Physical Therapists' Views and Experiences of Pregnancy-Related Low Back Pain and the Role of

Acupuncture: Qualitative Exploration

Jackie Waterfield, Bernadette Bartlam, Annette Bishop, Melanie A. Holden, Panos Barlas, Nadine E.
Foster

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Abstract

Low back pain (LBP) in pregnancy with or without pelvic girdle pain (henceforth referred to as
pregnancy-related LBP) occurs commonly. Although prevalence estimates vary owing to different
definitions and diagnostic criteria, LBP is reported to affect 45% to 75% of women at some stage during
their pregnancy,1,2 with a point prevalence of approximately 34%.2 Studies have shown that women with
LBP who are pregnant have a lower quality of life compared with healthy women who are not
pregnant,3 and pregnancy-related LBP is a common reason for sickness absence, with reports suggesting
that 20% to 23% of women take sick leave because of their pain.2,4 Support to reduce the pain and its
impact, therefore, is important.

Women who are pregnant with problematic LBP most often report their pain to their midwife, yet few
receive much in the way of treatment for their pain.2 It appears that LBP is often accepted as the “norm”
in pregnancy.2,5 In addition, factors such as health professionals' lack of knowledge about treatments
and fear of harming the developing fetus5 may contribute to this lack of treatment. Most women are not
referred from their midwife, primary care physician, or obstetrician to other health professionals for
treatment but are instead advised to self-manage. Self-management includes advice on posture and
lifting, simple home exercises, rest, and use of supportive belts. Those women who are referred to
physical therapists may receive therapist-led exercise, manual therapy, acupuncture, massage,
transcutaneous electrical nerve stimulation, and mobility aids.2,5–7

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Physical Therapy and Acupuncture

The use of acupuncture for musculoskeletal problems is increasing8 and has been recommended within
recent UK national guidelines for the management of persistent nonspecific LBP.9 The 2 available
reviews that have evaluated acupuncture for pregnancy-related LBP7,10 both show promising evidence
for its effectiveness in reducing evening pain and morbidity. Among individual studies, a trial (N=72) by
Wedenberg et al11 showed that pain scores were significantly lower following acupuncture than
following physical therapy, although it was unclear if this difference was due to the mode of treatment
delivery (acupuncture was individually delivered, whereas physical therapy was delivered in a group
setting). In Kvorning and colleagues' study12 (N=60), the percentage of patients reporting reduced pain
intensity was significantly greater among those receiving acupuncture than among those receiving
standard prenatal care (60% versus 14%, respectively). Elden et al,13 in a trial involving 386 women who
were pregnant, concluded that acupuncture is a safe treatment during pregnancy, having found no
reports of major adverse effects on the pregnancy, mother, delivery, or the fetus or neonate, even when
acupuncture was administered with stimulation that may be considered strong. Additionally, Park and
colleagues' recent systematic review14 showed that when adverse events are classified as being as
certainly, probably, or possibly causally related to acupuncture, the incidence of such adverse events
was 1.3%, with the most common being needle pain.

Acupuncture is within the scope of UK physical therapists' practice,15 and the Acupuncture Association
of Chartered Physiotherapists is the largest clinical interest group of the Chartered Society of
Physiotherapy in the United Kingdom. As with any practice, there is a professional responsibility to
remain competent in both technical skills and practice knowledge. Those therapists who use
acupuncture mostly attend postgraduate training courses in which theory, empirical evidence, and
safety are addressed.16 However, physical therapists' use of acupuncture in the management of
persistent nonspecific LBP in the general population shows wide variation,6 and their perceptions of
acupuncture as an intervention for pregnancy-related LBP have not been explored.

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EASE Back Trial

The EASE Back (Evaluating Acupuncture and Standard care for pregnant womEn with Back pain) trial is a
partially mixed-methods, sequential feasibility and pilot trial with 2 distinct phases. Phase 1 was a
mixed-methods approach that included a national survey17 of current practice of UK physical therapists'
use of acupuncture and qualitative interviews with midwives, physical therapists, and women who were
pregnant. Phase 2 was the pilot randomized trial itself.

The overall aims of phase 1 were: (1) to understand current practice and (2) to increase the robustness
of phase 2. The specific aim of the interviews with the physical therapists was to explore their subjective
experiences and perceptions about their knowledge and current practices and the role of acupuncture
in pregnancy; this sought to identify potential barriers and facilitators that might have an impact on the
delivery of the intervention (phase 2). Phase 1 findings, therefore, were used to develop the training
program for participating physical therapists and the interventions for the trial itself. This report focuses
on the contributions that the interviews with the physical therapists made to these developments.

