Acupuncture Forbidden Points for Low Back Pain in Pregnancy: A Literature Review Synthesis

Yo San University of Traditional Chinese Medicine, Los Angeles, California, USA

CRITICAL REVIEW

Acupuncture Forbidden Points for Low Back Pain in Pregnancy: A Literature Review Synthesis

Debbie R. Rodriguez, Lawrence J. Ryan

Yo San University of Traditional Chinese Medicine, Los Angeles, California, USA

Author: Debbie R. Rodriguez, MATCM, L.Ac

There has long been a controversy whether forbidden points truly exist, or if they have any bearing in contemporary practice. This study used literature review synthesis method to examine the application of acupuncture at the “forbidden points” for low back pain and pelvic pain in pregnancy. This study addresses the potential implications of needling the forbidden points during pregnancy.

Acupuncture Therapy; Pregnancy; Low Back Pain; Points, Forbidden

To experience low back pain in pregnancy is a very common occurrence. According to Sabino J and Grauer JN, between 50%-80% of pregnant women complain of low back pain at some point during pregnancy. There are a variety of reasons that contribute to the discomfort. These rationales include hormonal changes, physical changes, mechanical changes and circulatory changes as well. Sabino J and Grauer JN also report that up to one third of pregnant women cite back pain as a primary issue[1].

According to Saccomanni B, low back pain often begins between the fifth and seventh month of pregnancy[2]. However, some women have reported low back pain from as early as one month into pregnancy and 16 weeks into pregnancy. There are a few factors that appear to play a role in the occurrence of low back pain. Often, women who have experienced previous low back pain issues are more likely to experience low back pain during pregnancy. This observation also applies to younger women who have had more than one child. A sedentary lifestyle is also related to the occurrence of low back pain as well as body mass index (BMI)[2]. According to Greenwood CJ and Stainton MC, women who are short in stature, those with strenuous occupations or those with naturally large lumbar lordosis are also at risk for low back pain during pregnancy. The exercise habits of women prior to pregnancy also play a role in the incidence of low back pain[3].

When a woman becomes pregnant, there are certain physiological changes that occur in the body. The sacroiliac joints stretch and can cause pain that radiates to the buttocks and hamstring area of the leg. Low back pain during pregnancy is most often the result of postural changes that alter the center of gravity, the stretching of abdominal muscles, inter-vertebral disc compression, hormonal changes that cause inflammation, and uterine pressure on the vena cava causing hypoxia in the lumbar region[1].

Traditional acupuncture texts list specific points considered to be forbidden in pregnancy as well as acupuncture points for difficult labor. Forbidden points are those acupuncture points thought to have strong down-bearing qualities or those that enhance uterine contractions.However, the literature is not very clear as to the reasons why the points should not be used. There has been a controversy over forbidden points because a variety of books will have a variety of acupuncture points listed as forbidden.

The purpose of the current study is to complete a systematic analysis of literature pertaining to the needling of forbidden points for the relief of low back pain during pregnancy.

1 Method

The method used in this study was qualitative retrospective literature review synthesis[4-5]. The qualitative approach allows the researchers to methodically review and analyze data to find recurrent themes or patterns. The sources of the data for this research were derived from a variety of Chinese medicine and Western medicine journals as well as textbooks. Some textbooks were used due to the lack of published journal articles by traditionally trained acupuncturists regarding the use of forbidden points in pregnancy. It was observed that many of the published journal researches reviewed for this study were accomplished by medical acupuncture physicians who have been trained to move away from many of the tenets of traditional Chinese medicine (TCM).

Due to the lack of information on the specific subject of forbidden points, only those articles pertaining to areas outside of TCM gynecology were excluded. Included were articles that pertained to acupuncture for low back pain, acupuncture for pelvic pain, acupuncture for cervical ripening and neuroanatomy of acupoints that fell within the range of the forbidden points and acupuncture for labor induction. Included also was the physiology of pregnancy as well as the oxygen requirements for optimal uterine implantation.

The data generated by this study were organized according to their relevance to several designated categories: Wistar rat studies, low back/pelvic pain studies, and labor induction studies. By organizing the data into specific categories, themes that emerged within each category were observed in an inductive fashion facilitating ease of interpretation. The next step was to organize all of the articles according to topical themes. The two analyses were crossreferenced, and themes rose to the top for further interpretation and analysis. The researchers then asked the question ‘what is missing?’ That final process led to the development of themes asserted to support one or more of the stated hypotheses of the current study.

2 Results

2.1 Review of studies

Due to the scarcity of literature concerning forbidden points, studies were selected that involved the use of acupuncture points in Wistar rats as well as those that pertain to the forbidden to use for low back pain in human pregnancy as well as studies pertaining to the use of forbidden acupuncture points to induce labor including studies that examined the myo-electrical activities of using these points. The specific acupuncture points being examined are as follows: Hegu (LI 4), Sanyinjiao (SP 6), Guanyuanshu (BL 26), Xiaochangshu (BL 27), Pangguangshu (BL 28), Zhonglüshu (BL 29), Baihuanshu (BL 30), Shangliao (BL 31), Ciliao (BL 32), Zhongliao (BL 33), Xialiao (BL 34).

