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Table of Contents
Year : 2023  |  Volume : 5  |  Issue : 1  |  Page : 60-65

Prevalence of pelvic crossed syndrome in females with primary dysmenorrhea and its impact on physical activity: An observational study

Department of OBG Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission26-Apr-2022
Date of Decision24-Feb-2023
Date of Acceptance06-Jun-2023
Date of Web Publication11-Aug-2023

Correspondence Address:
Asmu Bhattarai
Department of OBG Physiotherapy, KLE Institute of Physiotherapy, Belagavi - 590 010, Karnataka, India. USM Hostel, KLE University, Belagavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_71_22

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Context: Pelvic crossed syndrome (PCS) often known as lower crossed syndrome, which is a clinical pattern of muscle imbalance around the pelvis, has been reported more frequently in females than males of the same age. Primary dysmenorrhea (PD), which is another prevalent condition in females, is a leading cause of work absenteeism. As menstrual pain has been reported with change in musculoskeletal structure around the pelvis and lumbar area, this syndrome could be a missing link, which describes the severity of the condition, and may have an impact on physical activity.
Aims: The objective of the current study is to find the prevalence of PCS in females with PD and its impact on physical activity.
Settings and Design: This was an observational study undertaken in colleges of Belagavi City for a period of 6 months.
Subjects and Methods: A total of 305 females with PD were recruited based on the inclusion criteria. They were assessed for PCS using Thomas test and modified Schober's test for muscle length and manual muscle testing grades for muscle strength, after which were subjected to Simple Physical Activity Questionnaire.
Statistical Analysis: The data were analyzed using SPSS version 23 software descriptive statistics and Chi-square test.
Results: The prevalence of PCS in females with PD is 28.5% with 44% of those experiencing severe PD, whereas 23% of those with moderate-to-severe PD. The impact of the same on physical activity was found significant with 67% of females with PD involving in only 1 h of physical activity for every 24 h.
Conclusions: Pelvic cross syndrome affects physical activity significantly and is prevalent in 28.5% of females with PD.

Keywords: Pelvic crossed syndrome, Physical activity, Primary dysmenorrhea

How to cite this article:
Mahishale A, Bhattarai A. Prevalence of pelvic crossed syndrome in females with primary dysmenorrhea and its impact on physical activity: An observational study. Indian J Phys Ther Res 2023;5:60-5

How to cite this URL:
Mahishale A, Bhattarai A. Prevalence of pelvic crossed syndrome in females with primary dysmenorrhea and its impact on physical activity: An observational study. Indian J Phys Ther Res [serial online] 2023 [cited 2023 Oct 1];5:60-5. Available from: https://www.ijptr.org/text.asp?2023/5/1/60/383682

  Introduction Top

Primary dysmenorrhea (PD) is another well-being issue faced by females of reproductive age. It is a condition of painful cramps before or during menstruation without any identifiable pelvic pathology, whereas secondary dysmenorrhea presents with menstrual pain with a definite pelvic pathology. PD is a prevalent condition among young female students and often presents with lower abdomen and back pain which is also felt in the bones, muscles, and skin of the surrounding organs.[1] Affected women experience a sharp, intermittent spasmodic pain usually concentrated in the suprapubic area. Pain may radiate to the back of the legs or the lower back.

Regarding the physiological mechanism of dysmenorrhea, it is well established that contraction of the myometrium, accompanied by shredding of endometrium, releases prostaglandin which contributes to the constriction of the muscle tissue, resulting in menstrual pain. Literature also provides evidence suggesting a connection between irregular positioning of the pelvis, lumbar vertebrae, and abdominal muscle spasm that can influence the position of the uterus, thus increasing the chances of painful menstruation. Exaggerated lumbar lordosis and anterior pelvic tilt are predominant presentations in the sagittal plane, observed in pelvic crossed syndrome (PCS). These postural alterations create a difference in the pelvic alignment and modulate the locational change of the uterus, a structure inside the pelvic cavity. PD, a monthly phenomenon occurring in the uterus, is hypothesized to increase with increasing tension in the soft tissues and muscles resulting from the anterior or posterior locational change of the uterus.[2]

