Acupuncture Research for Pregnancy

Acupuncture and pelvic pain in pregnancy

Elden et al[1] 2005 published a randomised single blind controlled trial involving 386 pregnant women in the British Medical Journal (BMJ).

Summary

The objective was to compare the efficacy of standard treatment for pelvic pain (a pelvic belt, patient education and home exercisers- for abdominal and gluteal muscles) to standard treatment plus acupuncture or standard treatment plus physiotherapy stabilizing exercisers (for the deep lumbopelvic muscles). The study time frame consisted of one week which was used to establish a baseline, followed by six weeks of treatment. The acupuncture treatment was given twice a week and the stabilizing exercisers sessions one hour per week (with patients then doing these exercisers several times a day on a daily basis). Follow up was carried out one week after treatment finished. Three physiotherapists gave standard treatment, two medical acupuncturists delivered the acupuncture treatment and two physiotherapists gave the stabilizing exercisers. Pain was measured by a visual analogue scale and by an indepent entexaminer before and after treatment.

Conclusion

Acupuncture was superior to stabilizing exercisers in the management of pelvic girdle pain in pregnancy. With acupuncture the treatment of choice for patients with one sided sacroiliac pain, one sided sacroiliac pain combined with symphysis pubis pain and double sided sacroiliac pain.

Treatment method

The women received 17 needles at each visit. Seven needles were used bilaterally on the distal points Baihui DU-20, HeguLI-4, Kunlun BL-60 and Zusanli ST-36with ten further acupuncture needles chosen according to localpainful points on palpation. They were selected from the following; Guanyuanshu BL-26, Ciliao Bl-32, ZhongliaiBl-33, Zhibian Bl-54, Henggu KID-11, Huantiao GB-30, Chongmen SP-12and the extra point Yaoyan (identified in the study as EX 21) The points were used bilaterally with the needles inserted to a depth of 15- 70 mm. Once De qi was achieved they were left in place for 30 minutes and manually stimulated every 10minutes.

Clinical Perspective

Although no serious complication were reported during treatment it is of concern that the acupuncture points Hegu LI-4, Kunlun BL-60 andCiliao Bl-32 are listed with no mention of their function in traditional Chinese medicine to induce labour[2] [3]. The women accepted into this study received acupuncture were from 12 to 31weeks gestation. Traditionally these points would be regarded as forbidden (or onlyto be used with great care) at this stage of a pregnancy. To me this is especially true when they are used in combination together. E-mail correspondence with the author Helen Elden confirmed that the four distal points Baihui DU-20, Hegu LI-4, Kunlun BL-60, Zusanli ST-36were used as routine points at each acupuncture treatment. She commented that they did not use TCM theory when choosing the points. The study states that these distal points were chosen due to their well known pain relieving effect. While the choice of Hegu LI-4 and Kunlun BL-60 as distal points for pelvic pain is of concern from a traditional Chinese medicine perspective it is also surprising considering that Hegu LI-4 was used in research as an induction point for women at term (Rabl et all 2001[4]). They concluded that“acupuncture was able to encourage ripening of the cervix and reduce the time interval between the expected date of delivery and the actual time of delivery”. From a personal Clinical Perspective the fact that 125 women received acupuncture at Hegu LI-4 and Kunlun BL-60 with no serious side effects is not sufficient enough to reconsider clinical practice. From a traditional Chinese medicine perspective there are arange of effective distal points to use in the treatment of pelvic girdle pain without resorting to the use of Hegu LI-4 and KunlunBL-60 and this is a small sample of women when compared to both the historical data and effective clinical use of these points to induce labour. This is an interesting study as while it confirms the befit of offering acupuncture for pelvic pain in pregnancy it also raises questions about the way point prescription acupuncture can be used by physiotherapists and medical acupuncturists.

