CASE REPORTS

PROSPECTIVE CASE SERIES ON THE EFFECTS OF LUMBOSACRAL

MANIPULATION ON DYSMENORRHEA
Denise A. Holtzman, DC,a Kristina L. Petrocco-Napuli, DC, MS, b and Jeanmarie R. Burke, PhDc

ABSTRACT

Objective: The objective of this prospective case series was to collect preliminary data as to the effectiveness of a
specific chiropractic technique, drop table method, in the treatment of primary dysmenorrhea.
Methods: Over a 4-week period, 16 females were screened for symptoms of primary dysmenorrhea and motion
restrictions of the lumbosacral spine. Thirteen subjects were enrolled into the study. Bilateral and unilateral lumbosacral
flexion and extension restrictions were treated using drop table manipulations 3 times during each of the 2 consecutive
menstrual cycles. Before entering the study and at the end of each menstrual cycle, the subjects self-reported ratings of
menstrual pain (abdominal, pelvic, and low back pain) and associated symptoms of primary dysmenorrhea using
Numeric Pain Scale. Numeric Pain Scale ratings for menstrual pain were the primary outcome measures.
Results: The median age was 26 years, and the median self-reported duration of the symptoms was 12 years. At
baseline, all subjects reported pain severity scores of 5 or higher for at least 2 of 3 anatomical sites: lower or general
abdominal pain and/or lower back pain. Using the 95% confidence interval (CI) as an estimate, clinically meaningful
changes (b5) in general abdominal pain and lower back pain were evident for most patients during the treatment phase,
whereas for lower abdominal pain, the improvements were subject and cycle dependent.
Conclusions: Menstrual pain associated with primary dysmenorrhea may be alleviated with treatment of motion
segment restrictions of the lumbosacral spine with drop table technique. (J Manipulative Physiol Ther 2008;31:237-246)
Key Indexing Terms: Spinal Manipulation; Chiropractic; Dysmenorrhea; Lumbosacral Region; Uterus

ysmenorrhea refers to lower abdominal pain, for The 2 categories of dysmenorrhea are primary and

D example, menstrual cramps of uterine origin that

occur with the onset of menstrual flow and persist
for 6 to 72 hours. Lower back and thigh pain, fatigue,
diarrhea, constipation, and headaches may also be present.
Dysmenorrhea is a common condition with varying degrees
of intensities and affects 45% to 95% of women.1,2 In
approximately 10% of these women, symptoms have a
significant impact on quality of life, activities of daily living,
and economic indicators of lost work hours and increased
health care costs.1,3
a
Associate Professor, Clinical Sciences Department, New York
Chiropractic College, Seneca Falls, NY.
b
Assistant Professor, Clinical Sciences Department, New York
Chiropractic College, Seneca Falls, NY.
c
Associate Professor, Research Department, New York Chir-
opractic College, Seneca Falls, NY.
Submit requests for reprints to: Denise A. Holtzman, DC,
Associate Professor, Clinical Sciences Department, New York
Chiropractic College, Seneca Falls, NY 13148
(e-mail: dholtzman@nycc.edu).
Paper submitted June 3, 2007; in revised form August 23, 2007;
accepted September 27, 2007.
0161-4754/$34.00
Copyright 2008 by National University of Health Sciences.
doi:10.1016/j.jmpt.2008.02.005
secondary. Primary dysmenorrhea is the most common and
refers to the presence of menstrual pain in the absence of an
organic pathology. Primary dysmenorrhea typically begins
within 6 to 12 months after menarche with menstrual pain
being present most menstrual cycles. Diagnosis of secondary
dysmenorrhea refers to the presence of menstrual pain
associated with pathological conditions, such as endome-
triosis, fibroids, polycystic ovarian syndrome, or pelvic
inflammatory disease.4
Primary dysmenorrhea is associated with an increase in
prostaglandins, which causes painful uterine contraction and
fluid retention.5 The most common medical treatments for
primary dysmenorrhea are the use of prostaglandin synthe-
tase inhibitors such as nonsteroidal anti-inflammatory drugs
or low-dose (high-estrogen) cyclic hormonal birth control.
Adverse effects of medical treatments and/or their failure
rates of 20% to 25% in treating menstrual pain have lead
many women to seek complementary and alternative
treatment options for primary dysmenorrhea.2,3,6
Various nonallopathic treatments for primary dysmenor-
rhea have been reported and include diet supplementation
and modification, herbal preparations, exercise, acupuncture,
magnets, and manual therapies.2,6 For example, supplemen-
tation of calcium carbonate (1200 mg/d) decreased menstrual