Mood swings, fatigue, headache, nausea, and edema during menstruation are associated with complaints of dysmenorrhea.[3] The prevalence of Primary Dysmenorrhea was found be highest in the age group of 16-25 years, according to a review in the year 2021.[4] Despite it being an issue of serious concern, appropriate measures to prove its association is less scientific and contradictory. Though earlier studies have already described the phenomena as a response to endocrine, vascular and immune mechanism, there is a dearth in literature about muscle dysfunction present in females with PD and its prevalence. However, there is a dearth in literature about muscle dysfunction present in females with PD and its prevalence in the same population.[5]

Physical activity is one of the most important domains of healthy living. The significance of physical activity in various aspects of health including weight control to the prevention of heart disease has been apparent. It has also been proven to have an impact on factors associated with cancer risk and depression.[6] Despite having numerous health benefits, there is still a lack in implementation of regular physical activity and dysmenorrhea is one of the major factors which withdraws females from engaging in their activities of daily living along with the physical activity. Literature has reported that females with PD are much lesser involved in physical activity than females without PD.[7] Thus, this study aims to find out the prevalence of PCS in females with PD, suggesting potential treatment option for the same, and its impact on physical activity.

  Subjects and Methods Top

This cross-sectional study evaluated the prevalence of PCS in young female students of Belagavi City, Karnataka, India. A total of 355 females were included in the study by convenience sampling. The sample size was calculated using the formula: (N = z2 pq/d2) based on the reference article by Das et al.[8]

Scientific and ethical approval was provided before the commencement of the study by the Institutional Research Ethical Committee (KAHER IPT ERC SI.No. 649). The study was conducted in various institutions in Belagavi City. Before screening the participants, approval from each institution principal was obtained. All the participants were asked to report their menstrual pain on Visual Analog Scale and those who reported 4 or more than 4 were considered for further examination. The inclusion criterias were; nulliparous women between 18 and 25 years of age, reporting 4 or more than 4 on visual analog scale and willingness to participate in the study. Females with secondary dysmenorrhea, any hip or pelvic surgeries in past 1 year, and on muscle relaxant or antispasmodic were excluded from the study.

At enrollment, all the participants were evaluated for demographic data including age, height, weight, and body mass index (BMI). Before getting examined for the muscle tightness and weakness, participants underwent 5 min of warm up including brisk walking, back stretches, and back rotation.[9] PCS was examined using modified Thomas test, modified Schober's test, and manual muscle testing (MMT). Modified Thomas test was used to measure the tightness of iliopsoas bilaterally using a universal goniometer.[10] Modified Schober's test was used to evaluate the thoracolumbar extensors flexibility.[11] Abdominals and gluteus MMT was recorded according to medical research council (MRC) grading.[12] After which the participants were subjected to simple physical activity questionnaire (simPAQ) to determine the hours involved in physical activity.

Outcome measures

Muscle length test for iliopsoas using Thomas test

Participants were asked to lie in supine position with buttocks at the end of the couch. They were instructed to flex the non-tested limb to the chest. During the knee to the chest position, the lumbar spine was flattened and the pelvis was stabilized and the length of opposite side Iliopsoas was measured with Goniometer.[13] The same procedure was repeated on the other side. The Iliopsoas was considered tight if hip extension is <15° [Figure 1].
Figure 1: Iliopsoas length testing

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Muscle length test for thoracolumbar extensors using modified Schober's test

The participants were instructed to stand erect with lumbar, thoracic, and pelvis in neutral. The therapist palpated for the L5 vertebrae and the point was marked with the help of a marker. Then, 2nd marking is done 5 cm below and 10 cm above the first marking using a nonelastic measuring tape.