2.1.1 Wistar rat studies

When experiments on humans are not possible, rats are the most commonly used animal for this purpose. Silva AV, et al[6]conducted a study on pregnant Wistar rats to see if they could produce harm in the pregnancy outcome. A total of 48 rats were randomly divided into 4 groups. The groups used were as follows: control group where the rats were left in cages without manipulation; anesthetized control, where rats were anesthetized and manipulated but did not receive electroacupuncture (EA); and peripheral point and sacral point groups where rats were anesthetized and received 6 sessions of EA at 4 points: Hegu (LI 4), Sanyinjiao (SP 6), Xiaochangshu (BL 27), Pangguangshu (BL 28). The rats were killed on the 19th day of pregnancy and examined. They reported that there were no differences between the groups in the levels of glucose, aspertate aminotransferase (AST), alanine transaminase (ALT) or creatinine. They also reported that there were no adverse effects such as vaginal bleeding or expulsion of conception products. The conclusion was that there was no evidence to support the traditional belief that these particular points would cause ill effects.

The next study utilized pregnant and non-pregnant rats as well but the results are a little different. Liu JL, et al[7]conducted a study to observe the effect of EA of different acupuncture points on the electrical activities of the uterus. This study used a total of 79 Wistar rats that were anesthetized. The first part consisted of 40 non-pregnant rats randomized into control, Neiguan (PC 6), Hegu (LI 4) and Sanyinjiao (SP 6), with 10 rats in each group. In the next part of the study, 39 pregnant rats were evenly randomized into control, Neiguan (PC 6), Hegu (LI 4) and Sanyinjiao (SP 6) with 13 rats in each group. Electro-hysterogram was recorded by using bipolar stainless steel electrode inserted in the sub-perimetrium layer of the mid part of the uterus. EA of 2 mA, 5/15 Hz was applied to bilateral Neiguan (PC 6), Hegu (LI 4) and Sanyinjiao (SP 6) for 20 min. The results were that the amplitude and frequency of fast waves and amplitude of slow waves in Sanyinjiao (SP 6) increased significantly in the non-pregnant rats compared with the control group. EA at Hegu (LI 4) had similar results in increasing the frequency of fast waves but after EA at Neiguan (PC 6) both frequency and amplitude of fast waves and the frequency of slow waves decreased significantly. By comparison, in pregnant rats compared with the control group, both amplitude and frequency of fast waves and amplitude of slow waves of the electro-hysterogram in Sanyinjiao (SP 6) group increased significantly and lasted a longer time while the frequency of both fast and slow waves decreased considerably in the Neiguan (PC 6) group. Comparison between the Sanyinjiao (SP 6) and Neiguan (PC 6) groups showed significant differences in the frequency and amplitude of fast waves and the frequency of slow waves during and after EA. The conclusion in this study was that EA of Sanyinjiao (SP 6) and Hegu (LI 4) can activate the myo-electrical activities of the uterus in both pregnant and non-pregnant rats. The effect of EA at Sanyinjiao (SP 6) is stronger, and EA at Neiguan (PC 6) can inhibit the myo-electrical activities of the uterus.

By contrast, the next study attempts to demonstrate the ability of EA to regulate a dysfunction. Chen SP, et al[8]had the objective to observe the effect of EA of different acupoints on an abnormal electro-hysterogram in pregnant rats in order to analyze their ability to regulate dysfunctions of the viscera. A total of 48 pregnant Wistar rats (18-20 d) were anesthetized and randomized into control (10), Sanyinjiao (SP 6) (9), Hegu (LI 4) (8), Neiguan (PC 6) (10), Sanyinjiao (SP 6) plus Hegu (LI 4) (11). An electro-hysterogram was recorded by using a bipolar stainless steel electrode inserted in the sub-perimetrium layer of the left mid part of the uterus. Oxytocin and gesterol were given to the local uterus in order to induce an abnormal excitement and suppression of the electro-hysterogram. EA of 1-2 mA, 2/15 Hz was applied for 20 min to the groups. The frequency of fast and slow waves was analyzed. The results were that compared with the control group, EA of Sanyinjiao (SP 6) plus Hegu (LI 4) and Sanyinjiao (SP 6) had inhibitory effects on oxytocin-induced increases of the frequency and amplitude, and EA of Hegu (LI 4) also had an inhibitory effect on the amplitude of fast waves. It was determined that Sanyinjiao (SP 6) plus Hegu (LI 4) and Sanyinjiao (SP 6) could relieve or significantly relieve progesteroneinduced suppression of the frequency and amplitude of both slow and fast waves while Hegu (LI 4) and Neiguan (PC 6) had no effect on progesteroneinduced changes of the frequency.

A final study on rats has been included to illustrate how afferent fibers in the hypogastric and pelvic nerves are innervated in the adult virgin rat. Berkley KJ, et al[9]conducted studies on 30 Wistar virgin rats. The rats were injected with different fluorescent dyes into different parts of the reproductive, lower urinary and lower digestive tracts. Anesthetized rats were studied electro-physiologically in order to evaluate the two nerves by electrical stimulation. In both studies, sensory innervation of the reproductive tract shifted from the pelvic to the hypogastric nerveshifted entry into the spinal cord from the L5-S1to the T12-L3dorsal root ganglia respectively. The dye shifted from the vaginal entrance to the uterine horns with fibers from both nerves densely innervating the cervix region. The results from this study provide strong evidence that afferent fibers in the pelvic and hypogastric nerves of nulliparous adult rats serve different functions in reproduction and sensation. Pelvic nerve fibers seem closely tied to sensory and behavioral processes associated with mating and conception whereas hypogastric fibers seem closely tied to pregnancy and nociception, with fibers in both nerves serving functions during parturition. While this study does not involve acupuncture, it does speak to the afferent innervation of the hypogastric and pelvic nerves in pregnancy.

