BMJ  2005;330:761 (2 April), doi:10.1136/bmj.38397.507014.E0 (published 18 March 2005)

Primary care

Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial

¹ Perinatal Center, Department of Obstetrics and Gynecology, Institute for the Health of Women and Children, Sahlgrenska Academy, East Hospital, 41685 Gothenburg, Sweden, ² Department of Occupational Therapy and Physical Therapy, Sahlgrenska Academy, Sahlgrenska Hospital, Gothenburg, ³ Department of Orthopedics, Sahlgrenska Academy, Molndal Hospital, Molndal, Sweden

Abstract

Objectives To compare the efficacy of standard treatment, standard treatment plus acupuncture, and standard treatment plus stabilising exercises for pelvic girdle pain during pregnancy.

Design Randomised single blind controlled trial.

Settings East Hospital and 27 maternity care centres in Gothenburg, Sweden.

Participants 386 pregnant women with pelvic girdle pain.

Interventions Treatment for six weeks with standard treatment (n = 130), standard treatment plus acupuncture (n = 125), or standard treatment plus stabilising exercises (n = 131).

Main outcome measures Primary outcome measure was pain (visual analogue scale); secondary outcome measure was assessment of severity of pelvic girdle pain by an independent examiner before and after treatment.

Results After treatment the stabilising exercise group had less pain than the standard group in the morning (median difference = 9, 95% confidence interval 1.7 to 12.8; P = 0.0312) and in the evening (13, 2.7 to 17.5; P = 0.0245). The acupuncture group had less pain in the evening than the stabilising exercise group (-14, -18.1 to -3.3; P = 0.0130). The acupuncture group had less pain than the standard treatment group in the morning (12, 5.9 to 17.3; P < 0.001) and in the evening (27, 13.3 to 29.5; P < 0.001). Attenuation of pelvic girdle pain as assessed by the independent examiner was greatest in the acupuncture group.

Conclusion Acupuncture and stabilising exercises are efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy. Acupuncture was superior to stabilising exercises in this study.

Introduction

Pelvic girdle pain is common among pregnant women, causing severe pain in one third of affected women.^{1 2} Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints. The pain may radiate in the posterior thigh and can occur in conjunction or separately in the symphysis. After pregnancy, problems remain serious in about 7%, causing severe discomfort and reducing ability to work.^{2 3}

Pelvic girdle pain must be reproducible by specific pain provocation tests. The posterior pelvic pain provocation test and Patrick's fabere test have the best sensitivity if pain is evident in the sacroiliac joints.^{4 5} Modified Trendelenburg's test and palpation of the symphysis have better sensitivity if pain is evident in the symphysis pubis.⁵ These tests have high intertester reliability.^{4 5}

Standard treatment may consist of a pelvic belt, a home exercise programme, and patient education. A systematic review has shown that the efficacy of these interventions remains questionable.⁶ Current treatment increasingly includes stabilising exercises and acupuncture.^7-9 However, insufficient evidence is available to give strong recommendations for or against any particular treatment.¹⁰ We compared the efficacy of acupuncture or stabilising exercises as an adjunct to standard treatment with standard treatment alone for the treatment of pelvic girdle pain in pregnant women.

Methods

This was a randomised single blind trial at East Hospital, Sahlgrenska Academy, and at 27 maternity care centres in the hospital's reference area in Gothenburg, Sweden, from 2000 to 2002.

Participants
Doctors and midwifes at the 27 maternity care centres preselected consecutive patients. Participants filled in a previously validated questionnaire¹ and a diary for baseline information for one week before the inclusion visit. An independent physiotherapist then assessed patients. This included a detailed standardised physical examination and collection of baseline data. The tests used were the posterior pelvic pain provocation test, Patrick's fabere test, a modified Trendelenburg's test, Lasegue test, and palpation of the symphysis pubis.^{4 5}

The main inclusion criteria were healthy women at 12-31 completed gestational weeks, well integrated in the Swedish language, with singleton fetuses and defined pregnancy related pelvic girdle pain. We excluded patients with other pain conditions, systemic disorders, or contraindications to treatment. Patients were randomised after baseline assessment.

Treatment protocols
The study comprised a one week baseline period, six weeks of treatment, and follow-up one week after the last treatment. Patients were asked to avoid other treatments during the intervention period. Three experienced physiotherapists gave standard treatment, two experienced medical acupuncturists did acupuncture, and two experienced physiotherapists gave the stabilising exercises.

Standard treatment—General information was given about the condition and anatomy of the back and pelvis. Adequate advice was given about activities of daily living. The physiotherapist made sure that the patient understood and respected the relation between impairment, load demand, and actual loading capacity as well as the importance of necessary rest. The purpose of this information was to reduce fear and enable patients to become active in their own treatment. Patients were given a pelvic belt and a home exercise programme designed to increase strength in the abdominal and gluteal muscles.

Acupuncture—Patients received the same treatment as the standard group but in addition had acupuncture. Local acupuncture points were selected individually after diagnostic palpation to identify sensitive spots. A total of 10 segmental points and seven extrasegmental points were used (see bmj.com). Treatment was given twice a week over six weeks.

Stabilising exercises—Patients received the same treatment as the standard group but in addition did stabilising exercises modified because of the pregnancy (see bmj.com).^{11 12} The training programme started by emphasising activation and control of local deep lumbopelvic muscles. Training of more superficial muscles in dynamic exercises to improve mobility, strength, and endurance capacity was gradually included. Patients received treatments individually for a total of six hours during six weeks. They were told to integrate the exercises in daily activities and to exercise in short sessions several times a day.