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Method

Design

As the aim of the qualitative interviews with physical therapists was to explore their experiences and
perceptions, we utilized an exploratory inductive approach. This approach was centered on Charmaz's
social constructivist grounded theory18,19 and phenomenology,20 allowing the complexity and diversity of
the real world of the physical therapists to be explored. Here, grounded theory methods are considered
“as a set of principles and practices, not as prescriptions or packages”20(p11) and, therefore, are seen as
“flexible guidelines, not methodological rules, recipes and requirements.”20(p11) In this approach, the
central feature is gaining insight into an individual's experience21 and how this insight may bring forward
new understanding of, and challenge previous assumptions22 around, the use of acupuncture in
pregnancy-related LBP. Therefore, in line with Moustakas20 and Guest et al,23 we took a pragmatic view
that sees no tension in applying a phenomenological epistemology to data collection (ie, exploring
subjective human experience) and extending this investigation into a grounded theory approach to
analysis, that is “grounding” the analysis inductively in the data and iteratively testing all propositions
and concepts against new data.

To achieve this aim, we adopted a purposive sampling strategy to ensure a range of experience and
perspectives.24 The lead researcher (B.B.), an experienced qualitative researcher, supported by other
members of the research team, undertook the interviews. For the focus groups, we recruited
participants from a teaching hospital and clinics local to the research center. Three focus groups took
place, each of 5 to 7 physical therapists of differing seniority and musculoskeletal clinical experience; all
participants were employed by the UK National Health Service (NHS). Two focus groups included
physical therapists working within community-based, musculoskeletal outpatient settings who utilized
acupuncture for musculoskeletal pain problems and would be referred women who are pregnant, and
one focus group included physical therapists from a Women's Health Service (based in an acute hospital
setting linked to a maternity center) who regularly treated women who are pregnant and have
pregnancy-related LBP. In addition, we invited 30 physical therapists to participate in in-depth,
semistructured individual telephone interviews. These were therapists who were experienced in both
acupuncture and treating women who are pregnant and had consented to further contact when
returning questionnaires (n=341 of 629) from the physical therapy national survey on the management
of pregnancy-related LBP.17 Interviews continued until data saturation was achieved. The 2 data
collection methods enhanced the rigor of the study,25,26 with focus groups allowing for breadth and
descriptions of the culture and social systems that the participants shared, and individual interviews
allowing for personal accounts to be developed, thereby adding completeness to the data.27

We developed an interview guide from the background literature and from the open responses from the
survey and pilot tested it in the first focus group and interview; on review, no changes were required,
and these data were included in the main study. The focus groups and interviews were digitally
recorded, lasted 45 to 60 minutes, and were undertaken by experienced researchers at a mutually
convenient time and place. At the end of all interviews, we summarized the main points and invited
participants to confirm, dissent from, or qualify this summary as a means of respondent validation.28

Ethical Considerations

For all participants, we provided invitation letters, information sheets, and consent forms fully
explaining the study and addressing issues of confidentiality and anonymity, with an opportunity to ask
questions at any stage. We gave all participants unique identification numbers to preserve their
anonymity.

Data Analysis

We adopted an exploratory thematic analysis within a constructivist grounded theory framework and
checked emergent findings in subsequent interviews in an iterative cycle.19,23 Initial analysis was
undertaken by the first author (J.W.), an experienced qualitative researcher and physical therapist, and
included a process of coding, categorizing, and developing themes for each focus group and interview.
The data from the interviews were then brought together; this process was not to aggregate the data
for a unified picture or to converge data to find a single conclusion but to seek different layers of
understanding.29 We explored relationships among themes and, where there were commonalities,
developed overarching themes. To enhance the credibility of the analysis, 2 other members of the
research team, who brought differing disciplinary perspectives to bear on the data (B.B., social science;
P.B., physical therapy and acupuncture), independently coded a random selection of interviews and
checked emerging codes for consistencies and deviant cases. We created an audit trail to ensure
transparency of the research process and the decisions made.30

Role of the Funding Source

The EASE Back study is funded by the National Institute for Health Research's (NIHR's) Health
Technology Assessment Programme. This article presents independent research funded by the NIHR
under its Health Technology Assessment (Grant Reference Number 10/69/05) and is supported by an
NIHR Research Professorship to Dr Foster (NIHR-RP-011-015). The views expressed are those of the
authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.

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Results

A total of 21 physical therapists participated, and their demographic characteristics are summarized in
the Table.

Table.