2.1.2 Studies pertaining to low back pain or pelvic pain in pregnancy

For the purpose of this investigation, importance was placed on the specific acupuncture points used in each of the studies reviewed. Ee CC, et al[10]conducted a systematic review of acupuncture compared with physiotherapy in the treatment of back pain. The researchers reported that pelvic and back pains are some of the most common minor complications in pregnancy. They describe the most prescribed method of treatment to be exercise physiotherapy. They report that studies suggest that physiotherapy in combination with acupuncture may improve low back pain.

Wedenberg K, et al[11]conducted a study to compare the effects of acupuncture for low back and pelvic pain in pregnancy with physiotherapy. In this study, 60 pregnant women, no more than 32 weeks gestational age, were divided into two groups of 30. The women in the acupuncture group received treatment 3 times a week during the first two weeks then twice a week for a total of 10 treatments within one month. Needle gauge ranged from 0.25-0.38 mm thick and 1-10 cm long. Two to ten needles were used, the first being auricular acupuncture and then body points as needed. The needles were stimulated toelicit the qi sensation. The most commonly used points were Guanyuanshu (BL 26), Baihuanshu (BL 30) and Kunlun (BL 60). The needles were stimulated by rotating them or tapping them gently 15 min into the treatment. The results of this study were that all 30 women in the acupuncture group finished the study compared to 18 in the physiotherapy group. Both groups had been similar in pain levels initially; however, after treatment, the mean morning visual analogue scale (VAS) score had declined from 3.4 to 0.9 in the acupuncture group and from 3.7 to 2.3 for the physiotherapy group. The evening values declined from 7.4 to 1.7 and 6.6 to 4.5 respectively. The mean VAS scores were lower after acupuncture treatment than physiotherapy. There were no adverse events in any of the patients. The conclusion was that acupuncture relieved pain and diminished disability in low back pain during pregnancy better than physiotherapy.

The next study reviewed is one where the researchers were looking for adverse effects from acupuncture because there were not enough studies to assure the treatment is safe. Elden H, et al[12]conducted a study to determine if there were any adverse effects from acupuncture on the pregnancy, mother, delivery or fetus/neonate in comparison with women who received stabilizing exercises as adjunct to standard treatment. There were 386 women in a controlled, single blind trial. They were randomly assigned to standard treatment plus acupuncture (125), standard treatment plus specific stabilizing exercises (131), or to standard treatment alone (130) for 6 weeks. Treatments were started as early as the second trimester and they used strong acupuncture treatment. 43 women were randomly picked to have cardiotocography on the fetus after they had experienced 43 treatments. The results were that there were no adverse effects noted. They used 17 needles with 10 located in the lumbosacral area. Their conclusion was that acupuncture administered with stimulation that may be considered strong only led to minor adverse complaints. There were no adverse reports with regard to the pregnancy delivery, mother or fetus/neonate. What is interesting to note is the selection of points they chose. Those points are listed as: Baihui (GV 20), bilateral Hegu (LI 4), Guanyuanshu (BL 26), Ciliao (BL 32), Zhongliao (BL 33), Zhibian (BL 54), Henggu (KI 11), Kunlun (BL 60), Huantiao (GB 30), Chongmen (SP 12) and Zusanli (ST 36). Several of the points are considered forbidden, yet they did not have any adverse effects.

Elden H, et al[13]also conducted a study, which was randomized, double-blinded controlled involving 115 pregnant women who presented a clinical diagnosis of pelvic girdle pain and who scored greater than 50 on the VAS. These women were randomly allocated to standard treatment plus acupuncture or to standard treatment plus non-penetrating sham acupuncture for 8 weeks. The needles were 0.30 mm and inserted to a depth of 15-50 mm. The participants received 12 acupuncture treatments which lasted 30 min twice a week for 4 weeks and then once a week for 4 weeks. The needles were left in place and manually stimulated every 10 min. No attempt was made to evoke the qi sensation. The results were that pain decreased from 66 to 36 in the acupuncture group and from 69 to 41 in the non-penetrating sham group according to the VAS. Women from the acupuncture group were at their regular work to a higher extent than women in the sham group. The acupuncture group had superior ability to perform daily activities. The conclusion was that the acupuncture did not have a significant effect on pain or in the degree of sick leave compared with nonpenetrating sham acupuncture.

