Graded Motor Imagery for Primary Dysmenorrhea

Effect of Graded Motor Imagery on Pressure Pain Threshold and Pain Intensity in Women With Primary Dysmenorrhea: A Randomized Controlled Trial

The goal of this clinical trial is to learn if graded motor imagery can reduce pain sensitivity and period pain in women with primary dysmenorrhea (painful periods with no medical cause).

The main questions it aims to answer are:

1. Is there a decrease in pressure pain threshold (increased pain sensitivity) with graded motor imagery?
2. Is the intensity of menstrual pain reduced by graded motor imagery?
3. Is GMI helpful to reduce menstrual symptoms and pain catastrophizing (negative thinking about pain)?

Researchers will compare full GMI (active intervention), a sham GMI(inactive intervention), and a wait-list (no intervention) to see if GMI works better than the alternatives.

Participants will:

1. Take part in a 6-week graded motor imagery program, sham program, or no intervention control.
2. Do laterality recognition, motor imagery, and mirror therapy exercises in the graded motor imagery group.
3. Complete pain and symptom assessments before and after the program, and again at follow-up.

Study Overview

• Status: Recruiting
• Conditions: Primary Dysmenorrhea (PD)
• Intervention / Treatment: Behavioral: Graded Motor Imagery (GMI)

Detailed Description

Women with primary dysmenorrhea have decreased pressure pain threshold (PPT) at local abdominal and lumbar sites and at remote sites (tibialis anterior). This is indicative of central sensitization, rather than just peripheral, prostaglandin-driven pain. This sensitization extends out of the menstrual window and is associated with increased pain catastrophizing (a cognitive-affective amplifier of central pain processing). All of these factors contribute to primary dysmenorrhea being an appropriate target for brain-directed intervention.

Graded Motor Imagery (GMI) is a three-phase physiotherapy program aimed at restoring the normal representation of pain in the cortex and reducing movement-related threat appraisal. Phases progress from implicit motor imagery using left/right body-part recognition tasks, followed by explicit mental rehearsal of pain-free movement. The third phase involves mirror therapy with visual feedback of normal movement. This sequenced approach targets the two measurable mechanisms underlying central sensitization in dysmenorrhea: altered pressure pain sensitivity and elevated pain catastrophizing. GMI has proven to be effective in complex regional pain syndrome, phantom limb pain, and genito-pelvic pain. However, it has not been specifically tested in primary dysmenorrhea.

This three-arm randomized controlled trial compares full GMI, sham GMI, and a wait-list control over six weeks of online-delivered sessions. The sham program is identical to GMI in terms of therapist contact time and structure of sessions, but employs non-pelvic imagery content (to control for non-specific effects of attention and engagement). The outcome is measured at baseline, 6 and 10 weeks by a blinded assessor.

• Study Type: Interventional
• Enrollment (Estimated): 81
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Punjab Province
    • Lahore, Punjab Province, Pakistan, 54782
      • Recruiting
      • Dr. Saqib Rabbani
      • Contact: Dr. Saqib Rabbani; Phone Number: +923000425708; Email: beh.sciences@uhs.edu.pk
      • Contact: Email: drmehaknaeem@gmail.com
      • Principal Investigator: Mehak Naeem, DPT

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Female sex (aged 18-30 years)
2. Diagnosis of primary dysmenorrhea confirmed by a physician (painful menstruation for ≥6 consecutive cycles, in the absence of identifiable pelvic pathology on clinical and/or ultrasound evaluation)
3. Pain ≥4/10 NRS experienced during the last period.
4. Confirmed altered pressure pain threshold: PPT ≥2 standard deviations below published norms for age-matched healthy women, measured at baseline assessment
5. Regular menstrual cycle (21-35 days)
6. Capable of engaging in virtual video sessions and taking online tests.
7. Consent to withhold new analgesic or hormonal treatments during the study period.

Exclusion Criteria:

1. Secondary dysmenorrhea (endometriosis, adenomyosis, fibroids, pelvic inflammatory disease, ovarian cysts ≥3 cm confirmed on imaging)
2. Current use of hormonal contraceptives (which alter prostaglandin levels and pain processing)
3. Pregnancy or lactation
4. Concurrent chronic pain condition (fibromyalgia, CRPS, chronic low back pain, chronic pelvic pain unrelated to menstruation)
5. Neurological or psychiatric disorder that would impair motor imagery ability (stroke, schizophrenia, active psychosis)
6. Cognitive impairment affecting informed consent capacity
7. Participation in another clinical trial within 4 weeks before enrollment
8. Previous exposure to graded motor imagery or mirror therapy
9. Regular use of NSAIDs or opioids for non-menstrual indications

