Reviews Obstetrics www.AJOG.org OBSTETRICS Acupuncture for pelvic and back pain in pregnancy: a systematic review Carolyn C. Ee, MBBS, BAppSci (Chinese Medicine/Human Biology); Eric Manheimer, MS; Marie V. Pirotta, MBBS, PhD; Adrian R. White, MA, MD, BM BCh sleep in late pregnancy, and both acupunc- The objective of our study was to review the effectiveness of needle acupuncture in ture and physiotherapy may improve treating the common and disabling problem of pelvic and back pain in pregnancy. Two pain.13 Several case reports and -1 retro small trials on mixed pelvic/back pain and 1 large high-quality trial on pelvic pain met spective case series have suggested that the inclusion criteria. Acupuncture, as an adjunct to standard treatment, was superior to acupuncture may relieve pelvic and back standard treatment alone and physiotherapy in relieving mixed pelvic/back pain. Women pain in pregnancy.14-17 with well-defined pelvic pain had greater relief of pain with a combination of acupuncture Complementary and alternative ther- and standard treatment, compared to standard treatment alone or stabilizing exercises and apies are growing in popularity and are standard treatment. We used a narrative synthesis due to significant clinical heterogeneity used by more than a third of the US pop- between trials. Few and minor adverse events were reported. We conclude that limited ulation.18 They continue to be used- dur evidence supports acupuncture use in treating pregnancy-related pelvic and back pain. ing pregnancy,19 and 60% of women Additional high-quality trials are needed to test the existing promising evidence for this with lower back pain in pregnancy report relatively safe and popular complementary therapy. that they would accept complementary therapies for treatment of their20 pain. Key words: acupuncture, back pain, pelvic pain, pregnancy Acupuncture is used by more than 2 million people in the US 18annually. It involves stimulation of anatomical loca- elvic and back pain are amonguse ofthe different definitions, and some ex- tions on the skin (acupoints) by various P most common “minor” complica- perts advocate differentiating pelvic measures, most commonly by penetra- 1 3 tions in pregnancy.Estimates of preva- from back pain in pregnancy. tion of the skin by metallic needles (nee- lence of pelvic and back pain in preg- The exact etiology remains 4unclear 2 dle acupuncture). Acupuncture analge- nancy range from 24-90%.This and is thought to be related to the inter- sia involves complex neurohumoral difference is most probably due to the action between physiological changes in mechanisms involving endogenous opi- pregnancy and risk factors such as phys- ates and monoamines,21 with evidence From the Department of General Practice, ical work and previous back or pelvic of sustained depression of dorsal horn 2,5 University of Melbourne, Melbourne, pain. The pain can result in significantneurons in the spinal 22 cord.Adverse Australia (Drs Ee and Pirotta); Center for morbidity. Twenty-five percent of events are reported to be 23minimal, and Integrative Medicine, University of women with pelvic pain in pregnancy life-threatening events such as pneumo- Maryland School of Medicine, Baltimore, will seek medical help for their pain, 8% thorax are considered rare in the hands MD (Mr Manheimer); Peninsula School of are severely disabled, and 7% continue to of a trained practitioner.24 Medicine and Dentistry, University of have pain beyond the pregnancy.6 The Our aim in this review was to determine Plymouth, Plymouth, UK (Dr White). majority of women with back pain in whether acupuncture is more effective Received May 11, 2007; revised Oct. 3, 2007; pregnancy report disturbed sleep from than “standard treatment,” no additional accepted Nov. 5, 2007. their pain.7 Disability often involves- simtreatment, placebo acupuncture, “sham” Reprints: Carolyn Ee, 200 Berkeley St, 8 Carlton, Victoria 3053, Australia. ple activities of daily andliving can - reacupuncture, or other treatments in the 9 [email protected]. sult in significant absenteeism.Back management of pain and disability due to Carolyn Ee was funded by General Practice pain in pregnancy also increases the risk pregnancy-related pelvic and back pain. Education and Training Australia. Eric of postpartum back 5pain. We chose to include both pelvic and back Manheimer was funded by grant number R24 Provision of education, advice, and the pain in our review, as many investigators AT001293 from the National Center for do, because of the ongoing debate and un- Complementary and Alternative Medicine prescription of exercise by a physiothera- (NCCAM) of the US National Institutes of pist appear to be the standard recommen- certainty regarding etiology and treatment Health. Adrian