Acupunctureand morning sickness

Smith et al in 2002 published two articles from theirresearch on nausea and vomiting in pregnancy. The first looked at theeffectiveness of acupuncture [5] and the second at the safety ofacupuncture treatment in early pregnancy [6]

Summary

The objective was to compare; traditional acupuncture treatment,acupuncture at Neiguan P-6 only, sham acupuncture and no acupuncture treatment for nausea and vomiting. 593 women who were less than 14 weeks pregnant were randomised into 4 groups and received treatment weekly. The acupuncture group, in which points were chosen according to a traditional acupuncture diagnosis, received two 20 minute acupuncture treatments in the first week followed by one weekly treatment for the next four weeks. The sham acupuncture group were needled at points close to but not on acupuncture points. Both the acupuncture group and the sham acupuncture group received their treatment from the same acupuncturist. The outcomes of treatment were measured in terms of nausea, dry retching, vomiting and health status. When compared to the women who received no treatment; the traditional acupuncture group reported less nausea throughout the study and less dry retching from the second week The Neiguan P-6acupuncture group reported less nausea from the second week and less dry retching from the third week. The sham acupuncture group reported less nausea and dry retching from the third week. So while all three acupuncture groups reported improvement with nausea and dry retching, it was the traditional acupuncture group that had the fastest response. Patients receiving traditional acupuncture also reported improvement in five aspects of general health status (vitality, social function, physical function, mental health and emotional role function) compared to improvement in two aspects with the Neiguan P-6 and Sham acupuncture groups. In the no treatment group there was improvement in only one aspect. Although there were no differences in vomiting found in any of the treatment groups the authors speculated that more frequent treatments might have produced greater benefits. In assessing the safety of acupuncture in early pregnancy data was collected on perinatal outcome, congenital abnormalities, pregnancy complications and the newborn. No differences were found between study groups in the incidence of these outcomes suggesting that there are no serious adverse effects from the use of acupuncture treatment in early pregnancy.

Conclusion

Acupuncture is a safe and effective treatment for women who experience nausea and dry retching in early pregnancy. Acupuncture comments

Treatment method

The traditional acupuncture treatment involved the insertion of up to 6 needles per treatment. De qi was obtained and the needles left for 20 minutes. Points were selected according to the following pattern differentiation. Liver qi stagnation: Taichong LIV-3, Neiguan P-6,Yanglingquan GB-34, Shangwan REN-13, Youmen KID-21, Lianqiu ST-34,Zusanli ST-36 Stomach or spleen deficiency: Zusanli ST-36, Neiguan P-6,Zhongwan REN-12 Stomach heat: Neiting ST-44, Jianli REN-11, LiangqiuST-34, Liangmen ST-21, Neiguan P-6, Quze P-3 Phlegm: Fenglong ST-40, Yinlingquan SP-9, Burong ST-19,Pishu BL-20, Youmen KID-21 Heart qi deficiency: Tongli HE-5, NeiguanP-6, Zusanli ST-36, Juque REN-14 Heart fire: Neiguan P-6, Juque REN-14, Xinshu BL-15 Local abdominal points were also used, selecting from ST-19, Chengman ST-20, Liangmen ST-21, Youmen KID-21,Futonggu KID-20, Juque REN-14, Shangwan REN-13, Zhongwan REN-12,Jianli REN-11 and Xiawan REN-10.

Clinical Perspective

This is a very interesting study, as it explores the use of traditional diagnostic patterns compared to the use of a point formulated treatment. In doing so it provides information both to acupuncturists and the western medical health professions about the most effective use of acupuncture. This reseach provides reassurance to the medical profession that acupuncture is a safe and effective treatment in early pregnancy as well as confirming the effectiveness of traditional diagnosis over using prescription point acupuncture.