237
238 Holtzman et al
Manipulation and Dysmenorrhea
pain, fluid retention, and food cravings by 48%.7 An anti-
inflammatory diet reportedly reduces menstrual pain and
fluid retention by reducing prostaglandin production.7 Based
upon their phytochemical ingredients, the proposed mechan-
isms for various herbal preparations, such as black cohosh,
evening primrose oil, dong quai, licorice, and ginseng,
include acting as anti-inflammatory agents, antispasmodic
agents, sedatives, analgesics, and diuretics.8
Many chiropractors currently treat patients for primary
dysmenorrhea with spinal manipulative procedures.9 As
summarized by Proctor et al,3 chiropractic theory suggests
that spinal manipulative procedures may be effective
because of the mechanical connection between the sacrum
and the uterus via ligamentous attachments and the
neurologic connection between uterine function and the
sacral nerve roots. Based upon potential neuromechanical
mechanisms, one chiropractic hypothesis suggests that spinal
manipulations of lumbosacral joint restrictions correct
aberrant joint motions, and the resultant sympathetic
response inhibits uterine contraction and increases blood
flow to the pelvic region. Another chiropractic hypothesis
suggests that spinal manipulation of the lumbosacral spine
interferes with referred pain originating from the same pelvic
nerve pathways associated with uterine dysfunction and
primary dysmenorrhea.3 Similarly, spinal manipulative
procedures that affect sacral position, which decreases
tension on the broad ligament of the uterus and pelvic
nerve roots, may alleviate menstrual pain.10 In conclusion,
the lumbosacral spine was chosen as the area of treatment for
this case series because of the possible impact that joint
dysfunction of the lumbosacral spine (L5 through S1 spinal
segment) may have on uterine function.
In light of the above chiropractic theory and proposed
hypotheses, the safety and efficacy of spinal manipulative
interventions for primary and secondary dysmenorrhea
have been addressed. The evidence, to date, from 4 trials
of high-velocity low-amplitude manipulation, and one of
Toftness manipulation did not support the clinical efficacy
of spinal manipulation for menstrual pain; however,
there were no adverse effects to spinal manipulative
interventions.3 The available evidence in this Cochrane
review highlights the lack of well-designed research to
evaluate the effectiveness of specific spinal manipulative
techniques for specific conditions. Even though pragmatic
randomized controlled trials are acceptable, the standardi-
zation of treatment with respect to duration of treatment,
spinal segment(s) treated, spinal manipulative techniques
used, frequency and number of treatments, and timing of
treatments in the menstrual cycle are important methodo-
logical issues that still need to be addressed to more
conclusively assess the overall efficacy of spinal manipula-
tion for primary and secondary dysmenorrhea.3
Based upon the Cochrane review of the original
investigations on spinal manipulation for primary dysmenor-
rhea, the research studies failed to identify specific spinal
Journal of Manipulative and Physiological Therapeutics
March/April 2008
segments to treat. For example, both Hondras et al11 and
Kokjohn et al12 manipulated any clinically relevant spinal
segments between T10 and L5 through S1 and/or the
sacroiliac (SI) joints. The detection of restrictions in both
studies involved static palpation techniques, and the
clinicians were allowed to treat multiple restrictions within
a single treatment session. Boesler et al13 performed high-
velocity low-amplitude manipulations of any spinal segment
from cervical region to lumbosacral region and/or SI joint
that was restricted as detected by inactive range of motion
and static techniques. Myofascial stretching of any restricted
spinal region and mobilization of the SI joint were also an
allowed treatment modalities.13 Thomason et al14 manipu-
lated multiple misalignments in lumbar spine based upon
radiographic findings using high-velocity low-amplitude
techniques with the subjects in a side posture position. The
rationale for this study is to a start line of research that will
lead to a conclusive randomized control trial relative to the
role of a specific manipulative technique to treat specific
restrictions of the L5 through S1 spinal segment related to
dysmenorrhea, thereby, controlling for the confounding
variables listed above from the Cochrane review.
The objective of this prospective case series was to collect
preliminary data as to the effectiveness of a specific
chiropractic technique, drop table methods in the treatment
of primary dysmenorrhea. The current research design
standardized the treatment intervention, with respect to the
motion segment treated, to only include flexion-extension of
the lumbosacral joint using the drop table technique at a
mechanically set tension level and the number and timing of
treatments in the menstrual cycle.
METHODS
Study Population
The subjects were recruited from population of chiro-
practic students. Over a 4-week period, 16 potential subjects,
premenopausal women, were interviewed in the Biody-
namics Laboratory at New York Chiropractic College,
Seneca Falls, NY, regarding their health history and
symptoms related to primary dysmenorrhea. Subjects self-
reported medications, herbal remedies, and other alternative
therapies that they were currently using to alleviate
menstrual pain and symptoms. Subjects filled out a Numeric
Pain Scale (NPS) for pain and associated symptoms of
dysmenorrhea (Fig 1). They received a physical examination
that included postural assessments from the posterior,
anterior and lateral views, lumbosacral range of motion
tests, lower extremity muscle testing, dermatome evaluation
(via pinwheel), abdominal examination, vitals (pulse,
temperature, respiration, and blood pressure), and soft tissue
palpation for hypertonicity.15 The piriformis, quadratus
lumborum, and erector spinae in the lumbar spine were
manually palpated for trigger points as per Travell et al.16
The Institutional Review Board of New York Chiropractic
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 3
Fig 1. Numeric Pain Scale for assessing the severity of menstrual
pain and symptoms of primary dysmenorrhea.
College approved this study. All subjects provided written
informed consent to participate in the study. No monetary