White was supported by the dations for treatment.10 Evidence for theof this problem. DH-National Coordinating Centre for Research benefits of physical therapies and support Capacity Development (NCC RCD). belts is inconclusive.3,11,12 A Cochrane - reMATERIALS AND METHODS 0002-9378/$34.00 view found that water gymnastics helps re- We searched the following electronic da- © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.11.008 duce sick leave in pregnancy, a specially tabases from their inception until July shaped pillow improves back pain and 2006: 254 American Journal of Obstetrics & Gynecology MARCH 2008 www.AJOG.org Obstetrics Reviews The Cochrane Central Register of Controlled Trials (CENTRAL), National TABLE 1 Library for Health Complementary and Modified Cochrane Back Review Group (BRG) criteria for methodological Alternative Medicine Specialist Library, quality assessment of randomized, controlled trials CINAHL, EMBASE, AMED, and Acu- 1. Was the method of randomization adequate? briefs. We searched MEDLINE from its 2. Was allocation concealment adequate? 3. Was an appropriate sample size calculation used to ensure adequate inception until November 2006. Due to power to detect significant differences due to treatment? funding limitations, we only searched for 4. Were participants blinded to intervention? trials written in or translated into 5. Were caregivers blinded to intervention? English. 6. Were cointerventions avoided or similar? We based our MEDLINE search strat- 7. Were cointerventions reported for each group separately? 8. Was the acupuncture treatment adequate? egy on the Cochrane highly sensitive 9. Was the withdrawal and dropout rate described and acceptable? 25 search strategyand combined this with 10. Did the analysis include an intention-to-treat analysis? specific intervention and disease identi- 11. Was the outcome assessor blinded to the intervention received? 12. Was the timing of outcome assessment in both groups similar? fiers. The key MeSH terms and keywords .............................................................................................................................................................................................................................................. used were “acupuncture,” “acupuncture Details of operationalization available from the authors upon request. therapy,” “electroacupuncture,” “Medi- Ee. Acupuncture in treating pelvic and back pain in pregnancy. Am J Obstet Gynecol 2008. cine, Chinese traditional,” “pregnancy complications,” “pregnancy,” “peripar- tum,” “prenatal care,” “pelvic pain,” have had a nonmusculoskeletal cause for dles. According to acupuncture theory, “back pain,” “low back pain,” “lumbar their pain (eg, malignancy, urinary tract activation of de qi may be one indication back pain,” “sacroiliac joint pain,” and infection, obstetric complication). Trials that acupuncture is exerting its beneficial “symphysis pubis pain.” using laser therapy alone without the use effects). Details of the control group in- We attempted to identify unpublished of needles were excluded from our re- tervention and cointerventions were also trials by contacting prominent acupunc- view. We included auricular acupunc- extracted. We attempted to contact the ture researchers in the US, UK, Europe, ture trials, but only if this was combined chief investigators for missing trial data. Australia, and Sweden and by searching with body acupuncture, and intended to Trial quality was assessed by 2 inde- reference lists of identified trials. We also perform a separate analysis for such tri- pendent reviewers according to 2 scales. searched Computer Retrieval of Infor- als. We postulated that the neurohu- The first scale used was a modified Jadad mation on Scientific Projects (CRISP) moral mechanisms involved in these scale assessing adequacy and reporting of and Current Controlled Trials (CCT) for other therapies may differ from those in- the randomization method, participant ongoing trials. volved in needle acupuncture; in addi- blinding, testing of participant blinding Two reviewers independently assessed tion, we noted that most experts would after treatment, and reporting of drop- study eligibility. Our inclusion criteria agree that acupuncture by definition in- outs and withdrawals. We regarded a were randomized controlled trials com- volves insertion of needles into the score of 2 points or less out of a total of 5 paring acupuncture therapy against a skin.26,27 points as indicating a poor quality trial. control group for pelvic and back pain in Two reviewers independently ex- The second scale used was modified pregnancy. We defined acupuncture as tracted data from eligible trials as defined from Cochrane Back Review Group cri- needle insertion into