Volume 6, Number 2 | Summer 2011

Clinical Report 1 (Acupuncture)
Two Cases of Low Back Pain in Pregnant Women Relieved
Using Low Acupuncture and Moxibustion Stimulation Dose
Evaluated with VAS and RDQ

Yoshihiko Koido1), Keiko Tsujiuchi1), Shuichi Katai2)
1) SERIE WOMEN’S HEALTH CARE
2) National University Corporation of Tsukuba University ofTechnology, Faculty of Health Sciences,
Acupuncture and Moxibustion specialist course

acupuncture and moxibustion treatment for low
back pain during pregnancy using only lightstimulation.
[Cases]In this study 2 pregnant women with the chiefcomplaint of low back during the later half of theirpregnancy visited an acupuncture and moxibustion[Introduction]
Katai et al. reported that they used in Japan needles
with a diameter of 0.16 mm for the acupuncture andmoxibustion treatment of low back pain during
pregnancy, inserting and retaining those into
reactive sites verified through palpation to a depthof about 5 mm, thereby achieving definite results1).
On the other hand, multiple RCTs conducted abroadshow a tendency that relevant evidence is about tobe clarified2). However, Lund et al. reported in 2006
that the comparison of the effects obtained in a deep
needling group treated using the common deep
insertion and a shallow needling group, where thinneedles were inserted only superficially showed, thatboth treatment forms led to pain relief and nodifference in the effectiveness could be found3). Afterthat no further reports examining the effectivenessof acupuncture and moxibustion treatment using alighter than the usual stimulation are found.

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clinic in a city on the outskirts of Tokyo with apopulation of 3.7 million.
Case No.1 was a multipara 29 weeks and 6 days
pregnant with a single fetus, who complained of painin the left buttock. Her age was 33 years, height 159
cm, weight 51 kg, weight before pregnancy 46 kg,
BMI 18.2, weight increase was 5 kg and she had ahistory of low back pain (Figure 1).
Case No. 2 was a primapara 28 weeks and 2 days
pregnant with a single fetus, who complained of painin the right buttock and the development of pain on
the outside of the right lower leg associated with adiffuse feeling of discomfort upon walking for about
10 minutes. Her age was 33 years, height 154 cm,
weight 56 kg, weight before pregnancy 47 kg, BMI
19.82, weight increase was 9 kg and she had ahistory of low back pain (Figure 2).

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Age: 33 years
Height: 159 cm
Weight: 51 kg
Weight before pregnancy: 46 kg
BMI before pregnancy: 18.20
Weight increase: 5 kg
Gestational week: 29th week +6 days
Single fetus
Multipara (1 delivery)
LBP history: yes
Blood pressure: 102/60 mmHg
Blood pressure before pregnancy: 98/58
mmHg○ indicates on a body surface map the painful
Figure 1: Profile of patient No. 1

6

Accordingly, this study investigates the effects ofAge: 33 years
Height: 154 cm
Weight: 56 kg
Weight before pregnancy: 47 kg
BMI before pregnancy: 19.82
Weight increase: 9 kg
Gestational week: 28th week + 2 days
Single fetus
Primapara
LBP history: yes
Blood pressure: 100/60 mmHg
Blood pressure before pregnancy:
100/60 mmHg

○ indicates on a body surface map the painful
Figure 2: Profile of patient No. 2

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 2 | Summer 2011

Table 2: Treatment[Methods]
In both cases the trunk ROM test and sacroiliac
stress test were performed as physical examination.
Since patient No. 2 complained in addition to thepain in the right buttock about right lower leg
symptoms, additionally sensory and muscle tests
and the sciatic nerve stretch test were performed,
deep tendon and pathologic reflexes and Kemp's sign
checked as well as arterial pulses palpated4-6) (Table
1).
Table 1: Physical examination