compensation was provided to the patients for participation
in the study.
Inclusion Criteria
1. Only subjects that were premenopausal between the
ages of 20 and 45 were included in the study.
2. Their cycles were regular (occurred every 24-32 days).
3. Subjects self-reported that symptoms of primary
dysmenorrhea occurred during all of their menstrual cycles
during the previous year, that is, minimum duration of
symptoms for 1 year.
4. Subjects who scored higher than 5 for all of the primary
symptoms (low back pain, lower abdominal pain, general
abdominal pain) on the NPS for pain associated with
dysmenorrhea were included. Lower abdominal pain was
equivalent to pelvic pain.
5. Based on the chiropractic theory that ligamentous
attachment (broad ligament) of the sacrum to the uterus
could affect uterine function, only subjects with restrictions
in the lumbosacral joints (extension, flexion, bilateral, or
unilateral) were included according to chiropractic examina-
tion of the lumbar spine and lumbopelvic region.
Exclusion Criteria
1. Subjects who had a history of polycystic ovarian
syndrome, uterine fibroids, pelvic inflammatory dis-
ease, or any gynecologic cancers such as ovarian,
uterine, or cervical types were excluded.
In summary, the subjects needed to meet all of the
inclusion criteria without having any preexisting medical
Holtzman et al 239
Manipulation and Dysmenorrhea
conditions affecting reproductive health. Once enrolled, the
treatment phase began 21 days postonset of the last menses.
If the subject was already past this point in her cycle at the
time of the initial physical, the treatment began 21 days
postonset of her next menstrual cycle. This is an arbitrary
number based upon the onset of premenstrual symptoms
typically being a few days before the onset of menses.5 This
schedule should have allowed for the subject to be treated at
least once before the onset of symptoms (day 21).
Manual Examination of the Lumbosacral Spine
At each treatment visit, the treating clinician determined
the presence of (bilateral or unilateral) flexion or extension
restrictions of the lumbosacral spine. The clinical diagnosis
was based upon a global assessment that included motion
palpation procedures17 Each motion palpation procedure
used in the global assessment is described below. The
clinician performed each motion palpation procedure, listed
below, sequentially at each treatment visit.
The Thompson sacral leg lift test is a manual examination
procedure to assess the existence of the anterior-inferior
malposition of the sacral base on one side. This chiropractic
listing shares the same adjustive procedure as a unilateral
flexion restriction of the lumbosacral joint.18 Subjects were
prone on the treatment table, and the clinician stabilized the
sacral apex with a calcaneal hand contact.19 The clinician
then instructed the subject to lift one leg and then the other
leg as high as possible while maintaining the knee in
extension. The clinician assessed the difficulty of performing
the Thompson sacral leg lift test by each leg and the height
achieved for each leg. If the clinically observed performance
of Thompson sacral leg lift test was not the same for both
legs, then the clinician recorded the presence of an anterior-
inferior malposition of the sacral base on the side that the leg
lift was deficient.
To confirm the clinical diagnosis and the static listing
correlated with motion palpation findings, the clinician
performed another motion palpation procedure. For this
procedure, the subject rested prone on the treatment table.
The clinician used a reinforced inferior hand thenar contact
on the lateral edge of the sacral apex and then applied a
posterior to anterior, superior to inferior, and lateral to medial
force with torque (produced by radial deviation of the contact
hand) to the lumbosacral joint to produce joint flexion,
contralateral to the side of thenar contact (Fig 2A). The
clinician qualitatively assessed increasing resistance during
joint motion through the end play zone.15 If the clinician
detected increasing resistance through the end play zone,
then a flexion restriction for the lumbosacral joint contral-
ateral to contact was recorded.
The Webster's heel to buttock test is a manual examina-
tion procedure to assess for a unilateral posterior-superior
sacral base malposition, which shares the same manipulative
procedure as a unilateral extension restriction of the
240 Holtzman et al
Manipulation and Dysmenorrhea
Fig 2. Full view of patient and clinician positions and inserts of
hand contacts for motion palpation techniques for detecting
unilateral restrictions of the lumbosacral spine: (A) flexion and
(B) extension. Arrows represent the vectors of motion.
lumbosacral spine.20 The subject was prone on the treatment
table, and the clinician flexed both knees until the patient's
heels met their buttocks. The clinician assessed the manual
resistance encountered by each leg when moving the heel
toward the buttocks. If the clinician assessed increased
manual resistance of one leg compared with the other leg,
then the clinician recorded the presence of a posterior-
superior malposition of the sacral base on the side of
increased resistance.
If a unilateral extension restriction was suspected with
the Webster's heel to buttock test, then the clinician
performed another motion palpation procedure to confirm
the clinical diagnosis. For this procedure, the subject rested
prone on the treatment table. The clinician used a reinforced
hypothenar contact point on the sacral base, midway
between the posterior superior iliac spine and the second
sacral tubercle, and then applied posterior to anterior force
to the lumbosacral joint to produce joint extension, on the
same side of the hypothenar contact (Fig 2B). The clinician
qualitatively assessed increasing resistance during joint
motion through the end play zone.15 If the clinician
detected increasing resistance through the end play zone,
an extension restriction for that side of the lumbosacral joint
was recorded.
Bilateral restrictions were suspected when the clinician
detected bilateral positive findings for either the Thompson
sacral leg lift test (patient had great difficulty lifting both
legs) or the Webster's heel to buttock test (neither heel
could approximate the buttocks). The clinician performed
the following motion palpation procedures with the patient
