changes in pain before and after experimental treatments were compared by using
ANCOVA. P value of less than 0.05 was considered to be statistically significant.  This study obtained an IRB approval from The Catholic University of Korea, Uijeongbu St.
Mary's Hospital.

BODY.RESULTS:
There were no significant differences in the general characteristics of participants and
the characteristics of menstruation among the three groups (Table 1Table 1.General characteristics of participantsControl(n=46)Medication(n=46)Taping(n=33)Age14.2 ± 0.814.1 ± 0.914.1 ± 0.7Height159.6 ± 5.4159.3 ± 6.0157.7 ± 5.6Weight56.1 ± 10.253.7 ± 10.853.3 ± 11.0ReligionYes22 (32.4)26 (38.2)20 (29.4)No23 (41.1)20 (35.7)13 (23.2)Family relationshipVery good13 (33.3)15 (38.5)11 (28.2)Good18 (30.5)25 (42.4)16 (27.1)So-so12 (52.2)6 (26.1)5 (21.7)PersonalityIntrospective12 (57.1)8 (38.1)1 (4.8)Extroverted17 (40.5)12 (28.6)13 (31.0)Easy going15 (25.9)25 (43.1)18 (31.0)Sensitive, shy2 (50.0)1 (25.0)1 (25.0)ExerciseNever8 (29.6)10 (37.0)9 (33.3)2 times/wk26 (37.7)27 (39.1)16 (23.2)3 times/wk7 (36.8)6 (31.6)6 (31.6)Over 4 times/wk4 (50.0)3 (37.5)1 (12.5)Stress levelVery high7 (63.6)2 (18.2)2 (18.2)High19 (39.6)15 (31.3)14 (29.2)Low18 (32.7)24 (43.6)13 (23.6)Very low2 (22.2)5 (55.6)2 (22.2)Data are expressed as mean ± standard deviation or N (%).). There were no significant differences in menstrual cycle and days of severe
pain among the three groups; the most painful day was the first 1–2 days (62.4%), and some
reported that they suffered from menstrual pain over the whole period (10.4%) (Table 2Table 2.Menstrual characteristics of participantsControl(n=46)Medication(n=46)Taping(n=33)Menarche age12.0 ± 1.312.0 ± 0.912.3 ± 1.0Menstrual cycle<20 days6 (35.3)7 (41.2)4 (23.5)<25 days8 (41.2)7 (36.8)4 (21.1)<30 days15 (31.3)18 (37.5)15 (31.3)>30 days11 (44.0)9 (36.0)5 (20.0)Irregularity6 (37.5)5 (31.3)5 (31.3)Menstrual duration3–5 days23 (33.3)22 (31.9)24 (34.8)over 6 days23 (42.6)23 (42.6)8 (14.8)Days of severe pain1–2 days before3 (27.3)5 (45.5)3 (27.3)First 1–2 days28 (35.9)32 (41.0)18 (23.1)2–3 days7 (33.3)7 (33.3)7 (33.3)Whole period7 (53.8)1 (7.7)5 (38.5)Frequency of medicationOnce for the whole period18 (31.0)27 (46.6)13 (22.4)Once per day1 (33.3)1 (33.3)1 (33.3)Twice for the whole period6 (42.9)5 (35.7)3 (21.4)Over twice per day0 (0)3 (75.0)1 (25.0)None21 (45.7)10 (21.7)15 (32.6)Data are expressed as mean ± standard deviation or N (%).). Some students reported that they took pain medication, of them, 58 had
medication only once for the whole period, 3 took medication every day, and 4 more than
twice a day. Regarding the most painful site, 116 students out of 125 complained pain in the
lower abdomen, 80 in the back, and 25 in the pelvic area.  In the taping group, VAS pain score was significantly reduced compared with the other two
groups (from 6.91 ± 0.98 before to 3.94 ± 1.84 1 hour after), and the effect still remained
until 24 hours after (VAS score 0.36 ± 0.70). Furthermore, these statistically significant
differences in VAS scores were found between the medication group and the taping group.  As to changes in menstrual pain over time, in the medication group, VAS score was the
lowest at 4 hours after medication (4.17 ± 2.20), and it rose to 5.02 ± 2.55 at 8 hours
after, 5.13 ± 2.79 at 24 hours after. In the control group, VAS scores rose to 5.91 ± 2.26
at 8 hours after and 5.22 ± 2.82 at 24 hours after. In contrast, VAS score of the taping
group started to decrease significantly from 1 hour after the treatment (3.94 ± 1.84), and
it continued to reduce until 24 hours after (0.36 ± 0.70); the differences in the VAS scores
were statistically significant compared with the other two groups (p<0.001) (Table 3Table 3.Differences in VAS pain scores among groups over timeGroupBefore1 hour4 hours8 hours24 hours1Control7.11 ± 1.276.59 ± 1.456.48 ± 1.775.91 ± 2.265.22 ± 2.82Medication*7.02 ± 1.044.91 ± 2.144.17 ± 2.205.02 ± 2.555.13 ± 2.79Taping**6.91 ± 0.983.94 ± 1.841.67 ± 1.650.82 ± 1.070.36 ± 0.702Control7.26 ± 1.346.83 ± 1.376.17 ± 1.846.04 ± 2.135.35 ± 2.72Medication*6.85 ± 1.034.98 ± 1.983.89 ± 1.954.78 ± 2.214.87 ± 2.47Taping**7.15 ± 0.943.91 ± 1.651.42 ± 1.350.55 ± 1.060.27 ± 0.84*p-values correspond to between group comparisons for the changes over time for each
variable. **p<0.001: compared with the medication group. Data are expressed as mean
± standard deviation or N (%).). The results were similar in both first and second measurements.  For side effects or discomfort experienced after the taping treatment, 2 students reported
skin allergic reactions (6.1%), 1 dizziness (3.0%), and 30 no side effects at all (90.9%).
Concerning the amount of satisfaction with the treatment, 10 students responded that they
were very satisfied (30.3%), 21 satisfied (63.6%), and 2 so-so (4.0%).  For pain relief methods with which students would like to take in the future, 34 responded
that they would take pain medication (27.2%), 24 would endure the pain (19.2%), 5 would go
to a clinic (4.0%), and 62 would choose an alternative method (49.6%) (Table 4Table 4.Side effects and level of satisfactionSymptom, Satisfaction levelN%Side effects or discomfortsSkin allergic reactions26.1Dizziness13.0Headaches00None3090.9Taping satisfactionVery satisfied1030.3Satisfied2163.6So-so26.1Dissatisfied00Pain management to chooseMedication3427.2Endurance2419.2Seeing a doctor54.0Alternative therapy6249.6).