Acupuncture treatment
Used needles: length = 40 mm x diameter 0.14 mm
Stainless steel needles
Insertion depth: 3-8 mm
Insertion method: singular insertion, needle
retaining (about 10 minutes)
Moxibustion treatment
Used moxa: stick moxa
Heat dose: so that the patient experiences it ascomfortable
Stimulation duration: 2-5 minutes
Other: hot packs, far infrared irradiation

First visit

Lordosis, kyphosis

Trunk range of motion

Anteflexion (finger-floor distance), retroflexion,

Under constant observation about 5 to 10

lateral bending, rotation

acupoints were selected from among Inkokku

Sacroiliac joint stress

Gaenslen test、Patrick test

(KI10,

test

Newton test (compression test, distraction test)

Fukuryu (KI7, Fuliu), Taikei (KI3, Taixi),

Sciatica

Straight leg raising test (SLR test)

SuisenMuscle testing

Quadriceps femoris, anterior tibialis, extensor
hallucis longus, flexor hallucis longus muscles

Deep tendon reflexes

Achilles tendon reflex, patella tendon reflex

Pathologic reflexes

Babinski reflex

Intermittent

Neuronal (Kemp sign）

claudication

Vasal (artery palpation: dorsal artery of the

Yingu),(KI5,

Yongquan),

Chikuhin(KI9,

Shuiquan),

BokushinZhubin),Yusen(BL61,(KI1,

Pushen),Taihaku (SP3, Taibai) and around the regionof the chief complaint, or else into reactive
spots marked by coolness, dampness, lack of
power, muscle tension (Table 3).

foot, posterior tibial artery)
Palpation

Tenderness, percussion pain

For the acupuncture treatment 40 mm stainlesssteel needles with a diameter of 0.14 mm were usedand either singularly inserted to a depth between 3
and 8 mm or else retained for about 10 minutes.
For the moxibustion treatment moxa sticks wereapplied for 2 to 5 minutes to the extend, that patient
experienced the heat as comfortable. Hot packs andfar infrared irradiation were also applied as required(Table 2).

Table 3: Used acupoints
Used acupoints
Inkokku (KI10, Yingu), Chikuhin (KI9, Zhubin),
Fukuryu (KI7, Fuliu), Taikei (KI3, Taixi),
Suisen (KI5, Shuiquan), Yusen (KI1, Yongquan),
Bokushin (BL61, Pushen), Taihaku (SP3,
Taibai), around the region of the chief complaint
Reactive spots marked by coolness, dampness,lack of power, muscle tension.
Selection of a total of 5-10 points.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 6, Number 2 | Summer 2011

For the evaluation we used a pain scale and a Visual
Analogue Scale (below abbreviated VAS) as well as
the lumbago specific QOL scale Roland-Morris
Disability Questionnaire (below abbreviated RDQ).
The VAS was implemented before each treatment
and the RDQ during the first visit and 5 weeks later
before treatment (Table 4).
Table 4: Evaluation method and measurements

Evaluation method
Pain scale: Visual analogue scale（VAS）100 mm
Lumbago specific QOL scale: Roland-Morris
Disability Questionnaire（RDQ）
Measurement
VAS: before each treatment
RDQ: during first consultation and 5 weeks later
before treatment

The VAS was recorded as a 100-mm long line on thequestionnaire marked "no pain" on one end and"maximal pain" at the other end. The patientsthemselves marked the degree of pain on this line
and this position was then measured from 0 mm,
using the obtained numerical value as pain
evaluation8).
The RDQ is an evaluation method using aquestionnaire inquiring after the presence of low
back pain induced disability through 24 questions
pertaining to daily life activities like "stand", "walk","dress" etc., which the patients answer directly witheither yes or no. It is used widely worldwide andexpected to be employed for studies of therapies andlow back pain related factors9) (Figure 3). For an
evaluation using the RDQ a score between 0 and 24
points is obtained and increasingly higher scores

