Original Research ArticleSafe acupuncture and dry needling during pregnancy: New Zealand physiotherapists’ opinion and practice
Introduction
Women who are pregnant seek physiotherapy and acupuncture for a wide range of conditions, many of which are not related to pregnancy [1], [2], [3]. Acupuncture has been taught and practiced in New Zealand (NZ) by physiotherapists since 1982 [4], [5], [6]. Physiotherapists in NZ practice Western medical acupuncture and/or traditional Chinese acupuncture [7]. Dry needling (DN) or trigger point needling, the practice of brief insertion of a needle to deactivate a myofascial trigger point [8], has been taught as a component of acupuncture by the Physiotherapy Acupuncture Association of New Zealand (PAANZ) and practiced by physiotherapists in NZ since 1982. More recently, however, DN practice has been presented as its own entity, separate and distinct from acupuncture [4], [9] by an influx of overseas practitioners teaching DN over 14-hour-long weekend courses in NZ [10].
Acupuncture treatment provided by NZ physiotherapists for pregnant women has been considered “conservative” compared to the treatment of nonpregnant women with similar neurological and musculoskeletal complaints [11]. It has been suggested that in NZ the “fear of blame” for any potential miscarriage has contributed to conservative, possibly, defensive practice by physiotherapy acupuncturists [11]. It is unknown if DN practitioners offer treatment for women during pregnancy in NZ or if they have the same concerns regarding the potential for an early termination of pregnancy.
Internationally, such caution amongst practitioners has been attributed to the Chinese theories of “forbidden” acupuncture points in pregnancy [12], [13] and the prevalence of early pregnancy loss [14]. Miscarriage occurs in at least 10% of all clinically recognised pregnancies [14], however, a random sample of 2391 NZ women reported spontaneous abortion affecting almost one in three pregnant women [15]. Approximately 80% of these early losses of pregnancy occurred in the first trimester [14]. Carr [16] noted that “arguably the biggest fear amongst practitioners is the scenario in which a patient experiences a miscarriage or delivers prematurely and the acupuncture treatment is blamed by association”.
PAANZ cautions have been equally strong with past introductory acupuncture workbooks stating: “If the woman had just had acupuncture and spontaneously aborted, or went into premature labor, then the therapist and their acupuncture will tend to get the blame” [17].
Clarkson et al. [18] reviewed 17 acupuncture studies of pregnancy and found only one serious adverse event of premature labor was reported. A patient at 15-week gestation experienced premature contractions following the use of Hegu (LI4) to treat back pain. As the contractions stopped when the acupuncture was discontinued, they were termed “transient premature contractions” [19]. However, a key review finding was the paucity of adverse event reporting in this cohort [18] and further research was recommended.
Recently the safety of acupuncture during pregnancy, specifically the use of classical “forbidden” acupuncture points, has been debated in international acupuncture literature [16], [20], [21], [22]. The historically “forbidden” points in pregnancy relate to traditional Chinese medicine (TCM) theories, and beliefs developed from the use of acupuncture for difficult labor [12]. Some “forbidden” points, such as CV points 3–15, have obvious reasons, such as causing inadvertent uterine penetration in later trimesters [12], [16]. Other “forbidden” points are less obvious, such as Jianjing (GB21). It is often stimulated to treat head, neck and shoulder pain using either acupuncture or DN [23]. However, in Chinese medicine, GB21 is also associated with expediting labor, treating retained placenta and stimulating breast milk let-down [12]. Inconsistencies identified between texts further compounds practitioner confusion. Carr [16] lists LU7 as a “forbidden point” whilst Deadman et al. [12] does not. Others propose that the veracity of the “forbidden” points has not been proven using human trials, due to the avoidance of these points in practice [21], [24].
To date there is no published research on the suitability of DN during the three trimesters of pregnancy, and little evidence-based information exists on specific DN safety considerations in this patient cohort. Many trigger point locations correlate to classical acupuncture points [25], including the historical “forbidden” points (Table 1).
Physiotherapists in NZ who have undertaken acupuncture training through PAANZ or university postgraduate courses are aware of the notion of historical “forbidden” points and their location. It is not known whether this information is covered in the short-course DN training available in NZ. It is not known if DN physiotherapists avoid treating trigger points in the vicinity of the historical forbidden points or are aware of their effects.
The primary aim of this study was to examine the opinions, practice and level of understanding held by NZ physiotherapists providing acupuncture and DN for pregnant women. The survey explored whether practitioners were prepared to offer needling to pregnant women and which classical acupuncture points and/or trigger points they considered were safe to use during each trimester. The study was also interested in whether there were differences in opinion between those who practiced acupuncture and those who practiced DN. Multichoice questions, a patient vignette and open questions were utilized to draw on differing notions and practices.
For the purposes of this article, acupuncture (Western and traditional) and DN are defined according to the PAANZ Guidelines for Safe Acupuncture and Dry Needling Practice [11], as these were the definitions familiar to the study cohort in NZ.
Section snippets
Study design
This was a mixed-method study, comprising a survey and interviews of NZ physiotherapists. The survey results are provided, and the quantitative data are reported descriptively. The interview data will be reported separately in another paper. Ethics approval for this study was granted by the Auckland University of Technology Ethics Committee, application number 17/100.
Development of the electronic questionnaire
A literature search using the databases of MEDLINE, AMED, CINAHL, PubMed, PEDro, DARE and the Cochrane Database of Systematic
Demographics
A total of 124 anonymous EQ responses were received from NZ physiotherapy acupuncturists and/or dry needlers from the open invitation to participate in the survey. Missing data for the practicing respondents were low overall (11%) with the exception of the open questions regarding “suitable distal and local acupuncture points”, and “trigger points” for treatment of the vignette patient. Fifty-five percent and 51% of respondents skipped these questions respectively. If practitioners did not
Discussion
Negative defensive medicine has been defined as the avoidance of risky procedures on patients who could have benefitted from them [28]. Recent research does not demonstrate increased rates of miscarriage or premature labor when treating pregnancy-related complaints with acupuncture [18], [29]. However, conflicting opinions within contemporary literature [16], [20], [21], [22], [24] may be causing practitioners to hesitate before offering acupuncture to pregnant women.
This research indicates
Conclusion
The findings demonstrate a cautious willingness for NZ physiotherapy acupuncturists and dry needlers to offer women needling therapies for musculoskeletal conditions, particularly LBP and PGP, during pregnancy. However, fear of serious adverse events appears to influence practice. With large trials demonstrating efficacious and safe treatment of LBP and PGP in pregnant women it could be argued that women are not being offered relevant evidenced-based care. There is conflicting information on
Acknowledgements
The authors wish to acknowledge and thank the electronic questionnaire prize sponsor Acu-Future, NZ.
Competing interests
No competing financial interests exist. This research was not funded by an external body but undertaken by the authors personally. Jillian McDowell and Susan Kohut are executive members of PAANZ and are responsible for updating the PAANZ Guidelines for safe acupuncture practice biannually. Susan Kohut is on the executive of International Acupuncture Association of Physical Therapists. Debra Betts is employed by the New Zealand School of Acupuncture and Traditional Chinese Medicine as a
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