INTRODUCTION
Menstruation occurs cyclically in females as a result of the fluctuation of estrogen and progesterone during the reproductive years.1 Changes occur in the female body in response to these hormones which can cause menstrual related symptoms.1 Dysmenorrhea is characterized by lower abdominal pain during menstruation with pain that may also radiate into the lower spine, back and legs.2 Additional symptomatology that may accompany dysmenorrhea is fatigue, vomiting, headaches and backaches.2 In addition to the physical symptoms that accompany dysmenorrhea, social life can also be affected.3 Dysmenorrhea is a common reason for school and work absenteeism, increased anxiety and depression and an overall decreased quality of life.3
Females oftentimes associate dysmenorrhea as a normal occurrence and do not seek professional advice.4 Dysmenorrhea is one of the most common disorders a female can suffer from and is said to be present in 50-90% of females of reproductive age.5 Primary dysmenorrhea is different than secondary dysmenorrhea in that it has no known cause whereas secondary dysmenorrhea is associated with a pelvic pathology.4
Current treatments for dysmenorrhea range from medication such as NSAIDS and oral contraceptive pills to complementary alternative therapies such as physiotherapy, low intensity or high intensity exercise, and spinal manipulative therapy.6–8 Dietary changes, transcutaneous electrical stimulation, acupuncture and exercise have also been suggested to decrease symptoms.9
Three systematic reviews have showed promise for manipulative therapy to be a treatment option for dysmenorrheal.1,3,7 A randomized controlled trial osteopathic manipulation of 60 individuals with an average age of 33 showed a positive impact on quality of life.10 Because dysmenorrhea is associated with headaches and back pain, a chiropractor should be prepared to have patients presenting to their office that may be suffering from dysmenorrhea. Chiropractic care may help with dysmenorrhea symptoms if the pain radiates into the spine; therefore, adjusting the spine may help alleviate the pain.
Logan Technique is a chiropractic treatment that focuses on using light pressure to the sacrotuberous ligament for adjusting the sacrum.11 Logan Basic was founded by Hugh Logan in the 1920s.11 The sacrum and ilium make up the pelvic region which houses and protects the uterus. Making sure the structures are in alignment may potentially help a person suffering from dysmenorrhea. The adjustments applied with this technique utilize extremely light contact and pressure; this may be beneficial for a women with dysmenorrhea to have a lighter pressure for potential touch sensitivity due to their symptoms. There are virtually no contraindications and little risk at all due to the gentle nature of the adjustments. This technique involves working on the sacrotuberous ligament which eventually relaxes and therefore promotes the realignment of the sacrum into its natural position.11
CASE REPORT
History
A 28-year-old female student sought care in an academic chiropractic clinic for routine maintenance care for acute symptoms that would typically arise from studying. After developing trust with the student intern, the patient began to open up and discuss her struggles with menses. She had a 12-year history of almost debilitating menstrual symptoms, which included severe cramping (10/10 on pain scale), migraines, and heavy menstrual flow lasting around 9 days each cycle. She reported that she would have to be in bed frequently during the menstrual phase of her cycle. She also stated she oftentimes could not attend classes and social events due to migraines and cramps. Her symptomology was to the point of situational depression as she could not live with the quality of life that she wanted.
This patient had a history of extremely painful and difficult menstruation involving dysmenorrhea and cramps were reported to last the entire cycle. The flow of menstruation was reported to be heavy. She also experienced debilitating headaches. No treatments provided relief, but the patient used NSAID’s and a heating pad with hope of symptom reduction but to no avail. The patient ceased using oral contraceptives in December of 2022 after using them for 8 years. Upon stopping, she acquired many side effects, such as hypothyroidism and fatigue, that caused her to want to go medication free for her dysmenorrhea and track her menstrual cycle strictly with a tracking device and application.
Examination Findings
This patient had vital signs all within normal limits. She was 67 inches tall and weighed 122.7 pounds with a body mass index of 19.2. Examination of all organ systems appeared to be normal.
Orthopedic examination showed a mild decreased range of motion in the lumbar spine in all planes. Neurological testing showed 5/5 muscle strength grading for L4, L5, and S1. Normal sensation to dermatomes of L1, L2, L3, L4, L5 and S1. All deep tendon reflexes were 2/2.