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Graded Motor Imagery Protocol; Participants in this arm will be engaged in a 6-week graded motor imagery program, consisting of two supervised sessions per week and daily home practice. The intervention will have three phases: laterality recognition training with images of the pelvis and abdomen, explicit motor imagery of pain-free abdominal and pelvic movements, and mirror therapy/visual feedback with a mirror box to produce the illusion of normal and pain-free lower abdominal movement. A trained physiotherapist will deliver online sessions, and participants will complete about 15 minutes of home practice each day, which will be recorded in a diary.	Behavioral: Graded Motor Imagery (GMI); The intervention will be a structured 6-week graded motor imagery program focused on the modulation of pain processing and sensorimotor representation in women with primary dysmenorrhea. It will consist of three sequential steps. Firstly, laterality recognition training with pelvic and abdominal body images. Secondly, explicit motor imagery with pain-free abdominal and pelvic movements. Finally, mirror therapy/visual feedback for normal pain-free movement. The program will be delivered online by a trained physiotherapist with two supervised sessions per week as well as daily home practice. This intervention is different from usual exercise or education because it mainly focuses on the cortical and sensorimotor mechanisms rather than only physical conditioning.
Sham Comparator: Sham Graded Motor Imagery; Participants in the sham group will undergo a program of the same amount of contact time as well as duration over 6 weeks with the same number of sessions. The sham intervention will consist of three phases. Sham laterality discrimination tasks will be performed with distal body parts only (e.g., hands and feet) and without pelvic content. Moreover, the sham general relaxation imagery will have peaceful scenes rather than body movement. Lastly, sham mirror exposure will be done by looking at a mirror showing the contralateral hand but not at the pelvic area. The sham protocol aims to control non-specific effects of therapist contact, attention, and imagery engagement, and to remove the pelvic-specific cortical engagement as occurred in the active component of GMI.	Behavioral: Graded Motor Imagery (GMI); The intervention will be a structured 6-week graded motor imagery program focused on the modulation of pain processing and sensorimotor representation in women with primary dysmenorrhea. It will consist of three sequential steps. Firstly, laterality recognition training with pelvic and abdominal body images. Secondly, explicit motor imagery with pain-free abdominal and pelvic movements. Finally, mirror therapy/visual feedback for normal pain-free movement. The program will be delivered online by a trained physiotherapist with two supervised sessions per week as well as daily home practice. This intervention is different from usual exercise or education because it mainly focuses on the cortical and sensorimotor mechanisms rather than only physical conditioning.
No Intervention: Wait-List Control; Participants in the wait-list group will receive no intervention throughout the 10-week study. They will be given standard written information regarding menstrual health and will be allowed to use analgesics as needed, which will be noted as a covariate.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Pressure Threshold	Pressure pain threshold will be measured at local abdominal and lumbar sites, and at a remote site over the tibialis anterior muscle by using a handheld algometer. Three readings will be taken at each site and averaged. Higher values will indicate lower pain sensitivity.	Baseline, post-intervention at 6 weeks, and 4-week follow-up.
Menstrual pain intensity	Menstrual pain intensity will be assessed using a Numeric Rating Scale during active menstruation. Participants will rate their pain on the days of menstrual pain, and the scores will be recorded for comparison over time. Higher scores will indicate greater pain intensity.	Baseline, 6 weeks post-intervention, and 4-week follow-up.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Menstrual symptom severity	Menstrual symptom severity will be measured using the Moos Menstrual Distress Questionnaire. This questionnaire assesses the severity of physical and emotional symptoms related to menstruation. Higher scores indicate more severe menstrual symptoms.	Baseline, 6 weeks post-intervention, and 4-week follow-up.
Pain Catastrophizing	Pain catastrophizing will be measured using the Pain Catastrophizing Scale. This scale assesses exaggerated negative thoughts and feelings about pain. Higher scores indicate greater catastrophizing.	Baseline, 6 weeks post-intervention, and 4-week follow-up.

Collaborators and Investigators

• Sponsor: Dr. Mehak Naeem
• Collaborators: University of Health Sciences Lahore

Study record dates

Study Major Dates

• Study Start (Actual): April 6, 2026
• Primary Completion (Estimated): August 1, 2026
• Study Completion (Estimated): August 1, 2026

Study Registration Dates

• First Submitted: May 23, 2026
• First Submitted That Met QC Criteria: May 23, 2026
• First Posted (Actual): June 1, 2026

Study Record Updates

• Last Update Posted (Actual): June 1, 2026
• Last Update Submitted That Met QC Criteria: May 23, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Primary Dysmenorrhea; Graded Motor Imagery; Primary dysmenorrhea and pressure pain threshold; Primary dysmenorrhea and altered pain sensitivity; Non-pharmacological intervention for primary dysmenorrhea
• Other Study ID Numbers: UHS/DUGS-26/1959

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared owing to the confidentiality of study participants as well as the institutional restrictions. De-identified data may be available upon request to the corresponding author after getting institutional's approval.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No