1. Background
The word dysmenorrheam is derived from the Greek word for "dysmenorrhea" which means hard, difficult and abnormal, meno means moon, and rrhea means flow, and generally means monthly hard flow, to describe the problem of bleeding menstruation is used (1). Menstruation is one of the most important stages in the development of women which is sometimes considered to be puberty, but in principle it is one of the stages of puberty and is in the midst of this enormous process. Girls who have received enough information about this phenomenon find it to be one of the prominent stages of adolescence and can easily accept it (2). Dysmenorrhea means painful uterine contractions during menstruation (3) and is usually cramp in nature and is clinically divided into two major primary and secondary groups. Primary dysmenorrhea is called painful menstruation in the absence of pelvic disease. Usually the pain starts with the onset of menstruation and can last 24 to 48 hours. Research shows that dysmenorrhea alone is a major cause of absenteeism and loss of working hours, resulting in approximately 600 million hours of work lost annually due to dysmenorrhea in the United States (4). In Iran, more than 70 percent of girls develop this pain (5). Dysmenorrhea is associated with pain due to muscle spasms in the lower abdomen, which may spread to the waist along the thighs. This pain can be accompanied by symptoms such as nausea, vomiting, diarrhea, headache, dizziness, fatigue, painful breasts, weakness, intestinal and gastrointestinal symptoms and in severe cases syncope. These symptoms may occur two days or more before menstruation begins and may continue for up to three days after the bleeding begins (6). There are various theories regarding the mechanism of dysmenorrhea, but according to one theory, chemical intermediates derived from arachidonic acid metabolism are involved in the pathogenesis by releasing fatty acids and especially acidic fatty acids by interrupting progesterone secretion before the monthly period. Prostaglandins and leukotrienes are uterine cells. The inflammatory response caused by these factors causes cramps and systemic symptoms such as nausea, vomiting, bloating, and headaches, as well as uterine symptoms such as ischemia and severe pain from stenosis (7, 8). These symptoms are commonly referred to as dysmenorrhea. Usually, the easiest way to treat and treat these periodic problems is to take non-steroidal anti-inflammatory drugs that reduce the synthesis of the cyclooxygenase pathway, reducing prostaglandin synthesis and thromboxane. Ibuprofen is one of the most commonly used NSAIDs (9, 10). The use of prostaglandin inhibitors, birth control pills, calcium channel blockers, and skin irritation are common treatments that are often expensive and time-consuming and sometimes lead to drug side effects. Even some people refuse to do so (11). Women may experience abdominal pain as they begin menstruation or a few days earlier, mainly due to contractions within the body's muscles and spasms that enter the uterus and its muscles during this period. These contractions, which most women experience once a month, cause circulatory disturbances in the uterus and thus make the menstrual cycle painful and stressful for women. Many women experience painful menstruation even after marriage and during pregnancy, and this is sometimes repeated throughout the year (12). According to a study by Hernandez-Reif et al. in 2000, one of the best ways to prevent and prevent menstrual cramps is to enjoy a massage that is generally focused on the function of the uterus and its associated muscles and the circulatory flow in the area (13). Massage is used as one of the therapeutic methods in many chronic cases and clinical problems (14). Massage has been defined as a systematic form of touching the soft tissues of the body by the hands for therapeutic purposes such as relieving pain, increasing the comfort and comfort of patients. It is generally thought that exercise therapy can alleviate the discomfort associated with dysmenorrhea. Scientific papers provide different information (15), and the results of various studies have shown that exercise intensity has decreased symptoms (16). Physical activity and exercise as a non-medication have found a special therapeutic status. However, some studies have not reported a relationship between menstrual pain and primary dysmenorrhea with exercise level. There is some evidence that factors such as stretching and mental relaxation are effective (17).
Various studies emphasize that regular exercise, including abdominal, hip and groin stretching exercises, has positive effects on menstrual syndrome, and the more the positive effects of exercise, the greater the increase (18). Exercise reduces renin levels and increases estrogen and progesterone, aldosterone levels decrease, thereby reducing and improving physical symptoms reduces shortness (19). Daly (2008) and Brown et al. (2017) based on some empirical evidence stated that regular participation in exercise reduces primary dysmenorrhea and related symptoms (20, 21) but according to the study of Blakey et al. (2010) No association was found between participation in exercise and primary dysmenorrhea (22). Given the prevalence of dysmenorrhea and its effects on the quality of individual and social life and the general acceptance of complementary and non-toxic therapies, which can replace pharmacological methods and find the best way to control pain and avoid any side effects, the question is whether there is a difference between the effect of stretching and massage and the combination of massage-stretching on primary dissemination of female students of Kermanshah University of Medical Sciences?