Once again, our interest lies with the acupuncture points that were used. They are as follows: Henggu (KI 11), Zusanli (ST 36), Baihui (GV 20), Guanyuanshu (BL 26), Ciliao (BL 32), Zhongliao (BL 33), Zhibian (BL 54), Kunlun (BL 60), Huantiao (GB 30) and Hegu (LI 4). Lund I, et al[14]conducted a study of pregnant women who experienced low back pain and/or pelvic pain. The purpose of the study was to examine the effects of two alternative modes of acupuncture stimulation (superficial and deep) on perceived pelvic pain in late pregnancy. The inclusion criteria included gestational age from 22-36 weeks and they had to be in pain for more than two weeks. Pain on the VAS scale had to be above 60. The acupuncture sessions were given twice a week for five weeks. The duration of the treatment was 30 min. For each treatment, 10 classical points were selected for stimulation and chosen based on the site for pain. The points selected were Xiaochangshu (BL 27), Pangguangshu (BL 28), Zhonglüshu (BL 29), Shangliao (BL 31), Zhongliao (BL 32), and Zhibian (BL 54), Henggu (KI 11), and Zhongji (CV 3) in combination with the peripheral points of Sanyinjiao (SP 6), Xingjian (LR 2), and Hegu (LI 4). They applied stimulation to three or four the Bladder points bilaterally based on the neurological innervation of the painful area. During superficial stimulation, shorter, thinner needles were used and left in place until the end of the treatment. For deep stimulation, thicker longer needles were inserted intramuscularly. The needles were stimulated five times during the sessions by manual twirling until the patients reported the qi sensations. The results showed that there was no sufficient change between the two groups, deep or superficial needling. The women did report significant changes in the pain intensity as well as the emotional reactions and loss of energy after treatment.

Guerreiro da Silva JB, et al[15]conducted a study to investigate the effects of acupuncture in low back and pelvic pain during pregnancy as compared with those using conventional treatment alone. Sixty-one conventionally-treated women were randomly divided into two groups to either receive acupuncture treatment or not. Thirty-four women were in the control group, and 27 women formed the study group. The women in the control group were given conventional treatment of 500 mg of an analgesic drug called Paracetamol and an anti-spasmodic drug called Hyoscine, 10 mg. There were no differences in the groups other than one receiving acupuncture treatment. The women ranged in age from 15-39 years and 15-30 weeks of pregnancy. Part of the inclusion process was that the women experience at least minimal low back or pelvic pain and they could not have been treated with acupuncture within the previous year. Women were also asked to evaluate their ability to perform general activities such as walking and working. Treatment was performed once per week and occasionally twice when there was severe pain over an eight week period. The women had between 8 and 12 treatments during the eight week period. What makes this study unique is that traditional acupuncture rules and classical points were applied. The qi was elicited at each point. There was no EA or ear acupuncture used in this study. On the average, 12 needles were inserted and left in place for 25 min. The most commonly used points were Taixi (KI 3), Houxi (SI 3), Shenmai (BL 62), Weizhong (BL 40), Waiguan (TE 5), Huantiao (GB 30), Zulinqi (GB 41) and the Jiaji (EX-B 2) points, which are a group of 34 points on both sides of the spinal column approximately 1 cm lateral to the lower border of each spinous process. The authors state that these points are located 1 cm from the midline. The control group was given Paracetamol and Hyoscine which is a common combination used at this particular obstetric unit. The results were that all 61 pregnant women completed the treatment and completed the interviews. There were no side effects from the acupuncture. Two women mentioned small bruises at one or two of the points and one woman mentioned that she experienced a higher level of pain a few hours after the session. The results in the acupuncture group were a clear reduction in pain while the control group values fluctuated around the same level. The average pain intensity decreased by 50% in 78% of the acupuncture group with only 15% of the control group. The acupuncture group took less Paracetamol than the control group. After treatment, the acupuncture group improved significantly in functional capacity. This is the only study where there is mention of the acupuncturist’s education. The investigator had 600 h of post-graduate training in acupuncture as well as theory and the practice of TCM. He had 15 years experience and treated 50 patients daily.

Kvorning N, et al[16]created a study to evaluate the analgesic effect and possible adverse effects of acupuncture for pelvic and low back pain during the last trimester of pregnancy. In this study, 72 pregnant women that reported pelvic pain or low back pain were randomized to an acupuncture group or control group. The acupuncture group (37) and the control groups (35) were between 24-37 weeks pregnant. Traditional acupuncture points and local tender points were stimulated once or twice a week until delivery or complete recovery. The control group was not given sham acupuncture. During the study, each patient utilized the VAS to evaluate their pain levels. The acupuncture group was given acupuncture according to written instructions and periostal stimulation used whenever possible. At first, Taichong (LR 3) and Baihui (GV 20) were used initially if the patient was nervous along with local tender points. If they did not get good response, additional points were stimulated. The following points were stimulated using a needle of 60 mm in length, Kunlun (BL 60), Houxi (SI 3) or one of the lumbar and sacral points. Other areas needled included the minimal gluteal muscle tendon 3-4 cm distal to the anterior superior iliac spine, the sacroiliac tendons (needled obliquely towards the distal part of the ligament or using needles of 25 mm in length at the symphysisneedled perpendicularly. The qi sensation was elicited on the first visit. On subsequent visits, manipulation of the needed stopped as soon as the qi was obtained but then repeated 30-60 s with the needle left in place between stimulations. The needles were removed and the patient was allowed to rest for 10 min. In the first two week period, acupuncture was given twice a week and then later no more than once per week. During the study, pain decreased in 60% of the acupuncture group and 14% of the control group. Two acupuncture and zero control group patients were found to be completely free of pain during their last 3 weeks of pregnancy. Pain associated with activity decreased in 43% of the acupuncture group and 9% in the control group. There were no side effects reported although 38% of the patients reported local pain, heat or sweating, local hematoma, tiredness nausea and weakness. An interesting note is that pain in the acupuncture group lasted significantly longer than in the control group whereas no differences in the duration of pain during the last 24 h. In this particular case, sham treatment was foregone in order to prevent additional stress on the pregnant women.