prone on the treatment table to confirm the clinical
diagnosis: For a bilateral lumbosacral flexion restriction,
Journal of Manipulative and Physiological Therapeutics
March/April 2008
Fig 3. Full view of patient and clinician positions and inserts of
hand contacts for motion palpation techniques for detecting
bilateral restrictions of the lumbosacral spine: (A) flexion and (B)
extension. Arrows represent the vectors of motion.
the clinician used a reinforced calcaneal hand contact on the
center of the sacral apex and then applied a posterior to
anterior and superior to inferior force to create bilateral
flexion (Fig 3A). For a bilateral lumbosacral extension
restriction, the clinician used a reinforced thenar contact on
the sacral base and then applied a posterior to anterior force
to create bilateral extension (Fig 3B). The clinician
qualitatively assessed increasing resistance during joint
motion through the end play zone.15 If the clinician
detected increasing resistance through the end play zone,
a bilateral joint restriction was recorded.
Clinical Diagnosis
A clinical diagnosis required complete agreement
between the manual examination procedures and the
motion palpation procedures, indicating a single restriction
of the lumbosacral spine: unilateral flexion of either the
right or left joint, unilateral extension of either the right or
left joint, bilateral flexion, or bilateral extension. Table 1
summarizes the clinical decisions in the global assessment
that lead to a diagnosis of a single restriction of the
lumbosacral spine.
The reliability and validity of motion palpation procedures
to the diagnosis of spinal dysfunction or restrictions are
abundant in the evidence-based chiropractic literature.17,21-24
The most recent systematic review of the literature indicates
that the level of evidence to support the use of a global
assessment to diagnose spinal dysfunction or restrictions is
strong for intraobserver reproducibility with conflicting
evidence for interobserver reproducibility. 17 Although
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 3
Table 1. Clinical diagnosisglobal assessment decision matrix
Unilateral flexion
Test leg Right/left Right/left
Clinical diagnoses
Manual examinations
Thompson sacral leg lift test +/ /+
Webster's heel to buttock test / /
Motion palpation procedures
Unilateral flexion +/ /+
Unilateral extension / /
Bilateral flexion
Bilateral extension
consensus on the procedures and training of clinicians, as
adopted in this study, may be inherently thought to improve
interobserver reproducibility, the evidence for these metho-
dological approaches is equivocal.17,25,26 In addition, the
validity of motion palpation procedures to the diagnosis of
spinal dysfunction or restrictions still needs to be determined.
In summary, our clinical diagnosis of a single restriction of
the lumbosacral spine was dependent upon clinical judgment,
which is subjective in nature.
Treatment Intervention
Treating Chiropractors. Eighty percent of the manipulations
were delivered by a chiropractor with 20 years of clinical
experience in drop table methods. The remainder was
delivered by a chiropractor with 3 years of clinical
experience who was trained extensively in drop table
technique by the aforementioned chiropractor.
Treatment Schedule. During 2 consecutive menstrual cycles,
the subjects were treated 3 times according to the following
schedule. The first treatment was on day 21 of their
menstrual cycle with the second treatment occurring between
days 23 and 28 of their menstrual cycle, that is, within a few
days of the onset of menses, and the third treatment occurred
between days 1 and 3 of their menstrual cycle.
Rationale for Treatment Schedule. In agreement with the
proposed chiropractic theory for treating primary dysmenor-
rhea, the release of restricted motion segments of the
lumbosacral spine needed to occur before the onset of
menstruation to alleviate menstrual pain. The rationale for
the timing of 2 treatments in the postovulatory phase was to
treat restricted motion segments with spinal manipulations
before the onset of menstrual flow. The underlying
assumption for 2 treatments was that a single chiropractic
intervention session would not be effective for the
chronically occurring health condition of primary dysmenor-
rhea arising from a restricted musculoskeletal structure. This
was also the rationale for conducting the treatment phase
over 2 consecutive menstrual cycles and including a
treatment session during the first 72 hours of menstrual
flow, when symptoms may be occurring because of restricted
motion segments of the lumbosacral spine. The multiple
treatment visits also allowed us to document motion
Holtzman et al 241
Manipulation and Dysmenorrhea
Unilateral extension Bilateral flexion Bilateral extension
Right/left Right/left Right/left Right/left
/ / +/+ /
+/ /+ / +/+
/ / +/+ /
+/ /+ / +/+
+
+
restrictions of lumbosacral spine that may be effectively
treated with spinal manipulation to alleviate menstrual pain,
that is, potential dose-response information.
Treatment of Spinal Segments. The lumbosacral restrictions
were diagnosed as unilateral flexion, bilateral flexion,
unilateral extension, or bilateral extension according to
manual examination findings (Table 1). Continued inclusion
in the research study required that the subjects only present
with a single motion restriction of the lumbosacral spine at
each treatment visit. Although hand contacts used by the
chiropractor on the lumbosacral spine varied according to
classification of the motion restriction, the chiropractor
manipulated all subjects with a moderate force pelvic drop
that was repeated 3 times at the same tension. The
manipulations were all done on a drop table made by the
Lloyd Table Company (Model No 401 Drop Bench; Lloyd
Table Company, Lisbon, Iowa). Thus, the specific spinal
manipulative technique was drop table with a mechanically
set tension level. The specific motion segment treated was
the lumbosacral spine.
Below are the descriptions of hand contacts used to
manipulate the lumbosacral spine for flexion or extension
restrictions:
Unilateral flexion restrictions. The chiropractor delivered
a drop table manipulation to the lumbosacral joint by
using a modified inferior hand contact with a reinforced
thenar on the edge of the sacral apex (superior to inferior,
posterior to anterior, lateral to medial with radial