Now, considering the possible effects of stretching and massage training on dysmenorrhea and on the other hand, the specific nature of the researcher's intended exercises, it is important to study the effect of these exercises on dysmenorrhea and its specific manifestations. Therefore, due to the adverse effects of dysmenorrhea on the function of women, especially young girls, the numerous physical, psychological and social problems they cause, as well as the possibility of inappropriate, ineffective and occasional treatment with adverse effects, the present study may be applicable and Girls and women can also benefit from these benefits, so considering the importance of this issue, it seems necessary to investigate these disorders among students who have a major role in advancing the scientific and health goals of the community.
2. Objectives
The aim of this study was to compare the effect of combination of stretching and massage on primary dissemination of female students in Razi University of Kermanshah.
3. Methods
The present study is a semi experimental. The study population consisted of female students of Razi University of Kermanshah. Ninety 90 students who were eligible for inclusion in the study were voluntarily selected after completing their informed consent form.
The research tool was a researcher-made questionnaire for primary dysmenorrhea and the revised McGill pain questionnaire. Primary Dysmenorrhea researcher-made questionnaire included demographic characteristics, questions such as the nature of pain, pain location, duration of pain, time of onset of pain, history of menstrual pain in mother, history of menstrual pain in sister. Content validity was used by experts, physicians, health care workers, and professors to assess the content of the instrument and the purpose of the study. To determine the reliability of the questionnaire, the Alpha-Cronbach test was used, which was confirmed with a 0.72 index (23). Also, the results of exploratory and confirmatory factor analysis of the revised McGill Pain Questionnaire indicated that there were four subscales of continuous pain, varied pain, neuropathic pain and affective pain that the Cronbach's alpha coefficients were 0.87, 0.87, 0.83 and 0.86, respectively was (24).
After selecting the subjects and performing the initial tests, the exercise program consisted of (including 6 stretching exercises of abdominal, pelvic and groin) and Swedish massage and combination of massage and stretching exercises, respectively, regularly for 8 weeks, 3 sessions per week, and each session took about 15 minutes to complete (25).
Descriptive and inferential statistics were used for data analysis. Descriptive statistics, mean, standard deviation, and inferential statistics were used to compare the mean of three groups of massage, stretching exercises and massage-stretching group before and after the intervention and pre- and post-test by t-test Paired and one-way ANOVA with alpha level less than 0.05 was used to compare between exercises. It should be noted that Kolmogorov-Smirnov test was used to show the normal distribution of data at each factor level. SPSS software was used for statistical analysis.
4. Results
For analyze the results and test the hypotheses in this study, dependent t-test and one-way ANOVA were used and Kolmogorov-Smirnov test were used to check the normality of the data (Table 1).
Table 1.Significance Level of Kolmogorov-Smirnov Test (K-S)
| Variables | Massage Group | Stretching Group | Combined Practice Group | |||
|---|---|---|---|---|---|---|
| Mean ± SD | P Value | Mean ± SD | P Value | Mean ± SD | P Value | |
| Severity of McGill pain (pre-test) | 71.86 ± 42.10 | 0.281 | 71.43 ± 40.33 | 0.156 | 75.70 ± 39.40 | 0.052 |
| Severity of McGill pain (post-test) | 55.76 ± 37.16 | 0.269 | 54.20 ± 35.52 | 0.282 | 52.60 ± 29.82 | 0.086 |
| Duration of pain (pre-test) | 2.67 ± 1.24 | 0.163 | 2.63 ± 1.27 | 0.099 | 2.73 ± 1.38 | 0.175 |
| Duration of pain (post-test) | 2.37 ± 1.09 | 0.082 | 2.50 ± 1.10 | 0.22 | 2.03 ± 0.928 | 0.051 |
| The nature of pain (pre-test) | 1.23 ± 0.430 | 0.00 | 1.30 ± 0.466 | 0.00 | 1.37 ± 0.490 | 0.00 |
| The nature of pain (post-test) | 1.83± 0.379 | 0.00 | 1.90 ± 0.481 | 0.00 | 1.93 ± 0.365 | 0.00 |
According to the results of Kolmogorov distribution of scores for all three groups (massage, combination and stretching) in pain intensity variables, pain duration had normal distribution. However, the nature of the pain was non-normal for all three groups, so nonparametric tests should be used to determine the efficacy of the independent variable and to examine intra- and inter-group differences.
