Acupuncture Research
The research articles outlined below can be used to promote the use of acupuncture
in pregnancy. Some like the articles on pelvic pain, nausea and vomiting and breech
presentations have been selected for their publication in medical and midwifery
journals readily accessible to medical professionals. Others such as the prebirth
and cervical ripening articles are included as they represent the research available
to date. While clinical practice does not always reflect the methods used in research
and questions remain over the use of methods such as a placebo in acupuncture, or
the use of prescribed points rather than an individual diagnosis, western medical
research does offer opportunities to discuss and promote acupuncture to medical
professionals and the community. This is especially relevant in the area of obstetrics
were safety and evidenced based practice are primary concerns.
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
stabilising 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 stabilising 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 stabilising exercisers.
Pain was measured by a visual analogue scale and by an independent examiner before
and after treatment.
Conclusion
Acupuncture was superior to stabilising 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, Hegu LI-4, Kunlun BL-60 and Zusanli
ST-36 with ten further acupuncture needles chosen according
to local painful points on palpation. They were selected from the following;
Guanyuanshu BL-26, Ciliao Bl-32, Zhongliai Bl-33, Zhibian Bl-54, Henggu KID-11,
Huantiao GB-30, Chongmen SP-12 and 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 10 minutes.
Clinical Perspective
Although no serious complication were reported during treatment it is of concern
that the acupuncture points Hegu LI-4, Kunlun BL-60 and Ciliao 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 31
weeks gestation.
Traditionally these points would be regarded as forbidden (or only to 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-36 were 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 a range of effective distal points to use in the treatment of pelvic girdle
pain without resorting to the use of Hegu LI-4 and Kunlun BL-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.
Acupuncture and morning sickness
Smith et al in 2002 published two articles from their research on nausea and
vomiting in pregnancy. The first looked at the effectiveness of acupuncture [5]
and the second at the safety of acupuncture 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-6 acupuncture 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, Liangqiu ST-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, Neiguan P-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.
Moxibustion use for Breech Presentation
Cardini et al in 1998[7] had the following randomised controlled 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 women having their first baby (primigravidas)
at 33 gestation received moxibustion to Zhiyin Bl 67 while 130 women, also primigravidas,
received no intervention.
The moxibustion was administered for 7 days .Women were then assessed and a further
7 days of moxibustion treatment given if the position had not changed.
Outcomes were measured in terms of fetal movements, as counted by the mother for
one hour each day for one week and the number of cephalic presentations both at
35 weeks gestation and at delivery
At 35 weeks gestation 75.4% in the intervention group were cephalic (47.7% in the
control).
Women in both groups then had the option of undergoing external cephalic version
(ECV). One woman took this option from the intervention group and 24 from the control
group
At delivery the presentation of 75.4% of the intervention group were cephalic compared
to 62.3% in the control group.
The presentation did not change in any of the groups after 35 weeks except in those
undergoing ECV. In terms of fetal movement the moxibustion group experienced a greater
number of movements (a mean of 48.45 compared to the control group with a mean of
35.35).
Conclusion
That in prigravidas at 33 weeks gestation with breech presentation moxibustion treatment
for 1 to 2 weeks at Zhiyin BL-67 increased fetal activity during the treatment period
and cephalic presentation at 35 weeks and at delivery.
Treatment method
The women and their partner (or a person to help with the treatment) were given
a treatment and taught how to use the moxibustion in a hospital appointment within
24 hours of the scan confirming the breech position. They then applied the treatment
to Zhiyin BL-67 daily at home. Moxa sticks were used with the women sitting or in
a semisupine position and the partner delivering the treatment.
Clinical Perspective
As part of this study an attempt was made to assess if there was a difference in
delivering moxibustion sessions once or twice a day.
87 women used moxibustion for a total of 30 minutes (15 minutes to each point) while
43 women used moxibustion in the same way but received treatment twice a day.