Ternov NK, et al[17]did a retrospective report on 167 cases of acupuncture for low back pain and pelvicpain in late pregnancy. An interesting note here is that one of the criteria was the patients be without history of infertility or spontaneous abortion. Each acupuncture patient was given at least two treatments with an experienced midwife who was specially trained. The following acupuncture points were chosen: Chengshan (BL 57), Kunlun (BL 60), Houxi (SI 3) and Taichong (LR 3), Yinlingquan (SP 9), Zusanli (ST 36), Yanglingquan (GB 34) and Hegu (LI 4). The points were stimulated manually at three 15 min intervals, achieved qi and were left about 45 min. Between 4 and 8 tender points were stimulated. The points most frequently used were Taichong (LR 3) and Hegu (LI 4) together with local points in the lower back and girdle regions. What is interesting with this case is that there were no major adverse effects except for one patient with premature labor which resolved itself within 24 h. This particular patient had been given acupuncture on five occasions from week 13 before the episode of premature labor during the sixth stimulation in week 15. She had no further stimulation and was delivered uneventfully in week 42. Painful uterine contractions, nausea, thirst, discomfort from needles, sweating, accentuated pain, and sadness were reported. Three women delivered before full term. This is the first study to mention the cautions expressed by traditional acupuncturists. It is also noted that for safety reasons, acupuncture was provided during the second and third trimester of pregnancy. It was felt that the adverse effects reported were non-obstetric except for the episode of reversible uterine contractions found in one patient.

The following three research reports represent single case studies where the investigator reported how the patient progressed. Rouse S[18]reported on a case study about the use of acupuncture in the physiotherapy treatment of pelvic pain. A patient presented at 24 weeks gestation with pelvic and low back pain. She also reported that fatigue had become an issue. Her initial assessment was 24/40 with mild soreness over the pubic symphysis. The pain radiated down her inner thighs and she felt a slight ache in her back. The symptoms were more pronounced in the evening. The patient had suffered severe pelvic pain in the third trimester of her first pregnancy and was looking to acupuncture as a preventative measure. She was advised to begin wearing a maternity belt and was given advice for stability exercises. She found it to be helpful. However, her VAS indicator went up from 2/10 to 8/10 in one month. The patient was a good candidate for acupuncture since she had no contraindications. She was treated with the following acupuncture points. First visit: two Ashi points and Lieque (LU 7) bilaterally for 15 min. The next session utilized the same points and time duration. The next session: two Ashi points over the pubic symphysis and Lieque (LU 7) bilaterally for 20 min duration. In weeks 4-9, the two Ashi points and two Ashi points over the pubic symphysis and Lieque (LU 7) bilaterally for 25 min. This patient responded well to the treatment and her VAS score went from 8/10 to 3-4/10. The qi was elicited on the acupuncture points. The treatments were biweekly. There were no adverse effects of the treatment.

Cummings M[19]reported the treatment of a patient (ASJ) who presented for treatment for an acute episode of pain which had been present for 13 d. She had not responded to osteopathic treatment. Pain centered on her low back but could radiate to the upper hip girdles, buttocks, posterior thighs and inner thighs. The pain tended to occur on one side or the other. The pain was a dull ache but became sharp with some movements and was burning in nature after sitting for more than 15 min. It was made worse by sitting and was relieved by ice and light stretching. At this time, she was married but had no children. The treatment included direct needling to the tender muscles, assessment of the response and possibly adding EA. Four tender sites were manually needled with strong stimulation for about 10 s. The needles were left in place for 20 min. At the one week follow-up, she reported significant improvement for 5 d. Second treatment involved strong manual needling to symmetrical points in the quadratus lumborum and gluteus medius. Six points were needled for 5 s only. At the next visit, she reported post needling soreness for 24 h and then marked improvement. He continued to see ASJ and on her 7th treatment, she told him she was pregnant. When they confirmed the dates, he realized that he had been treating her during the early stages of her pregnancy. After he explained the risks to her, she decided to continue with pregnancy. She received 18 treatments during pregnancy without adverse effects. She had facet joint pain and it caused myofacial pain and leg length inequality. She delivered at term without incidence. This is a very interesting case due to the depth of needling that was done. The periosteal needling of the facet joint was the only relief this patient had been able to find. He needled to a depth of 55 mm. She continued treatment through her pregnancy since she had already had six treatments. This was the only relief she had been able to achieve out of all the modalities she sought.

Forrester M[20]treated a 21 year-old woman of 24 weeks pregnant who had been in a car accident and suffered from back pain. Dachangshu (BL 25) was gently needled bilaterally for one minute with Serin No.5. At her second treatment, she complained of a little more back pain, and then Shenshu (BL 23) bilaterally were added for 5 min. A week later, she reported that her back pain was better and only gaveher trouble if she sat or stood for too long of a period of time. At her fifth treatment, she was 27 weeks pregnant and reported her back pain was a little better but was experiencing worse leg pain. So, Chengshan (BL 57) bilaterally were added for 20 min, and she reported back that her back was a lot better. Then Jiaji (EX-B 2) points at the L2and L4levels bilaterally were needled for 20 min. This patient did not suffer any side effects.