Orthopedic testing showed Kemp’s, Slump, Yeoman’s, Hibb’s and Ely’s to be negative for sacroiliac pain or reproduction of low back pain. Valsalva test was also negative.
The chiropractic examination showed significant tension and of the right sacrotuberous ligament indicating a right anterior inferior sacrum position. The L5 spinous process was rotating away from the AI sacrum on the side of fixation. This was derived from the Logan technique evaluation which emphasizes full-spine postural distortions as the basis of care with the sacrum and the pelvis.
Management
The patient was initially adjusted with high-velocity, low-amplitude methods of adjusting using a table that applied drops as the doctor applied a thrust to the vertebrae that was misaligned in the lumbar and pelvic region. After being treated with this method of care for 14 months with no improvement with her menstrual symptoms, the patient began to open up about her struggle with dysmenorrhea and expressed interest in receiving Logan technique. Logan technique was applied to the right side of sacrum. One hand applied pressure against the sacral apex through the sacrotuberous ligament while the other corrected slight displacement of the vertebrae.
She was seen twice a week for 3 months. Re-evaluations were administered every 3 months to see if this frequency provided relief for her symptoms.
The QVAS Scale was used to monitor her progress. The QVAS is scored from 0-100, Scores over 50 are considered severe pain.12 A new QVAS was given during or after each menstrual cycle depending on timing of visit scheduled.12 Her scores are depticted on table 1.
Outcome
The patient consistently visited twice a week. After 2 visits, her symptoms dramatically improved. After 2 months of careshe became emotional about how much her “life has changed” since beginning care with the Logan basic technique.
At beginning of treatment plan, she scored for high intensity on a QVAS for her menstrual symptoms (76.6). After 3 months of treatment, her QVAS score decreased to low intensity (36) and remained in low intensity status for the duration of treatment. After about 3 months into her care, she missed 1 week of adjustments (2 visits) due to a vacation and after this her symptom intensity returned but not as severe as prior to intervention.
DISCUSSION
Menstrual symptoms commonly affect most premenopausal women and can greatly impact their quality of life.13 This case report showed that Logan technique could be a viable option for women seeking help with cramping and other complaints related to menses. Her improvement in symptom duration and intensity improved as did her QVAS score. Chiropractic may aid in reducing menstrual symptoms because nerves that run along the spinal column innervate the uterus. The sacrum in particular has nerves which innervate the uterus and Logan technique uses sacrum adjustments, which may have helped her menstrual symptoms.14
Lifestyle factors such as stress, alcohol consumption, bedtime, sleep, physical activity can all impact the prevalence of dysmenorrheal.1 Our patient had a low BMI, which could have impacted her dysmenorrhea. The word doctors also means to teach, as a chiropractor, it is important to help educate patients on lifestyle factors that could be contributing to ailments that they have in life. She reported that her quality of life improved after treatment.
The dramatic progress of this patient is the rationale for this case report. Logan technique has been shown to help other conditions, such as spinal stenosis and Ehlers Danlos syndrome.15,16 This technique may be beneficial to patients who have conditions that require a lower-amplitude force.
The doctor-patient relationship is an important aspect of healthcare. The patients’ view of the doctor’s empathy toward them influences the trust in the relationship. The trust developed in this relationship was strong enough for her to open up about her menstrual condition, which was not something she originally sought care for. The doctor was able to better understand the full clinical picture, knowing other symptomatology that could be contributing to the her back pain.
Another possible readon for the positive outcome is that the patient was consistent with appointments. Strict adherence to her care plan may have increased her ability to recover as well as she did. She also paid very close attention to her symptoms and cycles in order to be able to accurately report her symptoms. She used a tracking app to note the duration of her cycles and symptoms. Menstrual tracking applications are growing in popularity.17 They can track the presence of symptoms and some even have a qualitative element to record other symptoms.17
Limitation
The results here cannot be generalized. There are limited resources and research available on Logan technique and managing menstrual symptoms with chiropractic care. Logan technique is not a widely taught discipline; thus, relevant medical literature is scarce. There is more evidence needed to explore this avenue of chiropractic intervention.
Conclusion
Logan technique was beneficial for this patient in decreasing menstrual symptom intensity and duration and an improved her overal quality of life. Chiropractors may want to consider utilizing Logan technique for patients with menstrual complaints.
Consent
The patient provided written informed consent.