At the end of the first week 79% of the cephalic versions were obtained in the women
using moxibustion twice a day compared to 55.2 % in the daily treatments. But by
the end of the second week 15 additional cephalic versions were obtained in the
group having moxibustion treatment once a day.
This meant that at 35 weeks the results were termed as a nonsignificant difference
(72.4% in the once a day moxibustion group compared to 81% for the women having
moxibustion treatment twice a day).
From a safety perspective it was reassuring that no adverse events (such as intrauterine
death or placental detachment) were noted in the treatment group. It was also interesting
that while the number of premature rupture of membranes was similar in both groups
the number of premature births was lower in the intervention group and that the
use of oxytocin, before or during labour, was also reduced in the moxibustion group
(8.6% compared to 31.3%).
Prebirth acupuncture
Prebirth acupuncture has an interesting history with several studies examining the
effect of acupuncture used prior to labour.
Summary
Research on the use of acupuncture to prepare women for labour first appeared in
1974 with a study by Kubista and Kucera[8]. Their research concluded that acupuncture
once a week from 37 weeks gestation using the acupuncture points Zusanli ST-36,
Yanglingquan GB-34, Jiaoxin KID-8, and Shenmai BL-62 was successful
in reducing the mean labour time of the women treated.
They calculated the labour time in two ways, the first being as being the time between
a cervical dilation of 3-4 cm and the delivery time. In the acupuncture group the
labour time was 4 hours and 57 minutes (control group 5 hours and 54 minutes). The
second as the mean subjective time of labour, taken from the onset of regular 10
– 15 minute contractions until delivery, the acupuncture group had a labour time
of 6 hours and 36 minutes (control 8 hours and 2 minutes).
In 1987 Lyrendas et all[9] basing its study on the work of Kubista and Kucera contradicted
their research, concluding that acupuncture lengthened the delivery time. They calculated
the average lengths of the latent and active phase and the second stage of labour.
In their study 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 40 minutes).
In 1998 Tempfer[10] used the acupuncture points Bai Hui DU-20 , Shen Men HT-7,
and Nei Guan PC -6 from 36 weeks gestation. This study concluded that
acupuncture treatment had positive effect on the duration of labour by shortening
the first stage of labour, defined as the time interval between 3 cm cervical dilatation
and complete dilation. The acupuncture group had a median duration of 196 minutes
compared to the control group time of 321 minutes, (acupuncture group 3 hours and
26 minutes compared to the control group 5 hours and 35 minutes).
In contrasting these studies the following points should be noted;
Group numbers. In order to obtain accurate statistical comparisons
it is seen as ideal to have the number of women in the acupuncture group and control
group as evenly matched as possible. While this happened in the studies by Kubista
and Kucera (70 women in the acupuncture group 70 women in the control group) and
Tempfer (57 women in the acupuncture group and 63 women in control group) Lyrendas
et all had 56 woman in the acupuncture group and 112 woman acting as a control group.
Measurement of labour time It can be difficult to accurately define
the beginning of labour as often this is a subjective measurement on the intensity
or timing of contractions from the woman’s judgement, which will naturally vary
according to different woman’s perception of pain and expectations of labour. Even
if labour is medically defined as being a measurement involving cervical dilatation,
women can vary considerably in their presentation of early labour. For example in
the study by Tempfer twenty-seven women were excluded as they presented for admission
to the delivery unit with more than 3 cm of cervical dilatation.
Despite these difficulties an attempt was made in each study to measure the length
of labour from different starting points. It is worth noting that Lyrendas et all
used the most subjective, and therefore, least accurate method by taking the beginning
of labour as the time that women presented in delivery suite. It is also worth noting
that different statistics were used, Kubista and Kucera and Lyrendas et all used
a mean labour time while Tempfer used a median labour time. The median labour time
is considered to a more useful measurement when measuring data such as length of
time women spend in labour. This is because the median will give a more accurate
value when used for a wide variation in the data being collected were as the mean
is more suitable for data that falls into a bell curve distribution. The problem
with the mean being used is that the results can become extremely distorted by just
one or two values at either end of the data being collected.