2.1.3 Acupuncture for labor induction

Much of the research has shown how the forbidden points have been utilized in lower back pain in pregnancy without incidence. It is interesting to note that forbidden points have also been instrumental in the induction of labor. The next section will show the acupuncture points used for induction and which ones coincide with the forbidden point category.

The first study conducted by Tsuei JJ, et al[21]represented one of the earliest studies in the American literature. During a four month period, 12 patients had labor induced by using manual acupuncture and electrical stimulation. The ages of the patients ranged from 23 to 42 years; three were primiparas and 9 were multiparas. The gestational period varied from 19-43 weeks. Five patients had indications of stillbirth. The other patients were induced because they were overdue according to their menstrual history. None of the patients had uterine contractions prior to induction of labor. Bilaterally Hegu (LI 4) and Sanyinjiao (SP 6) were used. The needles were then connected to an electrical stimulator at a frequency of 5-9 Hz with an intensity of 5-9 V. The intensity was increased until the patient could feel the current but was not in pain. In 7 successful cases, the average time was 13 h and 6 min. In most of the cases labor was assisted with the electrical stimulation. The results were that in every case, uterine contractions occurred as soon as the patient experienced qi sensation. The contractions continued irregularly without change before or after the beginning of cervical dilation. In the cases of the stillbirths and missed abortion, 3 were successful with an average labor of 10 h and after two or three attempts, 2 were delivered the following day by Oxytocin drip. Primiparous women had an average of 26 h and 12 min of labor and the multiparous group had an average of 8 h and 44 min.

Harper TC, et al[22]conducted a study where women were only eligible if they were nulliparous and between 39 and 41 weeks of gestation with a singleton, vertex fetus. 56 women were randomized to receive acupuncture along with routine medical care (30) or to be in the control group and receive medical care alone (26). This was not a blinded study. Acupuncture treatments were given on three out of 4 consecutive days. Each visit consisted of continuous electronic fetal hear rate monitoring and external tocometry during treatment. The acupuncturist was trained in TCM. The acupuncture points used were Hegu (LI 4), Sanyinjiao (SP 6), Shangliao (BL 31) and Ciliao (BL 32). Low electrical stimulation was used for bilateral Shangliao (BL 31) connected to Ciliao (BL 32) with a current at 2 Hz during the 30 min treatment. All women completed their treatments except one. The results showed the time from enrollment to delivery was 21 h shorter for the acupuncture group but not statistically significant. Spontaneous labor occurred in 70% of the women in the acupuncture group but only in 50% of the control group. 17% underwent cesarean delivery in the acupuncture group while 39% in the control group had cesarean delivery. This study did not yield a statistically significant difference between the two treatment outcomes. However, there were a couple of important items to be noted. First, the women randomized to the acupuncture group delivered 50 h earlier than those in the control group. Additionally, there were more women who went into labor spontaneously in the acupuncture group and had a three-fold decrease risk of cesarean section than in the control group. The final conclusion of this study was that it could not prove or disprove if acupuncture was effective in initiating labor in nulliparous women at or near their due date. However, it did demonstrate that the efficacy of acupuncture for the initiation of labor was feasible. It was felt that a larger sample size and a sham acupuncture comparison were needed.

The next study is a double-blind, randomized controlled study in which Modlock J, et al[23]investigated whether acupuncture was effective in the induction of labor in post-term pregnancies. 125 healthy women at 41 weeks gestation were randomized into two groups. The acupuncture group received acupuncture twice on the same day at the following points Baihui (GV 20) and bilaterally at Hegu (LI 4), Sanyinjiao (SP 6), and Zhiyin (BL 67). The control group received sham acupuncture at the same points. The women were given 24 h after randomization. The goal was either labor or delivery. The result was that 7 women in the acupuncture group and 8 women in the control group reached goal. The conclusion of this study was that acupuncture for induction of labor at 41 weeks may not be effective.

In a study completed by Smith CA, et al[24], 364 women were randomly assigned to the trial: 181 women in the acupuncture treatment group, and 183 in the control group. The goal was to determine the clinical effectiveness of acupuncture to induce labor. Two sessions of acupuncture using local and distal points was administered 2 d prior to scheduled medical induction. Acupuncture did not reduce theneed for induction methods or the duration of labor for women with post-term pregnancy. This study did not mention which acupuncture points were used.

Rabl M, et al[25]conducted a study in which 45 women were evaluated. Twenty five were in the acupuncture group and 20 women were in the control group. Inclusion criteria were a confirmed date of confinement, uncomplicated pregnancy, singleton pregnancy in cephalic presentation. Exclusion criteria consisted of active labor premature rupture of the membranes, previous cesarean section, and pathology in the mother or fetus. The women received bilateral acupuncture every 2 d at Hegu (LI 4) and Sanyinjiao (SP 6). Cervical status was assessed according to the Bishop score and a fetal Fibronectin test. If a woman had not delivered 10 d after the estimated day of confinement, labor was induced by vaginal prostaglandin tablets. The results from this study showed that the cervical length in the acupuncture group was shorter than that in the control group on day 6 and 8 after the estimated date of confinement. The acupuncture group showed the time period from the first Fibronectin test to delivery was 2.3 d and the control group was 4.2 d. The average time period from the estimated date of confinement to delivery was 5 d for the acupuncture group and 7.9 d in the control group. Oxytocin was used in 56% of acupuncture control cases and 65% in the control group. The results were that Hegu (LI 4) and Sanyinjiao (SP 6) support cervical ripening at term and can shorten the time interval between the estimated time of delivery and actual delivery.

