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Three Part Question

In[Pregnant women] ( > 12 /40) with pelvic girdle/back pain] does [Acupuncture] [improve pain or function]

Clinical Scenario

A 22/40 pregnant lady presents to physiotherapy with pelvic girdle pain. The physiotherapist wants to know whether acupuncture will improve her pain and function.

Search Strategy

Medline 1966-09 using the PubMed Clinical queries database was searched using the following terms (Therapy/Narrow[filter]) AND (Therapy/Broad[filter]) AND (acupuncture AND pregnancy AND low back pain)

In addition the BestBETS database was searched using similar terms. Finally, the PEDrO (Physiotherapy best evidence) database was searched, Pedro Simple search: acupuncture and pregnancy, Pedro advanced search: therapy acupuncture, women’s health, incontinence: Lumbar spine and sacro iliac joints, with only papers already rated as 7/10 on the quality score being selected for inclusion. The Athens database was also searched: the databases were AMED, CINAHL and PUBMED with the terms pregnancy AND acupuncture AND low back pain

Google scholar was also search with the terms pregnancy and pelvic girdle pain and acupuncture a second search of pregnancy AND acupuncture AND low back pain

PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org
https://auth.athensams.net/
www.google.co.uk/scholer

Search Outcome

Altogether 20 abstracts were identified from the combined searches, after duplicates had been removed. Abstracts were screened. Full papers were obtained for those papers that answered, or potentially answered the three part search question. This resulted in 13 papers being obtained. These papers were rated for quality and risk of bias using a standard proforma (See appendix 1) with papers scoring over 6/10 being summarised in Table 1. This process resulted in 3 papers being rated as good quality and directly answering the PICO question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wang, SM 2009 USA	Pregnant women between 25-38/40 with back or pelvic girdle pain	RCT 2 groups : 1 group given Auricular acupoucntyure for 1 week group 2 sham acupuncture for 1 week. Both groupd were given basic advice on pain relief	VAS-P- measured at baseline, post Rx and 2/52	VAS-P: Statistically significant reduction VAS all groups compared to baseline (p=<0.0001)	Large p values – considered <0.5 = significant. Auricular acupuncture – need specialist pins/needles. Left in place for 1/52. Confidence interval 85% VAS-P only outcome measure for pain.
			DRI- measured at baseline, post Rx and 2/52	DRI: Statistically significant difference in all groups compared to baseline. (p=<0.0001)
Elden, Fagevik-Olsen, Ostgaard, Stener-victorin, Hagberg 2008 Sweden	115 ♀ PGP with a VAS ≥50 on 100mm scale; evening pain. 12-29/40 singleton foetuses’ Acupuncture naïve PGP diagnosed according to Ostgaards criteria	Both groups given ‘standard treatment’ = A&P info, pelvic belt, strength HEP, advice + one of the below Acupuncture = 8-9 tender points + 2 trigger points in segment/location of PGP + 2 distal/drainage points in segment + 2 extra segmental points to increase rx effect + manual stim every 10’ (up to 17 needles) Sham non-penetrating acupuncture (same points) All = 12 sessions 30’, 2x/wk for 4 wks then 1/wk for 4/wk – prone (unable to see needles except on in hand)	Pain related to motion morning and evening (VAS)	Intervention credibility: After 3 rx, pts receiving true acupuncture were more confident that rx could help their PGP than the sham group P= 0.034	Did not stratify for sick leave at randomisation = many more ♀ in sham group were on sick leave at beginning and end of study (? More rest therefore good or equal to true acupuncture group in maintenance of pain/function) Many women in sham group reported needle site pain/pressure and bleeding – sham likely to have some afferent nerve modulation
			QOL (EQ-5D and EQ-5D VAS)	Clinically significant improvement in QoL in both groups but no difference between groups after rx
			Function: Oswestry disability index (ODI) & Disability rating index (DRI)	Statistically more improvement in ADL’s (measured by DRI) in true acupuncture//sham group P=0.001
Wedenberg K, Moen B, Norling A. 2000 Sweden	n=60 pregnant women with LBP	acupuncture n=30 3 x week in 1st 2 weeks 2x week for next 2 weeks 30mins Points ear and common points BL26-30, Bl60 and CW2 physiotherapy group : 18 exclusion 1or 2 x week 10 treatment sin 6-8 weeks 50 mins each	VAS measures pre during and after	VAS significantly lower in acupuncture group	No standardised needle points Ear acupuncture first Needles were both rotated and tapped for de qi No standard no of needles No standardisation with no of visits or treatment treatment times different 12 dropouts in physio ( all accounted for) Difference on demographics of type/ area of pain No adverse effects from acupuncture ( just tiredness)
			DRI	DRI: acupuncture 27/28 good / excellent help significant difference after acupuncture
Elden 2005 Sweden	N= 386 3 groups N= 130 Standard: advice, anatomy, belt, HEP for glutes and abdominals N =125 Acupuncture ( twice a week ) maternal HR and FH measured before and after plus standard treatments 131=Standard plus stabilising exercises	RCT	VAS group 1	no significant difference	Results not displayed very clearly
			VAS group 2	AM -8 PM -34 significant difference
			VAS group 3	AM -4 PM -15
			Turning in bed	significant difference in group 2
Elden 2005 Sweden	N= 386 3 groups N= 130 Standard: advice, anatomy, belt, HEP for glutes and abdominals N =125 Acupuncture ( twice a week ) maternal HR and FH measured before and after plus standard treatments 131=Standard plus stabilising exercises	RCT	VAS group 1	no significant difference	Results not clearly displayed
			VAS group 2	AM -8 PM -34 significant difference
			VAS group 3	AM -4 PM -15 significant difference
			Turning in bed	significant difference in acupuncture group

Comment(s)

In all the studies evaluated there were no adverse affects. The evidence seems positive towards the use of acupuncture for the treatment of back/ pelvic girdle pain in pregnant women. However due to a) the lack of studies and b) the lack of heterogeneity within the studies it is diificult to draw robust conclusions.

Clinical Bottom Line

There is some evidence that suggests acupuncture may improve pain and function in women with back/ pelvic girdle pain. However due to the low number of the studies this is not conclusive. In most studies there was significant difference between groups.

References

1. Wang SM, Dezinno P, Lin EC, Lin H, Yue JJ, Berman MR, Braveman F, Kain ZN. Auricular acupuncture as a treatment for pregnant women who have low back and American Journal of Obstetrics and Gynecology 2009; 271
2. Elden H, Fagevik-Olsen M, Ostgaard HC, Stener-Victorin E, Hagberg H. Acupuncture as an adjunct to standard treatment for pelvic girdle pain in BJOG 2008; Dec 115 (13) 1655- 68
3. Wedenberg K, Moen B, Norling A. A prospective randomized study comparing acupuncture with physiotherapy for 2000; 79 (5), 331-5
4. Elden, Ladfors, Olsen, Ostgaard and Hagberg Effects of acupuncture and stabilising exercises as adjuncts to standard treatment in pregnant women with pelvic girdle pain RCT. 2005; 1-5
5. Elden, Ladfors, Olsen, Ostgaard and Hagberg Effects of acupuncture and stabilising exercises as adjuncts to standard treatment in pregnant women with pelvic girdle pain RCT. BMJ 2005; 1-5