Additional requirements for participating in the study As a requirement
for being in the acupuncture group in the Lyrendas et study women were required
to consent to having two lumbar punctures, one at 38 weeks gestation and another
six months after delivery. Having to consent to such an invasive medical procedure
would have certainly influenced the range of women who agreed to receive acupuncture.
It is interesting that in this study there was a control group of 16 women who received
a lumbar puncture (but did not receive acupuncture) they had the longest mean labour
time of 9 hours and 30 minutes (acupuncture group 8 hours and 30 minutes).
Conclusion
Although the research by Lyrendas et all appears to contradict the findings of both
Kubista and Kucera and Tempfer the full paper by Lyrendas et all contains interesting
details. A control group with twice the number of women in it from the acupuncture
group, taking the most subjective time for onset of labour as presentation to delivery
suite and a recruiting process that asks women in the acupuncture group to have
an invasive medical procedure such as a lumber puncture raises concerns that this
study may not be an accurate 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 were used weekly on primigravidea
women from 37 weeks until delivery.
The reasoning given for choosing these acupuncture points was that as a group they
would relax the women, tonify qi and improve circulation of blood to the pelvis.
The points were used bilaterally, with an even method with de qi being obtained
and the needles retained for 20 minutes. The women were treated in sitting position
and had on average three treatments.
Lyrendas et all. Despite stating in their study that the acupuncture points used
were the same as those used in the Kubista and Kucera study Sanyinjiao SP 6
was substituted for Jiaoxin KI 8. No reason was given.
Zusanli ST-36 and Sanyinjiao SP 6 were used to improve the circulation of the pelvic
organs. Yanglingquan GB-34 was used as an influential point for muscles and tendons.
Shenmai BL-62 was used as a tranquilizing point
They also used a different acupuncture method from the Kubista and Kucera study.
While the women received bilateral acupuncture with an even method and de qi was
obtained, the difference was that the women were treated lying on their sides. As
the total treatment time was 30 minutes, each woman would have only received acupuncture
for 10 to 15 minutes at each point.
The prebirth acupuncture was commenced at 36 weeks and women had on average five
acupuncture treatments
Tempfer. The acupuncture points Bai Hui DU-20 , Shen Men HT-7, and Nei Guan PC-6
were used. No reason was given why these points were chosen. Bilateral application
was used with the needles stimulated until de qi was obtained.
Treatment was given with the women in a resting position with each session lasting
20 minutes. A minimum of 4 sessions was recommended.
Clinical Perspective
In terms of how many pre birth treatments are considered effective Kubista and Kucera
found no effect on the duration of delivery time in woman who only received acupuncture
for one treatment and Tempfer ensured that women received at least four treatments
(twelve women were excluded from the Tempfer study because they received less than
4 treatments).
In terms of possible side effects from receiving acupuncture Tempfer found that
there was an increased frequency of premature rupture of membranes in the acupuncture
treatment group. They did not consider this a negative factor as they associated
this with an acceleration of the cervix maturing.
From a safety perspective there was no association with an elevated rate of complications
for mother or the fetus in those women receiving acupuncture in any of the studies.
In 2004 I was involved in an observational study looking at the effect of prebirth
acupuncture together with Sue Lennox, a midwife[11]. 169 women who received prebirth
acupuncture were compared to local population rates for gestation at onset of labour,
incidence of medical induction, length of labour, use of analgesia and type of delivery.
In the acupuncture group comparing all caregivers (including midwives, GP’s and
specialists) there was an overall 35% reduction in the number of inductions (for
women having their first baby this was a 43% reduction) and a 31% reduction in the
epidural rate. When comparing midwifery only care there was a 32% reduction in emergency
caesarean delivery and a 9 % increase in normal vaginal births.
There was no statistical difference in the onset of early labour in those women
receiving prebirth acupuncture.
Although this was a small naturalistic observation study rather than a randomised
controlled study it does reflect how acupuncture was used in clinical practice.