First hypothesis: There is a significant difference between the effect of stretching, massage and massage-stretching combination on the intensity of primary dissemination pain before and after the intervention in the stretching group.
Table 2.Paired t-Test Before and After the Intervention
| Mean ± SD | t | Df | P Value | |
|---|---|---|---|---|
| Stretching training group | 17.23 ± 6.07 | 15.53 | 29 | 0.00 |
| Massage group | 16.10 ± 10.22 | 8.62 | 29 | 0.00 |
| Combined practice group | 23.10 ± 15.36 | 8.23 | 29 | 0.00 |
The results of Table 2 show that pain intensity in the stretching, massage and massage-stretching group before and after the exercise was significant, indicating a significant effect of these exercises on the severity of primary dysmenorrhea.
Second hypothesis: There is a significant difference between the effects of stretching, massage and massage-stretching combination on the severity of primary dissemination pain before and after the intervention in the 3 groups.
Table 3.ANOVA Comparison of Three Training Methods
| Sum of Squares | Df | The Mean Square | F | P Value | |
|---|---|---|---|---|---|
| Before intervention | 0.100 | 0.905 | |||
| Intragroup | 867.33 | 2 | 433.16 | ||
| Intergroup | 133.14 | 87 | 749.16 | ||
| After intervention | 0.064 | 0.938 | |||
| Intragroup | 422.15 | 2 | 211.75 | ||
| Intergroup | 367.10 | 87 | 556.11 |
The results of Table 3 showed that there was no significant difference in pain severity between the three groups before and after the intervention, indicating a significant effect of all three exercises on the severity of primary dysmenorrhea.
Third hypothesis: There is a significant difference between the effect of stretching, massage and massage-stretching combination on the duration of primary dissemination pain before and after the intervention in the stretching group.
Table 4.Dependent t-Test for Pain Duration Before and After the Intervention
| Mean ± SD | t | Df | P Value | |
|---|---|---|---|---|
| Stretching training group | 0.133 ± 1.59 | 0.459 | 29 | 0.650 |
| Massage group | 0.433 ± 1.04 | 2.282 | 29 | 0.030 |
| Combined practice group | 0.833 ± 1.57 | 2.893 | 29 | 0.007 |
As Table 4 shows, the duration of pain in the stretching group before and after the exercise was not significant, indicating no significant effect of stretching exercises on the duration of primary dysmenorrhea. That is, tensile training did not have a significant effect on decreasing the duration of primary dysmenorrhea. Pain duration in massage and massage-stretching combination was significant, indicating a significant effect of these exercises on the duration of primary dysmenorrhea. That is, these exercises had a significant effect on decreasing the duration of primary dysmenorrhea.
Fourth hypothesis: There is a significant difference between the effect of stretching exercises, massage and massage-stretching combination on the duration of primary dissemination pain before and after the intervention in the 3 groups.
Table 5.ANOVA Test Comparison of Three Training Methods
| Sum of Squares | Df | The Mean Square | F | P Value | |
|---|---|---|---|---|---|
| Before intervention | 0.046 | 0.559 | |||
| Intragroup | 0.156 | 2 | 0.078 | ||
| Intergroup | 14.500 | 87 | 1.695 | ||
| After intervention | 2.417 | 0.095 | |||
| Intragroup | 5.422 | 2 | 2.711 | ||
| Intergroup | 97.567 | 87 | 2.417 |
Table 5 shows that there was no significant difference in pain duration between the three groups before and after the intervention, which indicates a significant effect of all three exercises on the duration of primary dysmenorrhea does not exist.
Fifth hypothesis: There is a significant difference between the effect of stretching exercises, massage and massage-stretching combination on the nature of primary dysmenorrhea before and after the intervention in the stretching group.
Table 6.McNemar Test of the Nature of Pain Before and After the Intervention
| Number | Exact Sig. (2-tailed) | |
|---|---|---|
| Stretching training group | 30 | 0.00 |
| Massage group | 30 | 0.00 |
| Combined practice group | 30 | 0.00 |
Table 6 showed that the nature of pain in the stretching, massage and massage-stretching group was significant, indicating a significant effect of these exercises on the nature of primary dysmenorrhea. That is, these exercises had a significant effect on reducing the nature of primary dysminesia pain.