deviated torque).
Bilateral flexion restrictions. The chiropractor delivered
the drop table manipulation to the lumbosacral joint by
using a reinforced calcaneal hand contact on the center of
the apex (superior to inferior, posterior to anterior vector).
Unilateral extension restrictions. The chiropractor deliv-
ered the drop table manipulation to the lumbosacral joint
by using a reinforced pisiform contact on the sacral base
on the side of the restriction halfway between the
posterior superior iliac spine and the second sacral
tubercle (tissue pull inferior to superior with a straight
posterior to anterior drop).
Bilateral extension restrictions. The chiropractor deliv-
ered the drop table manipulation to the lumbosacral joint
242 Holtzman et al
Manipulation and Dysmenorrhea
by contacting the sacral base with a superior hand
reinforced thenar contact (inferior to superior tissue pull
and delivering a posterior to anterior drop).
Subject Instructions. Patients were restricted from any other
manual therapy during the 2 months that they were
participating in the project. Patients were instructed to
monitor their medication dosage and frequency. At each
treatment visit, the chiropractor recorded the classification of
the motion restriction treated as well as of the use, dosage,
and type of any medications and/or conservative care and
presence of new illnesses and associated symptoms in the
patient's file.
Outcome Assessments
All subjects completed the outcome assessments at
baseline and after their third scheduled treatment for each
2 consecutive menstrual cycles. The outcome assessment
consisted of an NPS to measure menstrual pain and
menstrual symptoms. The NPS was an 11-point numeric
rating scale with text descriptors at the extremes of the scale
with 0 being no pain/symptoms and 10 being the worst pain/
symptoms you could possibly imagine (Fig 1). The subjects
marked an X through the number on the NPS to indicate
the severity of their pain or symptom. At baseline, subjects
were instructed to rate the severity of their symptoms of their
previous menstrual cycle before enrollment. Subjects were
instructed to rate the severity of their symptoms of their
current menstrual cycle during months 1 and 2 of the
intervention phase. In summary, the severity of the ratings
reflected their symptoms at their worst during a single
menstrual cycle. The primary outcome measures in the
current investigation were numeric ratings of pain severity
for the lower abdomen (pelvic), abdomen in general, and
lower back.
An NPS with a numeric rating scale is a valid
instrument for assessing menstrual pain.27 As such, the
NPS with a numeric rating scale was the appropriate
measurement instrument to meet the objectives of the
current investigation, instead of the Moos Menstrual
Distress Questionnaire (MDQ). The MDQ is a 47-item
self-report inventory consisting of 8 scales to measure
physical symptoms, mood, behavior, and arousal.28 Pain is
only one of the valid subscales for assessing symptoms of
primary dysmenorrhea.28 Data from the remaining 7
subscales measured symptoms of primary dysmenorrhea
that were deemed beyond the scope of this preliminary
research investigation. In addition, the use of an NPS
instrument to measure menstrual pain is in agreement with
other intervention studies on alternative treatments for
primary dysmenorrhea.11,12,29,30 The secondary outcome
measures in the current investigation were numeric ratings
of symptom severity of diarrhea, constipation, headache,
and fatigue.
Journal of Manipulative and Physiological Therapeutics
March/April 2008
Data Analysis
This study used an NPS. The NPS is a numerical rating
scale, although lacking ratio measurement scale qualities, is a
measure of pain intensity, and provides a simple measure-
ment method to detect treatment effects.31
The inclusion criterion was set at greater than a numeric
rating of 5 to indicate moderate to severe menstrual pain to
be treated. A clinically significant difference of less than a
numeric rating of 5 would allow for a treatment change from
moderate to severe menstrual pain to moderate to mild
menstrual pain,32 which was deemed comparable with a pain
reduction of 20 to 30 mm on a 100-mm scale. Data analyses
included descriptive statistics (mean, SD, median, and 95%
CIs) to describe clinically meaningful changes in menstrual
pain and associated symptoms of primary dysmenorrhea
during the treatment intervention.
RESULTS
Study Population
Sixteen females were recruited during a 1-month period.
After recruitment, subjects were immediately assessed. The
baseline assessment included collection of demographic data
and an intake questionnaire related to their general health and
history of dysmenorrhea. Of the 16 subjects recruited, 14
qualified for the study according to the inclusion and
exclusion criteria. One excluded subject experienced irre-
gular menstrual cycles, whereas the other excluded subject
did not have consistent symptoms of dysmenorrhea during
every menstrual cycle. One qualified subject did not enroll in
the treatment phase. Enrollment in the treatment phase was
time locked to the estimated onset of the subject's next
menstrual cycle and continued for 2 consecutive menstrual
cycles (n = 13).
The median age was 26 years (range, 23-40 years). The
median self-reported duration of the symptoms was 12 years
(range, 2-26 years). Two subjects reported using over-the-
counter medications, and none of the subjects reported using
herbal remedies to treat their symptoms. Twelve subjects
reported using conservative care, which included hot packs,
chiropractic adjustments, and massage therapy, to treat their
symptoms. Of these 12 subjects, 11 used hot packs, 4 sought
chiropractic care, and 2 sought massage therapy. None of the
subjects smoked, and only one subject reported drinking 1 to
2 alcoholic beverages per day. Subjects reported that their
reproductive health was normal, with 2 subjects reporting the
presence of ovarian cysts.
Allocated Treatment
Eight subjects followed the treatment schedule exactly,
with the following 2 exceptions. The first menstrual cycle
of the study for one subject was complicated by
pancreatitis and subsequent use of hydrocodone for pain,
1 to 2 tablets (500-1000 mg) every 4 hours. Although she
Journal of Manipulative and Physiological Therapeutics Holtzman et al 243
Volume 31, Number 3 Manipulation and Dysmenorrhea