Characteristics of Participants

Several overarching themes emerged from the analysis. Two of these themes (and contributing
subthemes) were linked to the aims of this article—exploring physical therapists' experiences and
perceptions about their knowledge and current practices and the role of acupuncture in pregnancy—
and are presented below, using illustrative quotations from both focus groups and individual interviews.
Identifiers such as “F1” and “F4” represent participants in a focus group, “FGA 121–135” indicates
dialogue taken from focus group A, “FGF” refers to the focus group facilitator, and “IV1 306–317”
indicates a quotation taken from individual interview 1. A dash (–) indicates a natural pause in speech,
and an ellipsis (…) denotes omission of background speech.

Theme: Physical Therapists' Experience and Confidence in Treating Women Who Are Pregnant
Referral patterns and experience.

It was clear from the interviews that many women who were pregnant and had LBP were referred to
physical therapists in the acute hospital setting (linked to the location of the maternity center), whereas
the numbers of women who were referred to therapists working in community-based, outpatient
musculoskeletal services were low, as is illustrated by the following quotations:

F2: I would see maybe 1 or 2 pregnant women a year. It's like feast or famine. (FGB: 20–21)

***

We started doing a pregnancy sort of related talk, but because it was quite a common group of patients
that we were seeing, so unless they're kind of at the end of their term or it's identified by the midwife or
the referrer that they're having extreme problems, they get prioritized straight into the talk [this center
had introduced a maternity back education class]. And then after that, if they kind of identify any
problems or they phone the service whilst they're sort of on an open appointment with us, we'll then
assess them one-to-one, but generally we're now seeing less of them because they're going to this talk
first. (IV3: 10–17)

The rarity of these patients presenting to community-based therapists had an impact on some physical
therapists' feelings of competence and confidence in what they can offer these women:

F2: I always feel that with these pregnant ladies coming in, because I see so few of them, I always feel in
situations like this, I'm never that sure whether I'm that good at it. It's not like the run-of-the-mill other
things that we see on a daily basis, because we see so few and it's quite a specialized thing, I just never
consider myself to be good at it.

F5: I would agree with that. I don't know what I'm doing. Just make it up as I go along and hope it works.
(FGB: 223–231)

Physical therapists' education and knowledge about pregnancy.

For some physical therapists, their lack of knowledge about pregnancy and their inexperience in treating
this group of patients were inextricably linked, leading to a sense of inadequacy and a lack of
confidence:

F3: I've always felt I could never offer this group enough. I always feel dissatisfied when they walk out
because you think they've come for pain relief and I've addressed it as well as I can, but it's not really
going to make much difference overall. So I always feel a little bit dissatisfied when they leave. (FGB:
242–245)

***

F6: The exercises I find having done [obstetrics and gynecology], and taking antenatal classes, you get a
bit more of an idea about the physiology in pregnancy, so that side doesn't intimidate me as much as
maybe someone who hasn't done that bit. But there's always that little edge that, oh, perhaps I could do
a little bit more. (FGB: 256–260)

***
F5: I'm not confident in advising people on – because I've had pregnant people where they've said they
can't do core stability, because the midwife's told them, “You're not allowed to do that.” So I'm always a
bit like “I don't know what to do.” And I've never had any training on how to treat pregnant people –
what you can and can't do.

F4: But how much, I haven't really gone into the evidence base for that because we don't tend to get that
many of them. (FGB: 276–289)

***

F5: I think for me its lack of knowledge, so I don't know much about pregnancy and what they can and
can't do at what stages. So then I'm on the back foot as to what to say to them because I don't know.
(FGB: 349–351)

For many therapists, their current practice was based on their student education:

F6: I don't think I've got the training to do it. There might be other stuff out there, but I don't feel that I'm
well enough equipped to deliver other things.

F1: Yeah. I think because we don't see them often enough, we don't – there isn't the training out there.

F3: I don't feel that we have had enough training in that topic at all. It's sort of undergraduate and then
any reading that I've done myself, which is usually via the CSP [Chartered Society of Physiotherapy]
website. Other than that, I've had no postgrad[uate] training in it at all. (FGA: 68–75)

Theme: Physical Therapists' Perceptions of Acupuncture and Pregnancy

Although many of the therapists used acupuncture in the management of other conditions, there
seemed to be a lack of willingness to offer it for pregnancy-related LBP, even if the patients themselves
inquired about acupuncture:

F5: I think most people who are in pain are very open to acupuncture because the general response I
always get—I don't know if you ever heard this—is, “Oh yeah, well, I'll try anything.”

F3: Yeah. Get that all the time.

FGF: And I know you've said that pregnant women often will just put up with the pain as long as the
baby's okay, but do you get much of that attitude among that population? That sort of “I'll try anything
to get rid of this pain”?

F5: Probably would be there, but I haven't asked them about it –.