Gribel GP, et al[26]conducted a study to compare the effects of using acupuncture or Misoprostol, an exogenous prostaglandin, to induce labor. In this study, 72 pregnant women were randomly distributed into two groups. The selection included women who were post-term, prelabor rupture of membranes, normal term pregnancy and controlled diabetic pregnant women. The acupuncture group (35) received EA at Hegu (LI 4), Sanyinjiao (SP 6), Taichong (LR 3), Shenshu (BL 23), and Ciliao (BL 32) every 7 h in a 24 h period. The points were bilaterally stimulated at alternating pulses of 5 and 50 Hz every 7 pulses. The Misoprostol group (32) received 25 mg every 6 h, up to 4 tablets in a 24 h period. The success of the procedure was determined by vaginal delivery within 24 h. Labor was induced in 74% of the acupuncture group compared with 53% in the Misoprostol group.

The last study to be discussed is Dunn PA, et al[27]where 20 post-date pregnant women were assessed in a controlled experimental format. The women were randomly assigned to either an acupuncture group or placebo group. The acupuncture group had EA at Sanyinjiao (SP 6) and Taichong (LR 3) and the placebo group had equipment attached but never activated. The frequency and length of uterine contraction was monitored for 1 h prior to stimulation and the last 2 h of a 4-hour test period. The results showed that there was a significant increase in the frequency and strength of uterine contractions in the acupuncture group.

2.2 Results and data overview and analysis

Analyzing the data collected for the current study, it was evident that the answer to the question ‘what are the forbidden acupuncture points?’ depends on the author or book/article reviewed. Of the six major texts that address the issue of forbidden points, a total of 13 points were observed as being designated as forbidden points. Across the six authors, the number of points designated as forbidden ranged from two to six points. However, only one of the thirteen points [Hegu (LI 4)] is common across all six authors. A second point [Sanyinjiao (SP 6)] was observed to be designated as forbidden point for five of the six authors, and another one [Jianjing (GB 21)] was designated by three of the six authors. Given the emergence of the data summarized above, the current authors observe that there is little consistency in documenting exactly what are the forbidden acupuncture points.

2.2.1 The use of forbidden points in pregnancy

Are the forbidden acupuncture points safe to use in pregnancy? According to the data generated in some research studies, the use of the forbidden points may be safe. However, it is important to consider the source of the research. We must keep in mind the perspectives of Western medical acupuncture physicians, who, by definition, discard many of the traditional points of view. Silva AV, et al[6], who questioned the existence of forbidden points, and in the research on Wistar rats, did not address uterine muscle contraction as a result of acupuncture. Liu JL, et al[7]initiated a more complete study wherein the myo-electrical activities with acupuncture were measured. The comparability of rat studies to human pregnancy must be studied further.

2.2.2 Mechanism of action of acupuncture for low back pain in pregnancy

What is the mechanism of action of acupuncture that either promotes or inhibits the use of forbidden points for low back pain in pregnancy? From the research data observed, there are two perspectives that emerge regarding the mechanisms of action of acupuncture. There are studies that show that many of the points designated as forbidden points, may be applied with beneficial results for pain management. Nonetheless, the question remains regarding how acupuncture points that have a positive impact on pain affect a pregnant woman. Pregnancy encompasses its own physiology[28]. As a result, thisquestion cannot be definitely resolved from the data generated in the current study. Considerably more investigation is warranted. From a neuroanatomical point of view, some of the mechanisms of action of acupuncture are so diverse, that they elude modern day science.

2.2.3 The use of forbidden points in induction of labor

How can forbidden points be used in low back pain and also in induction of labor without consequence? The data collected from the current research appear to indicate that if a woman’s body is not biochemically and hormonally ready to go into labor, acupuncture will not be effective in relieving low back pain or in inducing labor. The current study included a systematic review of ten research articles that pertained to the use of acupuncture to relieve low back pain during pregnancy. Of the ten studies reviewed, three of the articles[18-20]used single person case study methodology. The other seven studies represented results from a total of 874 patients with six of those seven studies[11-16]generating data from some level of randomized controlled investigation. Across the studies, the number of acupuncture treatments ranged from six treatments to eighteen or more. It is impressive to note that nine of the ten studies reviewed reported outcomes indicative of the fact that acupuncture can be an effective treatment for low back pain during pregnancy[11,13-20].

There are some studies that show acupuncture can be used for cervical softening. In the current study six research articles specifically explored the use of acupuncture to induce labor or to facilitate the ripening of the cervix. Five of the six articles represented research generated using randomized controlled methodology[22-25,27]. Across those studies, the indices of outcome ranged from measurements of the strength of contractions, frequency of contractions, cervical measurements and overall labor/delivery time, five of the six studies demonstrated noticeable differences regarding the variable targeted as the index of outcome[21-22,24-25,27]. Because of the range of variables used as the outcome measurement, the question as to whether acupuncture can be used for cervical softening or labor induction remains unresolved. As a result, again, further research regarding this question needs to be accomplished.