Moxibustionuse for Breech Presentation

Cardini et al in 1998[7] had the following randomisedcontrolled trial published in the Journal of American Association(JAMA)

Summary

The objective was to evaluate the efficacy and safety of moxibustion on Zhiyin BL-67 to correct breech presentation. 130 womenhaving their first baby (primigravidas) at 33 gestation receivedmoxibustion to Zhiyin Bl 67 while 130 women, also primigravidas,received no intervention. The moxibustion was administered for 7 days .Women were thenassessed and a further 7 days of moxibustion treatment given if theposition had not changed. Outcomes were measured in terms of fetal movements, as counted bythe mother for one hour each day for one week and the number ofcephalic presentations both at 35 weeks gestation and at delivery At 35 weeks gestation 75.4% in the intervention group werecephalic (47.7% in the control). Women in both groups then had the option of undergoing externalcephalic version (ECV). One woman took this option from theintervention group and 24 from the control group At delivery the presentation of 75.4% of the intervention groupwere cephalic compared to 62.3% in the control group. The presentation did not change in any of the groups after 35weeks except in those undergoing ECV. In terms of fetal movement themoxibustion group experienced a greater number of movements (a meanof 48.45 compared to the control group with a mean of 35.35).

Conclusion

That in prigravidas at 33 weeks gestation with breech presentationmoxibustion treatment for 1 to 2 weeks at Zhiyin BL-67 increasedfetal activity during the treatment period and cephalic presentationat 35 weeks and at delivery.

Treatment method

The women and their partner (or a person to help with thetreatment) were given a treatment and taught how to use themoxibustion in a hospital appointment within 24 hours of the scanconfirming the breech position. They then applied the treatment toZhiyin BL-67 daily at home. Moxa sticks were used with the womensitting or in a semisupine position and the partner delivering thetreatment.

Clinical Perspective

As part of this study an attempt was made to assess if there was adifference in delivering moxibustion sessions once or twice a day. 87 women used moxibustion for a total of 30 minutes (15 minutes toeach point) while 43 women used moxibustion in the same way butreceived treatment twice a day. At the end of the first week 79% of the cephalic versions wereobtained in the women using moxibustion twice a day compared to 55.2% in the daily treatments. But by the end of the second week 15additional cephalic versions were obtained in the group havingmoxibustion treatment once a day. This meant that at 35 weeks the results were termed as anonsignificant difference (72.4% in the once a day moxibustion groupcompared to 81% for the women having moxibustion treatment twice aday). From a safety perspective it was reassuring that no adverse events(such as intrauterine death or placental detachment) were noted inthe treatment group. It was also interesting that while the number ofpremature rupture of membranes was similar in both groups the numberof premature births was lower in the intervention group and that theuse of oxytocin, before or during labour, was also reduced in themoxibustion group (8.6% compared to 31.3%).

Prebirthacupuncture

Prebirth acupuncture has an interesting history with severalstudies examining the effect of acupuncture used prior to labour.