Table 2. Classifications of the motion restrictions of the lumbosacral spine

Cycle 1 Cycle 2
ID no. Treatment 1 Treatment 2 Treatment 3 Treatment 1 Treatment 2 Treatment 3
1 Unilateral flexion Unilateral flexion Unilateral extension Unilateral flexion Unilateral flexion Unilateral extension
2 Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion
3 Unilateral flexion Unilateral flexion Unilateral flexion Bilateral flexion Unilateral flexion Missed appointment
4 Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Bilateral flexion
5 Unilateral flexion Unilateral flexion Unilateral flexion Unilateral extension Unilateral extension Missed appointment
6 Unilateral extension Unilateral extension Unilateral extension Unilateral extension Unilateral extension Unilateral extension
7 Unilateral flexion Unilateral flexion Unilateral flexion Missed appointment Missed appointment Bilateral flexion
8 Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Bilateral flexion Unilateral flexion
9 Unilateral extension Unilateral flexion Unilateral flexion Unilateral extension Unilateral extension Unilateral extension
10 Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion
11 Unilateral extension Unilateral flexion Unilateral extension Unilateral flexion Unilateral flexion Unilateral flexion
12 Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion Unilateral flexion
13 Unilateral flexion Unilateral flexion Unilateral flexion Bilateral flexion Unilateral flexion Unilateral flexion

received all of her chiropractic adjustments according to Outcome Assessments

the study protocol, the effectiveness may be confounded
by the use of the prescribed pain medication for
pancreatitis. Another reported taking ibuprofen for a
headache that occurred with menstruation during her first
menstrual cycle of the study and before receiving her third
chiropractic manipulation.
For the remaining 5 subjects, the following variations in
the treatment schedule occurred: For one subject, the onset of
menses of her second menstrual cycle occurred on day 21.
Consequently, she received all 3 of her lumbosacral
manipulations on days 1, 3, and 4 of menstruation, instead
of 2 during the postovulatory phase and 1 during the first 3
days of menstruation (Table 2, ID 12). For another subject,
the onset of menses of her second menstrual cycle occurred
on day 21 and during the Thanksgiving Holidays. Conse-
quently, she only received one of her 3 lumbosacral
manipulations, which occurred during menstruation of
cycle 2 (Table 2, ID 7). Another subject received her third
lumbosacral manipulation of her second menstrual cycle on
day 5 of menstruation instead of during the first 3 days
because her menstrual cycle began before day 28, which
resulted in subsequent scheduling conflicts with treating her.
Because of scheduling around the Thanksgiving Holiday, 2
subjects missed their third lumbosacral manipulations that
were scheduled to occur on days 1 to 3 of menstruation of
their second menstrual cycle (Table 2, IDs 3 and 5). Outcome
assessment data for these 2 subjects were collected upon
their return to campus.
With the exception of the use of medication noted
above, all subjects refrained from the use of medications
and other conservative care during the treatment phase.
With the exception of the above noted medical condition,
all subjects were free of illnesses during the treatment
phase. Table 2 summarizes the clinical diagnoses of the
motion restrictions of the lumbosacral spine. All subjects
presented with a single motion restriction of the lumbosa-
cral at each of the treatment visits.
At baseline, all subjects reported a pain severity score of
5 or higher for at least 2 of 3 anatomical sites: lower or
general abdominal pain and/or lower back pain (Table 3).
Using the 95% CI as an estimate, we found that clinically
meaningful changes (b5) in general abdominal pain and
lower back pain were evident for most patients during the
treatment phase, whereas for lower abdominal pain, the
improvements were subject and cycle dependent (Table 3).
However, with the exception of 2 subjects (ID 5 and 6), these
subject and cycle-specific changes for lower abdominal pain
represented clinically meaningful differences from 5 or
higher to lower than 5. With the exception of fatigue, in
which 11 of 13 females reported their symptom severity
being 5 or higher, the remaining secondary complaints were
not consistently reported as clinically meaningful (5)
among our females (Table 4). Although the subjects reported
a decrease in perceived fatigue during the treatment phase,
these decreases were not deemed clinically meaningful (b5)
using the 95% CI as an estimate.
DISCUSSION
Although the limited evidence from 4 trials of high-
velocity low-amplitude manipulation and one of Toftness
manipulation did not support the clinical efficacy of spinal
manipulation for menstrual pain,3 the objective of this
prospective case series was to collect preliminary data as to
the effectiveness of a specific chiropractic technique, drop
table methods in the treatment of primary dysmenorrhea. The
interpretation of our preliminary data indicates that men-
strual pain associated with primary dysmenorrhea was
alleviated by treating motion segment restrictions of the
lumbosacral spine with a drop table technique. Secondary
outcomes were not as bothersome to our patients, and the
lack of a clinical treatment effect of the drop table technique
on these symptoms was an expected finding.
244 Holtzman et al Journal of Manipulative and Physiological Therapeutics
Manipulation and Dysmenorrhea March/April 2008