Sixth hypothesis: There is a significant difference between the effect of stretching exercises, massage and massage-stretching combination on the nature of primary dysmenorrhea before and after the intervention in the 3 groups (Table 7).
Table 7.Nature of Pain Before and After Intervention in 3 Groups
| Number | Mean | |
|---|---|---|
| The nature of pain (pretest) | ||
| Massage | 30 | 50.42 |
| Stretching exercises | 30 | 50.45 |
| Massage combination - stretching exercises | 30 | 50.48 |
| The nature of pain (posttest) | ||
| Massage | 30 | 50.43 |
| Stretching exercises | 30 | 50.46 |
| Massage combination - stretching exercises | 30 | 50.46 |
Table 8.Comparison of The Effect of Stretching, Massage and Massage-Stretching Exercises on the Nature of Pain
| The Nature of Pain (Pre-test) | The Nature of Pain (Post-test) | |
|---|---|---|
| Chi-square | 1.256 | 0.819 |
| Df | 2 | 2 |
| P value | 0.534 | 0.664 |
As Table 8 shows, there was no significant difference in the nature of pain between the three groups before and after the intervention, indicating a significant effect of all three exercises on the nature of primary dysmenorrhea. On the other hand, there was a significant difference between the three exercise methods in the nature of pain there is no.
5. Discussion
There was a significant difference between the effect of stretching exercises, massage effect and also the effect of massage-stretching combination on the severity of primary dissemination pain before and after the intervention. On the other hand, according to the results of the second hypothesis, there was no significant difference between the effects of stretching exercises and massage-stretching combination on the severity of primary dissemination pain before and after the intervention in the three groups.
The results of this study showed that 8 weeks of stretching exercises, massage individually and massage-stretching combination had a significant effect on decreasing the pain intensity of primary dysmenorrhea in girls. One of the mechanisms of menstrual pain is severe pelvic muscle contraction when blood is drawn out of the uterus. Pain occurs when the muscular wall of the uterus shrinks. Painful and mild contractions persist in the uterus, but for most women, the pain is so mild that they do not feel the pain. During menstruation, the lining of the uterus is strongly contracted to separate the inner lining of the uterine cavity (endometrium) and menstrual bleeding occurs. As the muscles of the uterine wall contract, the blood vessels of the inner layer of the endometrial uterus are pressurized; this temporarily results in a severe decrease in blood supply and oxygenation to the uterus (26).
Lack of oxygen leads to the release of chemicals in the body and eventually causes pain. When the pain-causing chemicals are released into the body, another chemical called prostaglandin is released into the body, which causes the prostaglandin itself to cause more severe uterine contractions and ultimately more pain. One of the mechanisms of pain during menstruation is the severe contraction of the pelvic muscles when blood is released from the uterus (27).
During stretching, flexibility and elasticity of the abdominal and pelvic muscles are increased and severe cramps and contractions are reduced and pain is reduced (28). Studies have shown that with increased flexibility of the abdominal and pelvic muscles, spasm and muscle contraction are reduced and as a result, pain is reduced (28), therefore, given the tensile nature that focuses on muscle elasticity and flexibility, Exercises have been able to reduce the severity of menstrual pain, the results of which are consistent with those of Salehi et al. (2012); Abbaspour et al. (2006); Shahrjerdi and Hosaini Studies, Mosallanejad et al. (2007); Blakey et al. (2010). Daly (2008) and Brown (2010), Chandler et al. (2009) agree (19, 20, 22, 29-33), and disagree with Label (1990) and Harlow and Park (1996) (7, 34).
To justify the mean reduction in pain intensity before and after the massage and tensile exercise, the effect of massage-tensile exercise in the three groups was apparently due to the significant decrease in pain intensity. Stretching has been equally effective in reducing pain intensity. Therefore, according to the results of the present study, massage and stretching exercise as well as the effect of massage-stretching combination as non-invasive methods are almost equally effective and effective in reducing the symptoms of sensory pain caused by primary disseminator. Helping girls with dysmenorrhea Select and apply one of these methods will depend on the individual's circumstances and circumstances.