Summary

Research on the use of acupuncture to prepare women for labourfirst appeared in 1974 with a study by Kubista and Kucera[8]. Theirresearch concluded that acupuncture once a week from 37 weeksgestation using the acupuncture points Zusanli ST-36,Yanglingquan GB-34, Jiaoxin KID-8, and Shenmai BL-62 wassuccessful in reducing the mean labour time of the women treated. They calculated the labour time in two ways, the first being asbeing the time between a cervical dilation of 3-4 cm and the deliverytime. In the acupuncture group the labour time was 4 hours and 57minutes (control group 5 hours and 54 minutes). The second as themean subjective time of labour, taken from the onset of regular 10 –15 minute contractions until delivery, the acupuncture group had alabour time of 6 hours and 36 minutes (control 8 hours and 2minutes). In 1987 Lyrendas et all[9] basing its study on the work of Kubistaand Kucera contradicted their research, concluding that acupuncturelengthened the delivery time. They calculated the average lengths ofthe latent and active phase and the second stage of labour. In theirstudy the acupuncture group had a total mean delivery time,calculated as time of admission to the delivery ward until delivery,as 8 hours and 30 minutes (control group time of 7 hours and 40minutes). In 1998 Tempfer[10] used the acupuncture points Bai HuiDU-20 , Shen Men HT-7, and Nei Guan PC -6 from 36 weeksgestation. This study concluded that acupuncture treatment hadpositive effect on the duration of labour by shortening the firststage of labour, defined as the time interval between 3 cm cervicaldilatation and complete dilation. The acupuncture group had a medianduration of 196 minutes compared to the control group time of 321minutes, (acupuncture group 3 hours and 26 minutes compared to thecontrol group 5 hours and 35 minutes). In contrasting these studies the following points should be noted; Group numbers. In order to obtain accuratestatistical comparisons it is seen as ideal to have the number ofwomen in the acupuncture group and control group as evenly matched aspossible. While this happened in the studies by Kubista and Kucera(70 women in the acupuncture group 70 women in the control group) andTempfer (57 women in the acupuncture group and 63 women in controlgroup) Lyrendas et all had 56 woman in the acupuncture group and 112woman acting as a control group. Measurement of labour time It can be difficult toaccurately define the beginning of labour as often this is asubjective measurement on the intensity or timing of contractionsfrom the woman’s judgement, which will naturally vary according todifferent woman’s perception of pain and expectations of labour.Even if labour is medically defined as being a measurement involvingcervical dilatation, women can vary considerably in theirpresentation of early labour. For example in the study by Tempfertwenty-seven women were excluded as they presented for admission tothe delivery unit with more than 3 cm of cervical dilatation. Despite these difficulties an attempt was made in each study tomeasure the length of labour from different starting points. It isworth noting that Lyrendas et all used the most subjective, andtherefore, least accurate method by taking the beginning of labour asthe time that women presented in delivery suite. It is also worthnoting that different statistics were used, Kubista and Kucera andLyrendas et all used a mean labour time while Tempfer used a medianlabour time. The median labour time is considered to a more usefulmeasurement when measuring data such as length of time women spend inlabour. This is because the median will give a more accurate valuewhen used for a wide variation in the data being collected were asthe mean is more suitable for data that falls into a bell curvedistribution. The problem with the mean being used is that theresults can become extremely distorted by just one or two values ateither end of the data being collected. Additional requirements for participating in the studyAs a requirement for being in the acupuncture group in the Lyrendaset study women were required to consent to having two lumbarpunctures, one at 38 weeks gestation and another six months afterdelivery. Having to consent to such an invasive medical procedurewould have certainly influenced the range of women who agreed toreceive acupuncture. It is interesting that in this study there was acontrol group of 16 women who received a lumbar puncture (but did notreceive acupuncture) they had the longest mean labour time of 9 hoursand 30 minutes (acupuncture group 8 hours and 30 minutes).

Conclusion

Although the research by Lyrendas et all appears to contradict thefindings of both Kubista and Kucera and Tempfer the full paper byLyrendas et all contains interesting details. A control group withtwice the number of women in it from the acupuncture group, takingthe most subjective time for onset of labour as presentation todelivery suite and a recruiting process that asks women in theacupuncture group to have an invasive medical procedure such as alumber puncture raises concerns that this study may not be anaccurate representation of the benefits of prebirth acupuncture.

Treatment method

Kubista and Kucera. The acupuncture points Zusanli ST-36,Yanglingquan GB-34, Jiaoxin KID-8, and Shenmai BL-62 wereused weekly on primigravidea women from 37 weeks until delivery. The reasoning given for choosing these acupuncture points was thatas a group they would relax the women, tonify qi and improvecirculation of blood to the pelvis. The points were used bilaterally,with an even method with de qi being obtained and the needlesretained for 20 minutes. The women were treated in sitting positionand had on average three treatments. Lyrendas et all. Despite stating in their study that theacupuncture points used were the same as those used in the Kubistaand Kucera study Sanyinjiao SP 6 was substituted forJiaoxin KI 8. No reason was given. Zusanli ST-36 andSanyinjiao SP 6 were used to improve the circulation of the pelvicorgans. Yanglingquan GB-34 was used as an influential point formuscles and tendons. Shenmai BL-62 was used as a tranquilizing point They also used a different acupuncture method from the Kubista andKucera study. While the women received bilateral acupuncture with aneven method and de qi was obtained, the difference was that the womenwere treated lying on their sides. As the total treatment time was 30minutes, each woman would have only received acupuncture for 10 to 15minutes at each point. The prebirth acupuncture was commenced at 36 weeks and women hadon average five acupuncture treatments Tempfer. The acupuncture points Bai Hui DU-20 , Shen Men HT-7, andNei Guan PC-6 were used. No reason was given why these points werechosen. Bilateral application was used with the needles stimulateduntil de qi was obtained. Treatment was given with the women in a resting position with eachsession lasting 20 minutes. A minimum of 4 sessions was recommended.

