Inspired by Nicolian et al 2019 and Vas et al 2019.[1,2]
Nicolian et al 2019 is the first paper to report a cost-effectiveness analysis of adding acupuncture to usual care of pelvic girdle and low back pain (PGLBP) in pregnancy. It was a pragmatic open randomised controlled trial with 2 parallel arms, and 200 women were randomised.
The trial was based in 5 maternity units in Paris between 2012 and 2014. Five sessions of acupuncture were provided by midwives, and the outcome was the proportion of days with self-assessed pain by numerical rating scale (NRS) ≤4/10. Cost-effectiveness was calculated from a societal perspective and considered only the time from inclusion to delivery. The incremental cost per day with NRS ≤4/10 was reported taking into account indirect non-healthcare costs including daily compensation for sick leave and productivity loss caused by absenteeism and presenteeism.
the term used for working while sick
it can cause productivity loss, poor health, exhaustion and workplace epidemicsWikipedia
Ninety-six women were allocated to acupuncture and 103 to standard care (total 199). The proportion of days with NRS ≤4/10 was greater in the acupuncture group than in the standard care group (61% vs 48%, p = 0.007).
I was surprised to see that the average total costs were higher in the control group (€2947) than in the acupuncture group (€2635) a difference of €-312 (95% CI: -966 to +325). This resulted from the higher indirect costs of absenteeism and presenteeism. Costs for the health system (employer and out-of-pocket costs excluded) were slightly higher for acupuncture as might be expected (€1512 versus €1452) a difference of €60 (95% CI: -272 to +470).
The cost of an acupuncture session in the protocol was valued using the average hourly wage of a midwife, €30.
The points used were principally around the pelvic girdle and low back plus points in the legs. Two sessions were performed in the first week followed by 3 sessions at weekly intervals. Sessions lasted 30 minutes, and the women were treated lying on their left side with cushions to ensure the position was comfortable.
We have known that there is a useful effect of acupuncture in pelvic girdle pain (PGP) in pregnancy since the landmark BMJ paper by Helen Elden. Unfortunately, Helen went on to try to answer critics of her first study by running a sham controlled trial using the so-called non-penetrating needle of Konrad Streitberger.[4,5] The study failed to discard the null hypothesis that there was no difference between real and sham needling, but Helen later commented to me that she often saw bleeding in the sham group, as it was very easy to penetrate the skin with the blunt telescopic needles. I subsequently found the same problem myself in a “Trust me…” experiment. She also commented that the effect in the real acupuncture group of her sham controlled trial was just as big as that in the original trial.
More good news though…
As I write this, another trial has popped up on PubMed. This one from an old friend of the BMAS – Jorge Vas. He is an irrepressible Spanish GP who does fabulous research as a hobby in his very limited spare time! He is also a very cool saxophonist dude.
Anyway, I heard him present a trial on ear acupuncture for lower back and/or posterior pelvic girdle pain (LBPGP) at the Spanish pain conference last year in Palma, Mallorca. He presented in Spanish and only had 20 minutes, so it was a bit quick for me to take it all in. I was wondering when it would hit the press, and the timing could not have been better.
In this paper midwives were the acupuncturists again – very sensible of course since they are likely to be the first point of contact for women with either PGLBP or LBPGP! But rather than 5 acupuncture sessions they only applied indwelling needles (Seirin Pyonex) in three points (Shenmen, Kidney and a reflex or reactive point related to the spine) and changed them after a week. The needles were in for two weeks in total. There were three other groups: the same needling in non-specific points (ankle, wrist and shoulder points); placebo devices with no needle; and standard obstetric care (advice, explanation and self-care techniques including use of simple analgesics).
The real ear acupuncture group was the only group to improve significantly when compared with standard obstetric care at the significance level adopted (p<0.005) – and no I have not included too many zeros there!
In conclusion, relatively brief acupuncture interventions performed by midwives appear to be both effective and cost-effective in pelvic girdle and/or low back pain in pregnancy.
1 Nicolian S, Butel T, Gambotti L, et al. Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: A randomized controlled trial. PLoS One 2019;14:e0214195. doi:10.1371/journal.pone.0214195
2 Vas J, Cintado MC, Aranda‐Regules JM, et al. Effect of ear acupuncture on pregnancy‐related pain in the lower back and posterior pelvic girdle: a multicentre randomised clinical trial. Acta Obstet Gynecol Scand 2019;:aogs.13635. doi:10.1111/aogs.13635
3 Elden H, Ladfors L, Olsen MF, et al. Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. BMJ 2005;330:761. doi:10.1136/bmj.38397.507014.E0
4 Elden H, Fagevik-Olsen M, Ostgaard H-C, et al. Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double-blinded controlled trial comparing acupuncture with non-penetrating sham acupuncture. BJOG An Int J Obstet Gynaecol 2008;115:1655–68. doi:10.1111/j.1471-0528.2008.01904.x
5 Streitberger K, Kleinhenz J. Introducing a placebo needle into acupuncture research. Lancet 1998;352:364–5. doi:10.1016/S0140-6736(97)10471-8