Table 3. Primary outcome measures

Pain ratings (NPS)
Lower abdominal General abdominal Lower back
ID no. Baseline Cycle 1 Cycle 2 Baseline Cycle 1 Cycle 2 Baseline Cycle 1 Cycle 2
1 8 5 6 2 0 4 6 2 4
2 10 3 5 6 0 1 8 2 0
3 7 3 3 7 3 2 4 3 1
4 9 4 6 7 3 3 2 1 1
5 9 8 9 3 3 2 6 2 3
6 8 7 6 0 0 0 6 4 3
7 10 3 2 9 2 2 8 3 3
8 9 8 1 5 8 0 6 6 2
9 8 3 2 7 8 7 8 2 7
10 7 5 4 8 0 3 2 3 1
11 6 2 1 0 3 0 7 3 1
12 10 7 1 10 7 1 10 7 7
13 7 7 1 8 5 2 5 3 2
Median 8.0 5.0 3.0 7.0 3.0 2.0 6.0 3.0 2.0
Mean SD 8.3 1.32 5.0 2.16 3.6 2.60 5.5 3.31 3.2 2.98 2.1 1.94 6.0 2.35 3.2 1.68 2.7 2.21
95% CI 7.5-9.1 3.7-6.3 2.0-5.2 3.5-7.5 1.4-5.0 1.0-3.2 4.6-7.4 2.1-4.1 1.4-4.0
Asterisk by ID number indicates medication use: ID 11 used prescribed pain medication for pancreatitis that occurred during her first menstrual cycle of the
study. ID 12 used ibuprofen for a headache that occurred with menstruation during her first menstrual cycle of the study and before receiving her third
chiropractic manipulation.

Table 4. Secondary outcome measures

Symptom severity ratings (NPS)
Diarrhea Constipation Headache Fatigue
ID no. Baseline Cycle 1 Cycle 2 Baseline Cycle 1 Cycle 2 Baseline Cycle 1 Cycle 2 Baseline Cycle 1 Cycle 2
1 5 5 4 5 0 0 2 2 1 6 4 6
2 8 0 0 6 4 4
3 5 2 2 5 3 3 5 2 3 6 3 3
4 3 0 1 3 1 0 0 0 1 5 3 1
5 5 1 3 5 0 3 1 0 0 6 0 3
6 0 0 0 0 0 0 0 0 0 7 3 2
7 2 1 1 7 2 2 7 3 3 10 2 2
8 3 2 0 3 0 0 1 5 3 5 9 4
9 0 0 0 0 0 0 0 0 0 10 8 9
10 3 1 2 0 0 0 3 0 1 2 0 1
11 1 0 0 0 1 0 0 0 1 4 0 1
12 7 5 0 7 5 1 0 3 0 10 10 7
13 3 1 4 3 0 0 8 9 3 5 8 7

Median 3.0 1.0 1.0 3.0 0.0 0.0 1.0 0.0 1.0 6.0 3.0 3.0
Mean 3.1 1.5 1.4 3.2 1.0 0.8 2.7 1.9 1.2 6.3 4.2 3.9
SD 2.15 1.78 1.56 2.69 1.60 1.22 3.20 2.70 1.30 2.43 3.51 2.64
95% CI 1.7-4.5 0.4-2.6 0.4-2.4 1.5-4.9 0.0-2.0 0.0-1.5 0.8-4.6 0.2-3.5 0.4-2.0 4.8-7.8 2.0-6.3 2.3-5.4
Asterisk by ID number indicates medication use: ID 11 used prescribed pain medication for pancreatitis that occurred during her first menstrual cycle of the
study. ID 12 used ibuprofen for a headache that occurred with menstruation during her first menstrual cycle of the study and before receiving her third
chiropractic manipulation.