BODY.DISCUSSION:
The systematic approach to taping therapy was made possible thanks to a Japanese doctor,
Arikawa, who established a contact test based on muscle action and its pathophysiology.
Taping therapy is being used for treating motor system diseases after diagnosing disorders
in joints and muscles by using tonic reflexes, associated reflexes, or the contact test of
muscles and tendons, and it has been expanding to the treatments of internal diseases. Since
it was first introduced in the early 1990s from Japan, it has been widely used in
orthopedics, rehabilitation, internal medicine, general surgery, gynecology, and sports
medicine. In addition, different health care professionals including medical doctors,
dentists, and oriental medical doctors are using the taping therapy17). Furthermore, as balance taping has fewer side effects and
is easy to use and learn, it is being widely utilized for different types of pain17).  The effects of taping therapy on menstrual pain have been shown in several previous
researches in Korea13, 18).  However, this study is different from them in several aspects.  First, the subjects of this study were different. In Song's research18), it was on the subject of female college students. Other
previous studies were on the subject of adults such as clinical nurses or women in their
early 20s19, 20). There was no research on female middle school students who just
experienced their menarche with pain. Furthermore, this study is meaningful in that it has
shown that balance taping could be an easy to use pain management method for young female
students.  Second, this study compared the effects of medication and taping therapy directly. In Lee
Kyungsook's research on pain medication for menstrual pain, 60.6% of female high school
students reported moderate pain21). Of
them, 11.7% took pain medication, and 66.7% of them reported that the first time they had
the medication was when they were in middle school. In Lim Kyungtack's research8), 6.9% of middle school students were absent
from school or left school early, and 45.3% took pain medication. In Kim Younghee's
research7), 61.5% of female college
students took pain medication. Of them, 92.3% were self-medicated. This study has shown that
the effects of the taping and the medication were equal, and the effect of taping treatment
continued for 24 hours, longer than the effect of the medication. Therefore, the result
indicates that balance taping could be used as an alternative method to medication,
preventing abuse of pain medication in the future.  Third, the taping application site was different. In this study, crossing taping was done
on the area between navel and pubic bone, along with sacroiliac joint taping in an X shape
instead of traditional straight line shape, producing an effective back pain reduction and
supporting the sacroiliac joint by covering the pelvic and hip areas.  Fourth, taping application time was different. In the case of female middle school
students, it is difficult to predict when the next period will come because their menstrual
cycles are mostly irregular, which might result in applying taping during a time of no pain.
In this study, taping was applied only once on the 2nd day (when it was the most painful) at
the school nurse's office.  Finally, while previous studies measured pain intensity only once, this study measured it
twice to obtain the repeatability of results.  However, the participants of this study were limited to female students at only one middle
school; it would be limited to generalize the results. Although exam periods were made an
exception to minimize stresses or psychological factors that might affect students'
perceived pain, there were limitations in controlling the external factors of stress. To
minimize menstrual pain and distress and to shorten the taping duration, further research on
applying taping before menstruation starts (before the pain starts) is required. Since the
pain relieving effect of the taping continued 24 to 48 hours afterward, a study to compare
the pain relieving effects of the taping and the medication of 3 doses a day is needed in
the future.  In conclusion, this study has shown that the pain relieving effects of the balance-taping
group were more effective than those of the control group. This finding suggests that
applying taping to women with severe menstrual pain may reduce the need for additional
medication. For female middle school students, balance-taping could be an effective pain
management method, preventing abuse of pain medication in the future.

Question: Compared to control what was the result of balance taping on effect of balance taping for prevention of menstrual pain in female middle school students after 4 hours?
Evidence: The balance taping group showed a
statistically significant difference in pain compared with the medication group from 4
hours after the taping, 
Answer: significantly increased