Figure 3: Main RDQ items[Results]
Multiple sacroiliac joint stress tests showed inpatient No. 1 positive results and in the region of thechief complaint tenderness was also found. In
patient No. 2 the lordosis of the spine was mildly
pronounced and anteflexion slightly restricted.
Although the straight leg raising test was both on
the left and right negative, elevation on the rightside to close to 70° elicited pain on the posterior sideof the thigh. On the right side lateral to theinterspinous spaces L3 to L5 and on the rightbuttock tenderness was found. However, the borderof the region of slightly decreased sensation was
indistinct and no anomalies were found for muscle
strength, deep tendon reflexes, pathologic reflexes
and similar neurologic tests. Moreover, arterial
pulses could be palpated (Table 6).

indicate a more severe impairment of daily life andlow back pain induced reduction in QOL (Table 5).

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 2 | Summer 2011

Table 5: All 24 RDQ items and evaluation
1

Spend most of the time at home because of low back pain

13

It hurts almost always

2

Frequently changes body position to alleviate the low back pain

14

Turning over in bed is difficult because of the low back pain

3

Walk slower than usually because of low back pain

15

Has little appetite because of the low back pain4

The usual house chores cannot be done at all because of low back pain

16

Have difficulties wearing socks or stockings because of the
low back pain

5

Uses handrails to climb stairs because of low back pain

17

Take care to walk only short distances because of the lowback pain

6

Spend more time resting by laying down because of the low back pain

18

Does not sleep well because of the low back pain (Please
select "Yes" under "Use sleeping pills because of the pain")

7

Cannot get up from an armchair (a chair supporting the body for
comfortable sitting, sit deeply back in a chair) without holding on tosomething because of the low back pain

19

Ask someone for help with the dressing because of the lowback pain

8

Sometimes ask people for help because of the low back pain

20

Spend most of the day sitting because of the low back pain

9

Dressing takes longer than usual because of the low back pain

21

Take care not to exert oneself when doing the householdchores because of the low back pain

10

Take care to stand only for short periods of time because of the lowback pain22

Get more easily irritated or angry at others because of the
low back pain

11

Take care not bend from the waist or kneel because of the low back
pain

12

Have difficulties of getting up from a chair because of the low back pain

Climb stairs slower than usual because of the low back pain

24

Spend most of the time in bed (futon) because of the lowback pain

Evaluation method: Assigning scores between 0 and 24 points. The higher the score the higher is the degree of daily life impairment,
indicating a decrease in QOL because of the low back pain.

Table 6: Results of the physical examination
Case No. 1

Case No. 2

Lordosisn.p.

mildly pronounced

Trunk ROM
anteflexion (fingerfloor distance)n.p.

n.p.（30 cm）

Gaenslen test

both left and right（－）

both left and right（－）

Newton test (compression test)

left （＋）

both left and right（－）

Newton test (distraction test)

both left and right（－）（－）

both left and right on the left（＋）

both left and right（－）

Patrick testright （－）

Straight leg raising test (SLR test)

Tenderness,

percussion pain（－）at 70° pain is triggered on the posterior side of
the thighTenderness around the left
sacroiliac joint

Tenderness to the right of the spaces between the
spinous processes of L3～L5 and on the right buttock

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

9Volume 6, Number 2 | Summer 2011

1) Case No. 1 (Graph 1)
Gestational weeks are plotted on the abscissa of the graph, while the ordinate shows on the left side theRDQ score and on the right side the VAS value. In patient No. 1 the RDQ score decreased from 12 to 5
points and the VAS of 46 mm also gradually decreased to reach 5 weeks later 20 mm.
Also, the nocturia of once per night reported during the first visit had decreased by the second visit to 0
times. During the daytime the urinary output per micturition increased, the drooping abdomen became
firm, appetite improved, fatigue decreased and the complaints improved.