As described in the introduction, neuromechanical of potential neuromechanical mechanisms, our subjects

mechanisms underlying the potential effectiveness of spinal
manipulation for dysmenorrhea may involve decreasing
tension on the broad ligament of the uterus and sacral nerve
roots. Based upon neurologic connection between uterine
function and the sacral nerve roots, a resultant sympathetic
response to spinal manipulation may inhibit uterine contrac-
tion and increase blood flow to the pelvic region. In support
presented with motion segment restrictions of the lumbosa-
cral spine. These data were consistent with a previous study
documenting a moderate correlation (r = 0.43) between SI
joint dysfunction and the symptoms of dysmenorrhea.10
Specifically, motion palpation procedures were used to
identify SI joint dysfunction and then were correlated with
subjective symptom ratings on the MDQ.10
Journal of Manipulative and Physiological Therapeutics
Volume 31, Number 3
Restrictions of the lumbosacral spine persisted in all our
subjects at each treatment visit. As such, the self-reported
decrease in menstrual pain with the drop table technique
may suggest an acute effect of spinal manipulation on
pelvic nerve pathways associated with uterine dysfunction
and primary dysmenorrhea. The resolution of neuromecha-
nical dysfunction of the lumbosacral spinal and the
associated uterine dysfunction with spinal manipulation
may require a longer duration intervention to restore normal
joint function. In addition, the strength of relationship
between neuromechanical dysfunction of the lumbosacral
spinal and symptoms of primary dysmenorrhea need to be
more conclusively established. The reliability and validity
of motion palpation procedures, although routine in clinical
practice, also need to be substantiated for the purposes of
evidence-based investigations.
Similar to research addressing roles of calcium carbonate
supplements and an anti-inflammatory diet, another potential
underlying mechanism for spinal manipulative procedures
may be a time-dependent attenuation of proinflammatory
cytokine secretion.33 Thus, it may be hypothesized that
spinal manipulations may alleviate pelvic pain through anti-
inflammatory mechanisms. However, previous research on
the effect of spinal manipulation on pain and prostaglandin
levels in women with primary dysmenorrhea does not
support a potential anti-inflammatory mechanism.11,12
The limitations of the study were a small sample size, no
control group, a study population of chiropractic students,
and the durations of the treatment intervention and baseline
monitoring of symptoms. During the treatment phase of 2
months, the subjects continued to present with lumbosacral
restrictions. The clinical improvements in the severity of
menstrual pain may be due to a palliative treatment effect.
Thus, patients would need to seek chiropractic care every
month to prevent/alleviate menstrual pain as opposed to the
more beneficial effect of restoring motion segment function
to alleviate the chronically occurring health condition of
primary dysmenorrhea. Although the median duration of
symptoms of primary dysmenorrhea was 12 years for our
subjects with a consistent presentation of symptoms during
each menstrual cycle, the baseline assessment only rated the
severity of the symptoms of their previous menstrual cycle
before enrollment in the treatment phase. Normal variations
in the severity of symptoms of primary dysmenorrhea of our
subjects are unknown and may only be assumed to be
moderate to severe during every menstrual cycle when the
subjects did not receive chiropractic care or use other
alternative or allopathic interventions.
Despite these limitations, the evidence from this pro-
spective case series report provides insights on designing
feasibility trials to evaluate this specific drop table technique
for primary dysmenorrhea. Our future research will involve
recruiting community dwelling female patients with primary
dysmenorrhea and randomizing them into a treatment group
(n = 30) and a sham control group (n = 30). The treatment
Holtzman et al 245
Manipulation and Dysmenorrhea
phase will be 6 months. It is hypothesized, with this longer
treatment phase, that some subjects in the treatment group
may begin to present with no restrictions of the lumbosacral
spine at months 5 and 6, and the severity of menstrual pain
will decrease. This would begin to determine the role of
chiropractic treatment as a palliative alternative therapy for
menstrual pain or as effective intervention for treating the
chronic symptoms associated with primary dysmenorrhea.
The dose-response for the former treatment effect is as
described in this report and would then need to be confirmed
with a large-scale randomized controlled trial, whereas dose-
response for the latter treatment effect would require further
feasibility trials before pursuing a large-scale randomized
controlled trial.
CONCLUSION
This prospective case series suggests the possibility that
menstrual pain associated with primary dysmenorrhea may
be alleviated by treating motion segment restrictions of the
lumbosacral spine with a drop table technique. The research
team needs to conduct a well-designed feasibility trial to
further evaluate the effectiveness of this specific spinal
manipulative technique for primary dysmenorrhea.
Practical Applications
Chiropractic treatment of the lumbosacral region
of the spine may have neurologic as well as
musculoskeletal implications regarding primary
dysmenorrhea.
Drop table manipulations alleviated menstrual pain
due to primary dysmenorrhea in the participants of
this study.
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