Sometimes some of the pain is due to anxiety, so it may be possible to reassure the patient that these symptoms are periodic (especially with the daily registration of symptoms) and that they are caused by hormonal changes, which can cause anxiety and thus the severity of their pain decrease (35). It is also likely that the decrease in psychological symptoms caused by massage is that massage reduces the symptoms of the syndrome, which reduces stress hormone levels, cortisol, and reduces symptoms such as depression and anxiety, resulting in relaxation and thus reduced pain.
It is worth noting that in explaining no significant difference in pain severity symptoms between the three methods of stretching, massage, as well as the combination of massage-stretching, the researcher failed to find a clear and precise cause for this issue and where this difference did not arise. Further studies are recommended to be considered in future research.
According to the third hypothesis, there is no significant difference between the effect of stretching exercises on the duration of primary dissemination pain before and after the intervention in the stretching group, but between the effect of massage and also the effect of massage-stretching combination on the duration of primary dissemination pain before and after intervention. Intervention There was a significant difference in the stretching group. On the other hand, according to the results of the fourth hypothesis, there was no significant difference between the effect of stretching exercises and massage-stretching combination on the duration of primary dissemination pain before and after the intervention in the three groups.
Unlike other sports for the long haul, he showed that the traits involved with blood flow, the proliferator involved, were involved. On the other hand, it can be directed to stress cells, blood circulation, endotracheal intubation and transduction of eyes and kidneys (36). Exercise at the time of pain; the transfer of most waste and processors, which may cause pain to be sustained from the abdomen and pain to the kidney (38%). Cats have shown that they are more likely to be affected by cancer and by increasing their pain and inflammation, and by reducing pain (37). The results of the present study showed that there is no significant relationship between stretching exercises on the duration of pain in girls with primary dysmenorrhea and the results of this study with Shahrjerdi and Hosaini (2009) (8 weeks training). Salehi et al. (2012) (Impact of a Pilates Exercise Course), Chandler et al. (2009) (19, 30, 33);
Researchers have not yet observed the same study, in addition to the limitations of the present study, there can be no definitive and precise reason to justify a significant difference between the groups of stretching, massage and massage-stretching groups.
There was a significant and negative relationship between the uses of massage on pain duration, meaning that the duration of pain massage decreased.
According to the fifth hypothesis, there is a significant difference between the effect of stretching exercises, massage and also the effect of massage-stretching combination on the nature of primary dysmenorrhea pain before and after the intervention in the stretching group. On the other hand, according to the results of the sixth hypothesis, there was no significant difference between the effect of stretching exercises and the combination of massage-stretching exercises on the nature of primary disseminated pain before and after the intervention in the three groups. The results of this study are in line with the research of Ghaedi et al. (2010), Kim (2004), Hernandez-Reif et al. (2000) (13, 38, 39).
According to the results of this study, there was a significant difference between the effect of stretching, massage and also the effect of massage-stretching combination on the nature of primary disseminated pain before and after the intervention in the stretching group. Significantly reduces symptoms of the nature of pain although the mechanism of this effect has not yet been elucidated, uterine contractions appear to be responsible for the development of painful menstrual cramps (40). It has on the uterine muscles as it ruptures Dan muscle tension and break the vicious cycle of stress and pain, pain in the reduced (41).
5.1. Conclusions
Finally, by summing up the results of the present study, there was no significant difference between the physical symptoms of severity, duration and nature of pain in all three groups of stretching, massage and massage-stretching combination. Symptoms among the three groups were that subjects received out-of-control information and training due to the researcher's subsequent awareness of the syndrome, the likelihood of individuals becoming sensitive to the syndrome. So this case probably caused a significant difference and a significant difference in performance. The experimental group relative to each other is not established.
Other possible causes for the lack of significant differences in physical symptoms between the groups of stretching exercises, massage, as well as the combination of massage - stretching movements, interactions associated with chemical constituents and neurotransmitters by endocrine glands in the body. It is secreted, as well as the physiological changes that occur as a result of the three methods mentioned in the body and are similar in all three ways (42).
Therefore, given the results of the present study, massage and stretching exercise, as well as their combination as noninvasive methods, were nearly equally effective in reducing the symptoms of primary dysmenorrhea. Dysmenorrhea can be equally effective in the treatment of symptoms associated with primary dissemination, and the use of one of the above methods can be equally effective and depends on the individual's facilities and conditions.