After stabilizing the pelvis by the therapist, participants were asked to bend forward keeping the arm relaxed maintaining equal weight on both the feet. The motion continued until the subjects started experiencing resistance and therapist feels that the pelvis has started tilting anteriorly. The distance between the 2 points marked and measured, while the trunk is flexed. If the difference was <20 cm, the muscle is considered tight [Figure 2].
Figure 2: Length testing of TLE. TLE: Thoracic lumbar extensors

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Muscle strength test for abdominals

Curl-up test was used to measure the abdominal muscle strength. After attaining crook lying position, participants were asked to curl their trunk forward with hands clasped behind the head for Grade-V, hands crossed over chest for Grade-IV and hand outstretched forward for Grade-III. Therapist stands at the side of testing table in order to ensure the scapular clearance off the couch. Participants then come forward flexing the trunk until the inferior angle of scapula clears off.[13]

Muscle strength test for gluteus maximus

Participants were directed to be in prone with knees flexed to 90°. Therapist standing on the side with one hand stabilizing the pelvis by applying downloads pressure at the back. As the participants were asked to lift the thigh off the couch while maintaining the knee flexion, resistance (mild resistance for Grade IV and maximum resistance for Grade-V) was applied manually at the lower part of posterior thigh in the direction of hip flexion by the other hand of the therapist. The muscle was graded according to the MRC grading.

Simple Physical Activity Questionnaire

Simple Physical Activity Questionnaire is a physical activity measurement tool designed to be used as a structured interview with good test-retest reliability.[14] SIMPAQ should take between 3-8 minutes to complete and is administered by clinicians or researchers. It estimates time in bed, structured exercise participation, and incidental or non-structured physical activity. It gives an estimation of total hours spent for physical activity.

Statistical analysis

The data were analyzed using SPSS version 23 (SPSS Inc.Chicago, IL,USA). Sample size was calculated by convenience sampling using formula: (N = z2 pq/d2). In accordance with Das et al., the prevalence was taken as 36.14%.[8] Frequency test was used to analyze the demographic data (age and BMI) of all the participants. Descriptive statistics determined the frequency of PCS in female volunteers. Chi-square test was used to find out the homogeneity of proportions in females experiencing moderate-to-severe PD with or without PCS and its significance with physical activity. These tests were applied at 95% confidence interval and 0.05 significant level.

  Results Top

The mean age of the participants was 21.42 ± 2.02 years, whereas the minimum age was 18 years and maximum was 25 years. The mean weight of the respondents was 57.16 ± 10.10 years, whereas the minimum weight was 42 kg and maximum was 98 kg. The average BMI of all the participants was 26.72 kg/m2 [Table 1]. Out of 305 female volunteers, 47 (15.4%) reported heavy, 58 (19%) reported mild, and 200 (65.6%) reported moderate bleeding during the last menstrual cycle.
Table 1: Demographic Profile

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One hundred nine (35.7%) were found to have an abdominal strength of Grade 3, 149 (48.9%) were found to have Grade 4, and 47 (15.4%) were Grade 5. Similarly, 7.9% had Grade 3, 61% had Grade 4, and 31% had Grade 5 strength of the right gluteus maximus, and the percentage distribution for strength of the left gluteus maximus was found to be 8.2% for Grade 3, 55.7% for Grade 4, and 36.1% for Grade 5 [Table 2].
Table 2: Muscle strength assessment

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The muscle length testing results showed that hip flexor tightness on the right was present in 208 (68.2%), and on the left, it was 184 (60.3%) out of total participants. Thoracolumbar tightness was present in 164 (53.8%) volunteers [Table 3].
Table 3: Muscle length testing

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PCS was found in 87 (28.5%) out of 305 females out of which 53 experienced moderate and 34 experienced severe pain during menses. A statistically significant difference was noted in VAS scores in terms of moderate and severe PD (P = 0.001) [Table 4].
Table 4: Pelvic crossed syndrome prevalence

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PCS was found in 67 female participants who scored 1 on SimPAQ. Similarly, 17 of them who only had 2 h of physical activity per day were found to be present with PCS. PCS was found in 87 (28.5%) of females who experienced very moderate-to-severe (39.08%) PD and severe (60.9%) PD [Table 5].
Table 5: Pelvic crossed syndrome with Simple Physical Activity Questionnaire score

