By Mary L. Hardy, MD
Back pain is a common complaint during pregnancy. Up to three-fourths of all pregnant women report having low back or pelvic pain with the highest pain intensity noted at 36 weeks.1,2 Management of pain with conventional analgesics presents a potential risk to the fetus and, thus, both patients and physicians may be reluctant to use such medication. Not only can back pain be a problem during pregnancy, but for 21% of these patients, pain may persist for more than two years after delivery.1 Patients at highest risk for developing persistent back pain were older patients, patients with a previous history of back pain, patients with more severe symptoms at an earlier stage of pregnancy and those with a higher weight gain at 24 months.1 Unfortunately, neither physiotherapy nor a patient education program prevented the development of back pain during pregnancy.2 Although there is no evidence that successful management of pain would decrease the persistence of pain after delivery, it seems desirable to find a safe strategy to manage pain as early and as effectively as possible. Acupuncture may be that strategy.
Two recent randomized controlled trials were performed using acupuncture in the third trimester to treat pelvic and/or low back pain. The first trial compared the use of acupuncture to physiotherapy in 60 pregnant patients enrolled between 20 and 32 weeks gestation (mean 24 weeks).3 The groups were equivalent at baseline for maternal age, gestational age, and percentage of primagravida patients. Interventions included an individualized physiotherapy program (10 50-minute treatments within 6-8 weeks, including pool therapy) or a semi-structured acupuncture treatment (10 30-minute treatments within one month). Acupuncture was initiated with the use of ear acupuncture for all patients followed by individualized body points as needed to relieve symptoms. The most commonly used points were listed and the needles were stimulated manually while inserted to increase the effect. The training of the acupuncturist was not noted.
Outcomes measured included a visual analog scale (VAS) for pain as well as a Disability Rating Index (DRI) that measured the ability to perform 12 common daily tasks. Interestingly, all the acupuncture patients completed treatment, but there were 12 dropouts in the physiotherapy group. Reasons included delivery (3), premature labor (3), inconvenient treatment hours (3), and failure to return for therapy (3). No such events were recorded for the acupuncture group. The results demonstrate that pain in both the morning and evening was lower in the acupuncture group following treatment (AM: VAS 3.4 vs. 0.9, P < 0.01; PM: VAS 7.4 vs. 1.7, P < 0.01). For the physiotherapy group, treatment lead to a significant decrease in evening pain, but not morning pain. Results for the acupuncture group were significantly better for both morning and evening scores compared to the physiotherapy group (AM: P = 0.02; PM: P < 0.01). DRI values also were significantly better in the acupuncture group after treatment compared to the physiotherapy group. It is worth noting that an intention-to-treat analysis was not performed in this study. Thus, the six subjects who were lost to follow-up and reasonably may be presumed to be non-responders were not included in the analysis. If they were included, it is likely that the preference for acupuncture would be even more marked. No adverse events were recorded in this study.
A similar study was performed using 72 women at 24-37 weeks of gestation (mean 30 weeks) who were complaining of pelvic and/or low back pain.4 Patients were assigned randomly to receive either acupuncture (one to two times per week until they delivered or the pain resolved) or to be part of a control group (presumably usual and customary care group, although this was not explicitly stated). The acupuncture strategy was different than the previous study. No ear points were included and a written semi-structured protocol was followed. Individual variation was allowed at the discretion of the acupuncturist. Needles also were stimulated manually, but the treatment time seemed to be shorter than in the previous study. The total number of visits per patient was not reported. Schematic diagrams accompanied this article to make location of the points explicit, but the training of the acupuncturist again was not noted.
Outcomes measured included a VAS pain scale and influence of pain on defined common daily activities. Data also were collected about delivery and APGAR scores of the babies at birth. The results are less fully reported here than in the previous study, but additional outcomes of interest are included here. Complete resolution of pain was reported in two acupuncture patients and no control patients. Pain intensity significantly decreased in the experimental group (60% vs. 14%, P < 0.01). Similar results were seen for pain associated with daily activities. Forty-three percent of the acupuncture patients vs. 9% of the control patients reported a decrease in pain related to daily activities (P < 0.001). No mothers in the acupuncture group reported using analgesic drugs, while five subjects in the control group needed medication for pain. Control patients also used more adjunctive therapy, such as TENS units, sacroiliac belts, or physiotherapy, compared to acupuncture patients. No serious adverse events were recorded in the acupuncture group and the birth outcomes were similar.
Similar results have been seen with a quasi-randomized, prospective effectiveness study conducted by a group in Brazil involving 61 women.5 Thus, the effectiveness of acupuncture for pelvic and low back pain in pregnancy has been replicated in three different settings.
However, there are a few caveats to keep in mind before sending all pregnant patients with back or pelvic pain to acupuncturists. First, patients with serious back problems should be dealt with in a conventional manner. Second, patients with a bleeding diathesis have a relative contraindication to acupuncture. Finally, patients should be referred to acupuncturists skilled in treating pregnant patients. Care should be taken especially in the first trimester to avoid certain points, which traditionally are felt to stimulate the uterus. As shown in the literature cited here, successful treatment involves individualization of therapy. The skill of the individual acupuncturists will influence the outcome. With these conditions being met, acupuncture is a very safe and effective therapy for the treatment of back and pelvic pain associated with pregnancy. Hopefully, management of pain will allow patients to address other risk factors for persistent pain, such as weight, thus avoiding pain after delivery.
References
1. To WW, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand 2003;82:1086-1091.
2. Ostgaard HC, et al. Back pain in relation to pregnancy: A 6-year follow-up. Spine 1997;22:2945-2950.
3. Wedenberg K, et al. A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy. Acta Obstet Gynecol Scand 2000;79:331-335.
4. Kvorning N, et al. Acupuncture relieves pelvic and low-back pain in late pregnancy. Acta Obstet Gynecol Scand 2004;83:246-250.
5. Guerreiro da Silva JB, et al. Acupuncture for low back pain in pregnancy—A prospective, quasi-randomised, controlled study. Acupunct Med 2004;22:60-67.
Hardy ML. Oh, my aching back: What's a mother to do? Altern Ther Women's Health 2005;7(4):30-31.
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