Graph 1: Course of patient No. 1

1st visit

2nd visit

3rd visit

4th visit

5th visit

6th visit

2) Case No. 2 (Graph 2)
In patient No. 2 the RDQ score of 16 points obtained during the first visit decreased 5 weeks later, at a
gestational age of 33 weeks + 3 days, to 0 points and the VAS of 74 mm gradually decreased to 0 mm. The
straight leg raising test that induced pain during the first visit upon elevation to 70° on the posterior sideof the thigh, but after the third visit this maneuver elicited pain any longer even at an angle of more than
90°.

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 2 | Summer 2011

1st visit

2nd visit

3rd visit

Graph 2: Course of patient No. 2

4th visit

5th visit

6th visit

2) Pathology
Low back pain during pregnancy may conceivably

Further, the nocturia of once per night reportedbeduring the first visit decreased to 0 and the patient

lumbodorsal muscles due to the increase in body

could sleep well. The sensation of cold of theweight, influence on posture because the enlarging

abdomen and feet had been replaced by warmth etc.

uterus shifts the center of gravity forward (postural),and otherwise similar improvements of complaints(2) loosening of pelvic ligaments around thelike in patient No. 1 were observed.

sacroiliac joint or the pubic symphysis through thecausedby(1)

increasedburdenontheaction of sex steroid hormones or relaxin may[Discussion]increase their mobility of these joints, resulting in

1) Clinical picture of low back pain during

an instability of the pelvic ring (pelvic ring

pregnancy

instability), (3) pregnancy induced increase in body

A Japanese study showed a prevalence of 50-70% forweight and changes in posture may place severe

low back pain during pregnancy. The pain occurs

stress on latent intervertebral disc degeneration

first either during early gestation or the second

and thus can cause a lumbar intervertebral disc totrimester and reportedly tends to get worse during

prolapse (lumbar intervertebral disk herniation)

the course of the pregnancy. Most cases are(Table 7). As opposed to the non-pregnant statecomparatively mild, but severe cases of low backthere are limits to x-ray, CT or MRI imaging or

pain

restricting

significantly

activities

decreasing

daily

the

QOL

livingandphysical examinations that can be performed during

are

also

pregnancy, so that the differential diagnosis is madeobserved10-14).

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 6, Number 2 | Summer 2011

relying on anamnesis and a minimum of physicalexamination15).
Surmising the pathology from the anamnesis andSocialfactors

physical examination the condition in patient No. 1

psturalwas considered to be due to pelvic ring instability
and that in patient No. 2 a postural lumbago.
However, low back pain treatment in recent years

Psycholo
gicalfactors

Biologicalfactors

Unknown

has shown, that not only biological factors, but alsosocial and psychological factors may be involved16).
causedbythepregnancymanyfactorslmbar
intervertebral
disk herniation

Others

Before the background of physiological changes

plvic ring
instability

areconsidered to contribute to low back pain during
pregnancy, but the details of the condition are not

Figure 4: Factors for low back pain during pregnancy

yet clear (Figure 4).
Table 7: Biological factors for low back pain during
pregnancy
PosturallumbagoPelvic ring
instability

Lumbarintervertebral
disk herniation

Increased burden on the lumbodorsal
muscles due to an increase in bodyweight.
Then enlarging uterus shifts thecenter of gravity forwards and thus
influences posture.
The action of sex steroid hormones orrelaxin loosen pelvic ligaments of thesacroiliac joint and pubic symphysis,
thereby increasing their mobility,
resulting in pelvic ring instability.
The pregnancy induced increase inbody weight and changes in posture
may place severe stress on latentintervertebral disc degeneration andthus can cause a lumbar intervertebral
disc to prolapse.