Clinical Perspective

In terms of how many pre birth treatments are considered effectiveKubista and Kucera found no effect on the duration of delivery timein woman who only received acupuncture for one treatment and Tempferensured that women received at least four treatments (twelve womenwere excluded from the Tempfer study because they received less than4 treatments). In terms of possible side effects from receiving acupunctureTempfer found that there was an increased frequency of prematurerupture of membranes in the acupuncture treatment group. They did notconsider this a negative factor as they associated this with anacceleration of the cervix maturing. From a safety perspective there was no association with anelevated rate of complications for mother or the fetus in those womenreceiving acupuncture in any of the studies. In 2004 I was involved in an observational study looking at theeffect of prebirth acupuncture together with Sue Lennox, amidwife[11]. 169 women who received prebirth acupuncture werecompared to local population rates for gestation at onset of labour,incidence of medical induction, length of labour, use of analgesiaand type of delivery. In the acupuncture group comparing all caregivers (includingmidwives, GP’s and specialists) there was an overall 35% reductionin the number of inductions (for women having their first baby thiswas a 43% reduction) and a 31% reduction in the epidural rate. Whencomparing midwifery only care there was a 32% reduction in emergencycaesarean delivery and a 9 % increase in normal vaginal births. There was no statistical difference in the onset of early labourin those women receiving prebirth acupuncture. Although this was a small naturalistic observation study ratherthan a randomised controlled study it does reflect how acupuncturewas used in clinical practice. It mirrors the feedback given bymidwives that prebirth acupuncture provides promising therapeuticbenefits in assisting women to have normal vaginal births andsuggests that a further randomized controlled study is warranted.

Acupuncturefor cervical ripening

A randomised controlled trial into the effects of acupuncture oncervical was published by Rabl 2001[12].

Summary

The objective was to evaluate whether acupuncture at term caninfluence cervical ripening and thus reduce the need for postdatesinduction. On their due dates 45 women were randomized into either anacupuncture group (25) or control group (20). The women were then examined at two daily intervals for cervicallength (measured with vaginal trasonography, cervical mucus andcervical stasis according to Bishops score). The acupuncture groupalso received acupuncture every two days at the acupuncture pointsHegu LI-4 and Sanyinjiao SP-6. If women had not delivered after 10 days labour was induced byadministering vaginal prostaglandin tablets. The time period from thewoman’s due date to delivery was on average 5 days in theacupuncture group compared to 7.9 days in the control group. Labour was induced in 20 % of women in the acupuncture groupcompared to 35% in the control group. There were no differences between overall duration of labour andthe first and second stage of labour.

Conclusion

Acupuncture at the points Hegu LI-4 and Sanyinjiao SP-6 supportscervical ripening and can shorten the time interval between thewoman’s expected date of delivery and the actual time of delivery.Acupuncture comments

Treatment method

Hegu LI-4 and Sanyinjiao SP-6 were used bilaterally. The needleswere inserted to achieve de qi and then retained for 20 minutes withno further stimulation.

Clinical Perspective

It was interesting that four women were delivered within 24 hoursof having their first acupuncture treatment while no women in thecontrol group delivered within 24 hours of their first examination. It is also interesting to note that none of the women from theacupuncture group went into labour during treatment or within onehour following treatment, reflecting that it is a practical optionfor women to receive acupuncture in a private clinical setting. From a safety perspective there was no difference in the number ofwomen experiencing difficulties during delivery, with 3 womenrequiring a vacuum extraction and two women requiring a caesareansection from each group.

References

http://acupuncture.rhizome.net.nz/Handouts-Research.aspx
by Debra Betts