Acupuncture for Pregnancy-Related Low Back Pain and Pelvic Girdle Pain

Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, Spring 2017, 120, 74–77

GOOD PRACTICE STATEMENT

Acupuncture for pregnancy-related low back pain and pelvic girdle pain

Introduction The AACP (2012) defines the forbidden points This statement is based on a synthesis of the best as Large Intestine (LI) 4, Spleen (SP) 6, and available current evidence. It will be subject to Bladder (BL) 60 and 67 because of the risk periodic review as the evidence base evolves. It of uterine contractions (Betts & Budd 2011; should be noted that the statement offers guid- Cummings 2011) since these points are used in ance, and should not be regarded as prescrip- traditional Chinese medicine to facilitate induc- tive; such general advice will always require to tion and turning breech babies. Furthermore, be modified in line with the needs of any indi- BL31, BL32, BL33 and BL34 (the sacral fora vidual patient and the clinician’s experience. mina) and abdominal points are to be specifical- All acupuncture should be performed accord- ly avoided because these may compromise cir- ing to the guidelines of the British Acupuncture culation to the developing foetus (Betts & Budd Council, the British Medical Acupuncture Society 2011), or potentially approximate the uterus if and the Acupuncture Association of Chartered the needle enters the foramen. Physiotherapists (AACP) (www.acupuncturesafety. Cummings (2011) theorized that acupuncture org.uk). is safe to use in pregnancy, and that forbidden points can be employed. Elden et al. (2005, 2008) found that forbidden points (i.e. LI4, BL32, BL33 Background and BL60) have not been found to cause serious The incidence of pregnancy-related low back adverse events, and no significant harmful effects pain (LBP) and pelvic girdle pain (PPGP) is were reported several randomized controlled tri- reported to be approximately 20% (Wu et al. als (RCTs) (Wedenberg et al. 2000; Guerreiro 2004; Kovacs et al. 2012; Malmqvist et al. da Silva et al. 2004; Kvorning et al. 2004). Carr 2012; Pennick & Liddle 2013). It is attributed (2015) stated that objective examination of the to multifactorial changes in posture, hormones, scientific literature does not reveal any sugges- joint laxity, muscle imbalance, asymmetrical tion of harm following needling at “forbidden” mechanical dysfunction of the pelvis and the points during pregnancy, despite historical or growing baby in utero. theoretical concerns. However, it must be noted In the general population, acupuncture has that the majority of this evidence is collated from been shown to reduce pain levels and improve research on generally healthy pregnancies. The physical function in adults with LBP (Witt et al. efficacy and safety of acupuncture in pregnancies 2006; Haake et al. 2007; Cherkin et al. 2009; complicated by specific obstetric conditions has Mayer et al. 2010). However, this cannot be ex- yet to be determined. trapolated to pregnancy-related pain without con- Langshaw (2011) identified some studies that sideration of the safety of this modality in this have reported powerful recordable uterine con- population. tractions after strong acupuncture at LI4 and SP6 that never caused early delivery, but could cause patient distress. Bishop et al. (2016) re- Safety of acupuncture in pregnancy ported some minor non-obstetric adverse effects The AACP guidelines for safe practice (AACP during acupuncture treatment in pregnancy, in- 2012) state that there is a danger of miscar- cluding: light-headedness; fainting; mild bruis- riage when treating patients in the first trimes- ing at the needle site; worsening of symptoms; ter of pregnancy. This has not been reported in vomiting; and pain at the needle site. All of the supplementary literature, and may be consid- above might be found in acupuncture of the gen- ered to be based on historical practice (Betts & eral population. Similarly, two recent systematic Budd 2011) rather than evidence (Carr 2015). reviews highlighted a low incidence of adverse 74 © 2017 Pelvic, Obstetric and Gynaecological Physiotherapy Acupuncture for pregnancy-related pain events that were non-obstetric in nature (Park 2004; Wang et al. 2009; Ekdahl & Petersson et al. 2014; Clarkson et al. 2015). In a system- 2010). This prevents a definitive statement be- atic review, Clarkson et al. (2015) found that ing made regarding the response