Outcome measures
Primary outcome measure—Patients scored their current intensity of pelvic pain related to motion on a 100 point visual analogue scale every morning and every evening in the diaries.

Secondary outcome measures—The independent examiner assessed recovery from symptoms. Patients were asked not to reveal any information about their treatment.

Statistical analysis
The statistician was blinded to group and treatment. In the analysis of the pain diaries we defined the median visual analogue scale baseline levels in the mornings and in the evenings for each patient by calculating the median for the days before treatment (five to seven days). The same calculations of median pain were done for the first week after the end of treatment. We calculated the medians, quartiles, means, and standard deviations when possible, and compared differences between the groups (see bmj.com).

Results

Randomisation and progress through the trial
Of 558 women referred for the first assessment, 172 did not meet the inclusion criteria; 386 women were included in the trial. Baseline characteristics were similar in the three treatment groups (see bmj.com).

Primary outcome measure
Table 1 shows changes in pain scores. The reduction in pain was most pronounced in the evening in the acupuncture group one week after the end of treatment, compared with the other treatment groups.

View this table: [in this window] [in a new window]   Table 1 Primary outcome measure: pain on visual analogue scale related to motion one week after treatment compared with baseline measurements

 

Secondary outcome measures
Table 2 shows that attenuation of pelvic girdle pain assessed by the independent examiner was greatest in the acupuncture group. Three of four subgroups of pelvic girdle pain improved after acupuncture compared with standard treatment and one of four subgroups improved compared with the stabilising exercise group.

View this table: [in this window] [in a new window]   Table 2 Secondary outcome measure: assessment of severity of pelvic girdle pain by an independent examiner before intervention and at follow-up after last treatment. Values are numbers (percentages) unless stated otherwise

 

Discussion

Acupuncture or stabilising exercises as an adjunct to standard treatment offer clear clinical advantages over standard treatment alone for reduction of pain in pregnant women with pelvic girdle pain. This is supported by the patients' own estimates and by independent examiners. The findings are of particular importance because no previous study has shown such marked treatment effects among pregnant women with well defined pelvic girdle pain. Earlier findings show beneficial effects of stabilising exercises for women.⁷ The training was aimed at affecting dysfunction of the muscle-tendon-fascia system that controls force closure of the pelvis.¹³ Exactly how the exercises influence this system is unknown, but research has shown that contraction of the transversus abdominis decreases the laxity of the sacroiliac joint.¹¹ The exercises were intended to affect mainly the local stability system, but whether adding global stabilising muscle exercises could have provided the same effect is not known.

The stabilisation group also got additional treatment of stretching exercises of specific muscles plus massage. All treatment was more or less multifactorial, and massage as well as stretching may have had some contributory effect. The main training, however, was the stabilisation exercises that were done on several occasions during the day, in contrast to the stretching or massage that was done only at the visits.

Previous studies of acupuncture for low back pain in pregnancy reported pain relief.^{8 9} However, these studies had methodological shortcomings, and the type of back pain was not clearly defined. Our findings are supported by physiological models explaining the mechanisms in the treatment of both acute and chronic pain conditions.¹⁴

Pain may be inhibited at the segmental level, and for this reason the acupuncture points were selected in muscle segments according to the patient's pain drawing, including diagnostic palpation to identify sensitive spots. The aim was to establish control of pelvic pain to prevent dysfunction of muscles of the spine and pelvis. Speculatively, control of pelvic pain was achieved through activation of both the segmental pain inhibitory system, involving the so called gate control mechanism, and the central pain inhibitory system, involving secretion of endogenous opioids. Extrasegmental points to the lumbosacral area were used to strengthen and lengthen the effect of the central control systems. In addition, well known general pain relieving points were selected. Whether the choice of acupuncture points and the method of stimulation in this study are optimal remains to be elucidated.

Earlier research found that poor muscle function in the back and pelvis at the beginning of pregnancy is related to severe pain and disability throughout pregnancy.¹⁵ The acupuncture treatment succeeded in establishing control of the pain, and this may have been important in preventing dysfunction of muscles. Our results are supported by earlier research on acupuncture for low back pain.^{16 17}

What is already known on this topic No cure exists for pelvic girdle pain during pregnancy No studies have been published on the effects of acupuncture on well defined isolated pelvic girdle pain during pregnancy What this study adds This study shows large treatment effects on pain among pregnant women with well defined isolated pelvic girdle pain Acupuncture was 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

A combination of several methods for treating pelvic girdle pain in pregnancy is probably better than individual treatments Each method needs to be evaluated individually, however, before combinations can be recommended for future research and treatment.

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This is the abridged version of an article that was posted on bmj.com on 18 March 2005: http://bmj.com/cgi/doi/10.1136/bmj.38397.507014.E0

We thank physiotherapists E Roos-Hansson and G Zetherstrom for invaluable help with assessment of the patients. We thank physiotherapists T Larsson and K Wettergren and midwife K Frygner for treating the patients. We also express our appreciation to all the women for their contributions to this study.

Contributors: See bmj.com

Funding: The Vardal Foundation, the Dagmar Foundation, the Trygg-Hansa Insurance Company, and Sahlgrenska University Foundation provided funding. The study sponsors had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Competing interests: None declared.

Ethical approval: Local ethics committee.

References

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(Accepted 28 January 2005)

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This article has been cited by other articles:

• Manheimer, E., Zhang, G., Udoff, L., Haramati, A., Langenberg, P., Berman, B. M, Bouter, L. M (2008). Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis. BMJ 336: 545-549 [Abstract] [Full text]  
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