It mirrors the feedback given by midwives that prebirth acupuncture provides promising
therapeutic benefits in assisting women to have normal vaginal births and suggests
that a further randomized controlled study is warranted.
Acupuncture for cervical ripening
A randomised controlled trial into the effects of acupuncture on cervical was published
by Rabl 2001[12].
Summary
The objective was to evaluate whether acupuncture at term can influence cervical
ripening and thus reduce the need for postdates induction. On their due dates 45
women were randomized into either an acupuncture group (25) or control group (20).
The women were then examined at two daily intervals for cervical length (measured
with vaginal trasonography, cervical mucus and cervical stasis according to Bishops
score). The acupuncture group also received acupuncture every two days at the acupuncture
points Hegu LI-4 and Sanyinjiao SP-6.
If women had not delivered after 10 days labour was induced by administering vaginal
prostaglandin tablets. The time period from the woman’s due date to delivery was
on average 5 days in the acupuncture group compared to 7.9 days in the control group.
Labour was induced in 20 % of women in the acupuncture group compared to 35% in
the control group.
There were no differences between overall duration of labour and the first and second
stage of labour.
Conclusion
Acupuncture at the points Hegu LI-4 and Sanyinjiao SP-6 supports cervical ripening
and can shorten the time interval between the woman’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 needles were inserted to
achieve de qi and then retained for 20 minutes with no further stimulation.
Clinical Perspective
It was interesting that four women were delivered within 24 hours of having their
first acupuncture treatment while no women in the control group delivered within
24 hours of their first examination.
It is also interesting to note that none of the women from the acupuncture group
went into labour during treatment or within one hour following treatment, reflecting
that it is a practical option for women to receive acupuncture in a private clinical
setting.
From a safety perspective there was no difference in the number of women experiencing
difficulties during delivery, with 3 women requiring a vacuum extraction and two
women requiring a caesarean section from each group.
References
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[1] Elden H, Ladfors l, Fagevik Olsen M, Ostaard H, Hagberg H. Effects of acupuncture
and stabilising exercisers as adjunct to standard treatment in pregnant women with
pelvic girdle pain: randomised singleblind controlled trail. BMJ 2005;330:761
[2] Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture.
Journal of Chinese Medicine Publications, Eastland Press; 2001 p 103& 318
[3] West Z. Acupuncture in Pregnancy and Childbirth..Churchill
Livingstone; p2001
[4] Rabl M, Ahner R, Bitschnau M, Zeisler H, Husslein P. Acupuncture for cervical
ripening and induction of labour at term – a randomised controlled trail.
Wien Klin Wochenschr 2001; 113 (23-24): 942-6
[5] Smith C, Crowther C, Beilby J. Acupuncture to treat neasea and vomiting
in early pregnancy: a randomized trail. Birth.2002Mar:29 (1):1-9
[6] Smith C, Crowther C, Beilby J Pregnancy outcome following women's participation
in a randomised controlled trial of acupuncture to treat nausea and vomiting in
early pregnancy. Complement Ther Med. 2002 Jun; 10(2):78-83.
[7] Cardini F, Weixin H. Moxibustion for correction of breech presentation.
JAMA 1998; 280:1580-1584
[8] Kubista E Kucera H. Geburtshilfe Perinatol 1974; 178 224-9
[9] Lyrendas S, Lutsch H, Hetta J, Lindberg B. Gynecol. Obstet.24; 217-224
[10] Tempfer C, Zeisler H, Mayerhofe Kr, Barrada M Husslein P. Influence of
acupuncture on duration of labour Gynecol Obstet Invest 1998; 46:22-5
[11] Betts D, Lennox S. Acupuncture for prebirth treatment: An observational
study of its use in midwifery practice. Medical acupuncture 2006 May;
17(3):17-20
[12] Rabl M, Ahner R, Bitschnau M, Zeisler H, Husslein P. Acupuncture for cervical
ripening and induction of labour at term – a randomised controlled trail.
Wien Klin Wochenschr 2001; 113 (23-24): 942-6