of individual there was a 14–17% chance of being affected conditions to acupuncture. However, each study by an adverse event in the pregnancy acupunc- showed positive benefits of acupuncture treat- ture groups, as compared to one of 15–19% in ment in the sample combining pregnancy-related the non-acupuncture intervention groups. Romer LBP and PPGP. et al. (2013) demonstrated that there was no dif- A recent systematic review by Gutke et al. ference in the occurrence adverse events between (2015) found strong evidence for the use of acu- an acupuncture and a control group. puncture in pregnancy-related LBP. Foster et al. Carr (2015, p. 418) advised clinicians “to treat (2015) ran a pilot trial comparing acupuncture, only where necessary”, and carry out a thorough non-penetrating acupuncture and standard care in examination and risk assessment with individual pregnancy-related LBP. They found reductions in patients. It must be remembered that the opti- pain and disability in the two acupuncture arms of mal dose for any intervention is the minimum the trial that were significantly greater than those required to be effective. There is a suggestion in the standard care group. Non-penetrating acu- that, the greater the amount of needle stimula- puncture or “sham” acupuncture may show ben- tion applied, the greater the incidence of ad- efits because of the effects of acupressure, contact verse events, although these remain mild to with a therapist or a potential placebo effect. Elden moderate (Wedenberg et al. 2000; Ternov et al. et al. (2008) reported that sham acupuncture also 2001; Kvorning et al. 2004; Elden et al. 2008). provided positive benefits and that needling may Auricular acupuncture resulted in the least num- not be necessary, but regular contact with a health ber of adverse events (Wang et al. 2009). professional may be just as beneficial. The evidence supporting the use of acupuncture in the management of LBP and PPGP in Efficacy of acupuncture in pregnancy- pregnancy does seem to be encouraging, and related low back pain and pelvic girdle pain there is an emphasis on individual patient exami- In a Cochrane Review, Pennick & Liddle (2013) nation and risk assessment in each case. identified interventions for preventing and treating pregnancy-related LBP and PPGP. These authors found moderate-quality evidence for Good practice points the efficacy of acupuncture in the treatment The AACP (2012) defines the traditional forbid- of PPGP, which significantly reduced evening den points as LI4, SP6, BL60 and BL67, which pain and improved function, especially after should be used with caution given that these are 26 weeks, in comparison to usual care or ex- historically contraindicated in pregnancy. The ercise. In a review of eight systematic reviews employment of traditionally forbidden points and nine RCTs, Selva Olid et al. (2013) reiterat- without any significant adverse outcomes was ed that there is moderate evidence for acupunc- noted in all RCTs reviewed that had assessed ture in pregnancy-related LBP and PPGP, and a for this outcome in pregnancy-related LBP and low incidence of adverse events. Research often PPGP (Wedenberg et al. 2000; Kvorning et al. focuses on pain indicators, but other benefits 2004; Elden et al. 2005, 2008; Lund et al. 2006). that have been noted are increased psychologi- Bladder 31, BL32, BL33 and BL34 (the sacral cal well-being (Guerreiro da Silva et al. 2004), foramina), abdominal points, the wall of the and improved mobility and sleep (Ekdahl & uterus, and strongly stimulating De Qi should Petersson 2010; Gutke et al. 2015). be avoided. Three RCTs differentiated pregnancy-related A reduction in visual analogue scale pain LBP and PPGP as part of the inclusion criteria scores has been seen in two, 30-min sessions (Elden et al. 2005, 2008; Lund et al. 2006), and (Ternov et al. 2001). Good outcomes with regard all identified significant benefits as a result of pain and functional ability have been found with using acupuncture. Six other studies researched an average of eight to 12 sessions on at least a women with both pregnancy-related LBP and weekly basis, and using at least 10 needles for PPGP, but did not stratify the women by diag- 25–30 min (Wedenberg et al. 2000; Guerreiro da nosis before randomization or during the analy- Silva et al. 2004; Kvorning et al. 2004; Elden sis (Wedenberg et al. 2000; Ternov et al. 2001; et al. 2005, 2008; Lund