2.2.4 Development of acupuncture theory

Is it time for acupuncture theory to be updated based on current scientific research? This question is also one that further emphasizes the need for additional research. Until such time that traditional acupuncturists and Western medical acupuncture physicians can work together to design research models that address both sides, the current researchers do not believe it is time to change acupuncture theory. The research regarding acupuncture at the forbidden points studied Wistar rats and their comparative biochemical parameters[6]. It was the work of Liu and associates which utilized an electrohysterogram with a bipolar stainless steel electrode that was inserted into the sub-perimetrium layer of the rat uterus to determine myoelectrical activities of the uterus in relation to acupuncture[7]. The level that those studies can be directly applied to humans is not entirely clear. Future studies need to examine the effects that acupuncture at specific sites has on the contractility of the uterus.

3 Discussion

Based on the research data generated in the course of preparing this document, the one overriding conclusion is that more specific research needs to be brought forward by TCM acupuncturists and Western medical acupuncture physicians. At this point, the current researchers believe the literature is somewhat one-sided because of the limited exposure to orthodox traditional Chinese medical theory that Western medical acupuncture physicians receive.

There are many people involved in the professional practice of acupuncture. Some are trained traditionally and some are not. When women come for acupuncture for low back pain during pregnancy, they are entrusting the practitioner with their bodies, their babies and their futures. It is up to practitioners to have sufficient knowledge and tools to deal with all facets of pregnancy in order to provide optimal service to our patients. As practitioner/scholars acupuncturists with advanced credentials and specialty experience should be encouraged to engage in careful research regarding the use of the forbidden points. Such research should start with those forbidden points that are less frequently designated in the literature. For example, only two of the six works that address the forbidden points designate the points, Shimen (CV 5), Xiawan (CV 10), Kunlun (BL 60) and Zhiyin (BL 67). Such research should begin with retrospective case studies of women who were pregnant and who were treated for pain conditions with acupuncture at the Shimen (CV 5), Xiawan (CV 10), Kunlun (BL 60) and Zhiyin (BL 67) points. If such retrospective studies manifest no strong contraindications, the path of research should be taken to the next stages of carefully monitored concurrent case studies, and thereafter to more advanced controlled studies regarding those and other points designated as forbidden.

The primary limitations of the study are based on the range of the research and other documents articles reviewed. While the researcher was thorough and comprehensive in her search for relevant studies,she is also aware that the concept of forbidden points is one that originated in the ancient texts and traditions of TCM, and that much of the nuances of the theory and practice relating to the forbidden points may not have been fully discerned, since only English language resources were utilized for the current study. For the current study, as with many other TCM research studies, the issue of ‘lost in translation’ is a real factor that must be considered. Secondly, the researcher believes that some data pertaining to the forbidden points is obscured because of the continuing rift between what the current researchers term as ‘orthodox’ TCM practices and the practices of Western medical acupuncturists. Without a doubt there remains a chasm of theory and practice tenets between those two groups. We will not be able to derive consistent and reliable data from writing, and research until we can truly integrate Eastern and Western thinking in medicine.

TCM doctors and Western medical acupuncture physicians should work together toward a common goal. Acupuncture is a powerful medicine that has been handed down by both oral and written traditions through the ages. The current researchers do not believe that at the present time can be so arrogant as to think that we have all the answers at this time. As the body of anecdotal and evidence based research develops further, it is in the best interests of our patients to provide them with a concise, cohesive, and proven medicine that benefits everyone.

4 Prospect

Consistent with the comments made above, further research might include the following:

More careful review of ancient texts to discern the perspective of the founders of TCM regarding the existence of and precautions to be taken in the use of acupuncture on the forbidden points during pregnancy.

Additional retrospective case studies that either rule out or confirm the authenticity of the several forbidden points that are designated less frequently in existing contemporary texts.

Subsequent to preliminary retrospective studies, concurrent carefully monitored case studies that focus on the use of one or more of the forbidden points during pregnancy.

A systematic study of state acupuncture board practice complaints to discern if any pertain to the use of any of the forbidden points during acupuncture, including a careful examination of the alleged damages resulting.

The existence of the forbidden acupuncture points that should be avoided during pregnancy remains a question left to further and more systematic research. The perspectives of mainstream TCM practitioners and researchers are likely to differ somewhat from the perspectives of the Western medical acupuncture community. Until TCM and Western medical acupuncture practitioners and researchers can achieve a common ground regarding their practice and research procedures, the questions posed in this research study are likely to remain unresolved.

Conflict of Interest

The authors affirm that there exist no conflicts of interest that would in any way bias the collection of data/information or interpretation of the results of this study.

Acknowledgments

This article is based on a Capstone Project submitted by Debbie R. Rodriguez in partial fulfillment of the requirements for the Doctor of Acupuncture and Oriental Medicine Degree at Yo San University Los Angeles, California in April 2013. Lawrence Ryan served as the advisor for the dissertation and edited the document for publication submission.

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Lawrence J. Ryan, M.D.

E-mail: lryan@yosan.edu

R246.2

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Date:January 14, 2014