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  Discussion Top

Primary Dysmenorrhea is an exceptionally prevailed condition in females that significantly affects various personal and social aspects, prompting non attendance, less hours at work, compromised physical activity, loss of concentration, poor academic performance and social relationship.[15] This condition has proactively been examined as a potential outcome of muscle imbalance around the pelvis.[16] PCS is a succession of muscle shortcoming and snugness around the dorsal and ventral part of the body at pelvic locale and has been viewed as more predominant in females than males of similar age.[8] These two circumstances have previously been associated with other etiological origins, however the effect of one on another has not be concentrated. Literature lacks evidence when it comes with regard to relationship of PD with imbalance of specific muscle group in and around the pelvis. As far as we could possibly know, this is the first cross-sectional study to find the prevalence of PCS in females with PD in relatively younger population (18–25 years).The present study aimed at evaluating the prevalence of PCS in females with PD with its impact on physical activity. On statistical analysis of data collected from 305 females with PD, the prevalence of PCS was found to be 28.5% with significant lesser participation in physical activity by those with the same condition.

The rate of PCS prevalence in the current study was found to be 28.5%, which is in consensus with a cross-sectional study from Kolkata which reported the prevalence of PCS in the same age bunch female grown-ups to be 36%.[8] This inconsistency could be the consequence of study population, as the study from Kolkata incorporated every female with and without PD; however, the present study was especially centered around females with PD.[17],[18]

In the current study, the prevalence of abdominal weakness in females with PD was found to be 84.6% (Grade 3-35.4% and Grade 4-48.9%), which is higher than the previous study from Gujarat, where it was found to be 65.40%. This could be possibly because the earlier study mentioned about the core as a whole and not in isolation. The muscle weakness was stated as just a normal variation and not a pathological state that could be a contributing factor for back pain.[18],[19] This could possibly because the earlier study mentioned about the core as a whole and not in isolation.[19]

PCS often demonstrates the presence of low back pain, which is similar in quality of menstrual low back ache. This hypothesis is also supported by Janda where the symptoms of dysmenorrhea are suppressed by correcting the movement of the lumbar, pelvis, sacroiliac joint and releasing the tightness of the surrounding muscle.[9] This further justifies the possibility of muscle imbalance responsible for PD.[17]

PD often withdraws females from engaging in their daily activities including work, college, and physical activity.[10] This study reveals that females who were diagnosed with PCS were less likely to involve in physical activity. Engaging in either planned exercise or regular activities of daily living was much lesser in females with PD diagnosed with PCS (35% of total) than the females with PD not diagnosed with PCS (17.17% of total). Thus, this study provides significant association between PD with PCS and its impact on physical activity. These results are consistent with the study performed in Iran in 2019 which supports the similar relation of PD and PCS.

Another muscle component to be looked into in PCS is iliopsoas. This particular muscle tightness has been hypothesized as a contributing factor for deep pelvic pain in many of the cases. The characteristic of pelvic pain is deeper and located around the pelvic area which is very similar to the pain experienced durin PD.[13],[20] The study revealed that the prevalence of iliopsoas tightness on the right side is 68.2%, whereas on the left is 60.3%, which does not come in around the statistics of hip flexor tightness given by Moe men et al. in the year 2021 in Egypt which is 91.4% on right and 93.5% on left.[21] The variation in the finding could probably be attributed to the difference in the age group of study population as the study in Iran recruited participants of comparatively younger population.

The current study evaluated the regularity of menstrual cycle and PD, which shows significant difference in the moderate-to-severe and severe category of PD which is inconsistent with the earlier study from Poland, which demonstrated no association between menstrual regularity and primary Dysmenorrhea.[22] As the prevalence of PCS was significantly higher in moderate-to-severe category of PD and so does regular cycles. Thus, this provides an indirect relationship between PCS and regular menstrual cycle. It is suggested that future studies should focus on studying the specific symptoms of PD in relation to the muscle imbalances and particular regime to be developed for its management.

Clinical implications

The study implies the role of physical therapists in assessment and management of PD as muscle imbalance potentially be one of the predisposing factors. Although the use of drugs and other treatments are sparsely practiced, assessment for muscular imbalance and its treatment should be addressed.

  Conclusions Top

The present study concludes that the prevalence of Pelvic crossed syndrome in females with Primary Dysmenorrhea is 28.7% with majority of them experiencing moderate pain during menstrual cycle. The obtained results clearly support muscular imbalance as one of the possible predisposing factors for PD. The study also highlights the detrimental impact of PD on physical activity; thus, there is a serious need to address these issues through any way possible.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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