et al. 2006; Ekdahl Guerreiro da Silva et al. 2004; Kvorning et al. & Petersson 2010). Increasing the amount of © 2017 Pelvic, Obstetric and Gynaecological Physiotherapy 75 Acupuncture for pregnancy-related pain stimulation and the depth of needling did not References appear to have a significant positive impact on Acupuncture Association of Chartered Physiotherapists the efficacy of the acupuncture; however, this did (AACP) (2012) Guidelines for Safe Practice. increase the number of mild to moderate adverse [WWW document.] URL http://www.aacp.org.uk/ events. member-home/references/guidelines/clinical/ 239-guidelines-for- safe-practice/file Betts D. & Budd S. (2011) “Forbidden points” in pregnan- Conclusions cy: historical wisdom? Acupuncture in Medicine 29 (2), Bishop et al. (2016) reported a lower use of ac- 137–139. upuncture by physiotherapists for the treatment Bishop A., Holden M. A., Ogollah R. O. & Forster N. of pregnant patients than for those with general E. (2016) Current management of pregnancy-related musculoskeletal pain conditions. They suggest- low back pain: a national cross-sectional survey of UK physiotherapists. Physiotherapy 102 (1), 78–85. ed that this may indicate a lack of confidence, Carr D. J. (2015) The safety of obstetric acupuncture: for- concerns about safety and a lack of specific bidden points revisited. Acupuncture in Medicine 33 (5), guidelines for physiotherapists about the use of 413–419. acupuncture in pregnancy. The evidence for the Cherkin D. C., Sherman K. J., Avins A. L., et al. (2009) safety of acupuncture in pregnancy, including the A randomized trial comparing acupuncture, simulated use of traditional forbidden points, has increased acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine 169 (9), 858–866. (Romer et al. 2013; Park et al. 2014; Carr 2015; Clarkson C. E., O’Mahony D. & Jones D. E. (2015) Clarkson et al. 2015), and should support it as Adverse event reporting in studies of penetrating acu- an option in the treatment of PPGP (Pennick & puncture during pregnancy: a systematic review. Acta Liddle 2013; Wild 2014) and pregnancy-related Obstetricia et Gynecologica Scandinavica 94 (5), LBP (Gutke et al. 2015). Current evidence lacks 453–464. the validity and reliability that is required to es- Cummings M. (2011) ‘‘Forbidden points’’ in pregnancy: no plausible mechanism for risk. Acupuncture in Medicine tablish specific guidelines on precise treatment 29 (2), 140–142. parameters, mainly because of a lack of compa- Ekdahl L. & Petersson K. (2010) Acupuncture treatment rability between the interventions used in RCTs. of pregnant women with low back and pelvic pain – an Overall, acupuncture for pregnancy-related LBP intervention study. Scandinavian Journal of Caring and PPGP is recommended since it can be a safe Sciences 24 (1), 175–182. and efficacious treatment modality for reducing Elden H., Ladfors L., Olsen M. F., Ostgaard H.-C. & Hagberg H. (2005) Effects of acupuncture and stabilising pain scores (Vleeming et al. 2008), improving exercises as adjunct to standard treatment in pregnant sleep and mobility (Ekdahl & Petersson 2010), women with pelvic girdle pain: randomised single blind and increasing functional capacity (Guerreiro da controlled trial. BMJ 330 (7494), 761. Silva et al. 2004). It can also be combined ef- Elden H., Fagevik-Olsen M., Ostgaard H.-C., Stener- fectively with other physiotherapy interventions. Victorin E. & Hagberg H. (2008) Acupuncture as an adjunct to standard treatment for pelvic girdle pain The following recommendations are made: in pregnant women: randomised double-blinded • Following a thorough examination and risk controlled trial comparing acupuncture with non- assessment, acupuncture is a safe treatment penetrating sham acupuncture. BJOG: An International modality for LBP and PPGP in uncomplicated Journal of Obstetrics and Gynaecology 115 (13), pregnancies. 1655–1668. Avoid abdominal points, or any approximation Foster N. E., Bishop A., Bartlam B., et al. (2015) • Evaluating Acupuncture and Standard carE for preg- of the uterine wall and sacral foramina (BL31, nant women with Back pain (EASE Back): a feasibil- BL32, BL33 and BL34). ity study and pilot randomised trial. Health Technology • Avoid very strong stimulation of acupuncture Assessment 20 (3), 1–236. points in pregnancy. Guerreiro da Silva J. B., Nakamura M. U., Cordeiro J. 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