3) Acupuncture treatment
The acupuncture treatment for low back pain
conceivably uses local treatment of the affected
region, or else distant treatment sites exploiting
channel sinews or channels. Lund compared the useof needles with a diameter of 0.3 mm to needle 3-4
points (on both sides) on the bladder channel with astimulation dose strong enough to obtain theneedling sensation for his treatment of a deep
needling group and needles with a diameter of 0.2
mm inserted only superficially into the same sites tobe retained there for the shallow needling group andfound, that pain was alleviated in both groups andreported he did not find any differences in theeffects3). (Table 8)

Table 8: Comparison of the treatment by Lund et al. and Katai et al.
AuthorPublication year
Lundl et. Al 2006

Shallow needlinggroup

Shuichi Katai et al.
2003

Treatment site
Lumboscral
regionabdomen legs
arms
Diameter
0.2mm

Legs
(lumgosacral
region)Number oftreated acupoints
10-14(calculated)

Therapeutic
tools
Deep needlinggroup

Stimulation
methodDiameter
0.3mm

Insertion into the muscles, twirling,needling sensation

Insertion throughthe skinperpendicularneedling
Diameter
0.16mmRetaining the needles at a depth of about
5mm, until the needle tip is brought incontact with the reation*diameter 0.3 mm (No.8 needle), 0.2mm (No.3), 0.16mm (No.1 needle)
12

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 2 | Summer 2011

Both examined patients had apart from the chief

points. Conversely, in patient No. 2 the nature of thecomplaint

likepelvic pain dealt with by Ando et al. differed, but

abdominal distention, shoulder stiffness, chilling,

here too the RDQ score had decreased after 5 weeks

leg cramps, nocturia, fatigue etc. Thus, regarding

to 0 points and improvements in the QOL were

the acupuncture treatment we palpated withobserved.

reference to the report by Katai et al. relevant

Thus the use of thin needles formerly often treatedchannel sinews and channels and selected mainly

as placebo or sham acupuncture, provides areactive spots along those, using thin needles for

comfortablesingular insertion to a depth of about 3-8 mm or else

elsewhere than locally, it offers a little invasive

needle retaining. For the moxibustion treatment wetreatment and allowed to obtain patient satisfying

used stick moxa, applying it to the region of the chief

therapeutic effects.

many

indefinite

complaints

acupuncture

treatment.

If

used

complaint and the reactive spots on the legsconfirmed through palpation, adjusting the amountIn recent years clinical and physiological studiesof heat so that the patient experienced it aspertaining to the use of press needles tend to clearly

comfortable.

show that minimal stimulation elicits physiologicalactivation19-20).

Forfurtherdevelopmentsof

Watanabe et al. reported that their investigation ofacupuncture and moxibustion medicine in the future

general patients with low back pain showed forinvestigation

lumbago patients consulting medical facilities astimulation are considered to be required andRDQ score of 7.417). Comparing the score for thefurther research in this field anticipated.

intensity of pain due to pelvic pain and the

Likely many factors contribute to the development of

impairment of activity of daily life in the 28th andlow back pain during pregnancy, clinical symptoms

36th gestational week Ando et al. reported, that inare very diverse and there are patients in whom

spite of instructions pertaining to posture during

sufficient effects cannot be achieved. In conjunction

daily life, exercise for the expectant mothers andwith an elucidation of the pathology of low back pain

instructions in the proper use of pelvic belts the pain

during pregnancy the mechanisms of acupuncture

intensity did not vary and there was a high degree ofand moxibustion are also expected to be clarified in

impairment of activity of daily life18).

the future.

The RDQ scores of the investigated patients during

The evidence for acupuncture and moxibustion using

their first visit were 12 and 16 points respectively,

weak stimulation methods must be substantiated ineach of which being higher than the mentioned 7.4

the future through RCTs etc.

of

the

effectsof

low-invasive

points, so that the QOL of these patients had been
decreased by the low back pain.

[Conclusion]
The results of this study examining two patients

The physical examinations performed in this study

suggested, that acupuncture and moxibustion using

on patient No. 1 suggested pelvic pain and from thelow stimulation doses allows to alleviate the degree

start of the acupuncture and moxibustion treatmentof low back pain during pregnancy and possiblyin the 29th gestational week pain and impairment of

improve the QOL.

activity of daily life gradually began to decrease, sothat 5 weeks later the RDQ score had dropped to 5
The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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