F3: I've never asked them. I've never given them the option of it. (FGA: 186–194)

***

F4: I recently had one pregnant lady asking about acupuncture for her back pain, but I was a bit of a
wuss [coward] and said that I'm not happy to do it, and after reading a few different bits, because I
wasn't sure which [acupuncture] points I was allowed to use and wasn't allowed to use, it said something
about avoiding coming into the third trimester, so I used that to get out of it a little bit, if I'm honest.
(FGB: 47–56)
Physical therapists' acupuncture education.

The reluctance to offer acupuncture for pregnancy-related LBP revealed in the previous quotations
seems, in part, linked to both the therapists' lack of general knowledge of pregnancy and doubts arising
from their acupuncture training, where participants often picked up mixed messages about its safety, as
illustrated below:

And I think it's the fear of not wanting, you know, we've all got this fear of not wanting to cause harm to
our patients. Because still, even on some of the basic courses that are running now, you're still treated
really as a precaution, contraindication. “Be really careful. You shouldn't be doing it,” you know. (IV1:
219–223)

***

F5: And having just done my acupuncture training, they don't actually say it's contraindicated, they just
say some points are contraindicated. I'm sure the trainer said that there is no evidence that labor has
ever actually been brought on through acupuncture.

F7: At the wrong time.

F5: At the wrong time, yes.

F7: We kind of know the points that should do it. We do, don't we? But there's still that worry, just like
this big phobia, which is understandable.

FGF: So what I'm hearing is that many of you have a concern that either through original training or
myths in the mysteries of time, there's this notion that acupuncture might bring on early labor, and, for
that reason, you're fearful of using acupuncture in pregnancy?

F7: And that's not just back pain, could be shoulder pain, toe pain. I wouldn't use it for any part of the
pregnant woman. (FGB: 533–547)

***

F5: That's the thing. Because we don't actually know how it works, do we? We're all from the Western
side of it, and we want to know how it works and why it works. And with acupuncture, strange things can
happen that you can't really explain, and I think that's where it comes from. (FGB: 559–562)

As illustrated by participant F7 above, there seems to be a reluctance to use acupuncture not just for
pregnancy-related LBP but also for any painful area during pregnancy, and this reluctance seems to be
linked to the fear of negatively affecting the course of the pregnancy, despite a general
acknowledgment that there is no evidence of such adverse effects:

F1: I think when I first trained as an acupuncturist, we were told not to actually go near pregnant
women, but over the course of my experience and having in-service training with various other people
like [name], that has been dispelled, you know, that myth. But I still haven't had the courage to actually
do any acupuncture on a pregnant lady. I think that's my biggest fear, the inducing of labor, which is still
there in the background, even though I know it's a myth.

FGF: This discussion has been absolutely fascinating because my next question was going to be “Is there
any particular aspect of managing these patients you find difficult?” and you've already gone there. But
in order to get a bit more comprehensive discussion on that, are there any other things that you want to
say about this particular patient group and what you find difficult about treating them?

F2: I think it's just pregnancy. And we just see it quite narrowly. And I think we're just scared of doing
something that you shouldn't. But at the back of my mind, when I see these patients, I'm always saying
by 12 weeks the fetus is completely formed, so I can't do anything to the fetus; it is completely formed.
It's the first trimester you really have to watch. But then after that you're not going to really do any harm
as long as you're doing nice positioning and so forth. (FGB: 321–339)

Personal and professional fear about acupuncture as a treatment.

Despite acknowledging that acupuncture in pregnancy was safe, participants in FGA and FGB still
expressed fears not only about the safety of acupuncture for the mother and fetus but also for
themselves:

F6: But if you happen to be in the field of therapy and something's gone wrong, you never know whether
it was your needles that had done that. There's always that worry at the back of your mind. Litigation. I
mean, litigation aside, you just don't want that on your conscience. Just because you're a caring human
being. (FGB: 506–510)

***

F2: The litigation fear, we live in that world, and we're led by America, and we know what happens there.
(FGB: 634–635)

***

F5: If something went wrong, it could come back on to you as a practitioner.

F1: I suppose there's a little bit of that with every patient with acupuncture as well, depending on who
they are. But with pregnancy, it's a sensitive area.

F4: And just because the consequences would be more severe if something happened. (FGA: 177–180)

***

F4: It's a fear thing that if you have practitioners who are needling pregnant women and something
happens, it puts you at a lot of risk, and the Trust [NHS hospital] at a lot of risk. (FGA: 310–313)

Many therapists talked about the lack of evidence for acupuncture generally and indicated that they
would like to have guidelines for its use in pregnancy and wanted to feel confident that someone would
back them up if things did go wrong, such as inducing early labor:

F3: I think if I was given a guideline and told that this patient is okay to have acupuncture—you can use
any of these points and you're fine—I would be quite happy to do it. But I don't want the responsibility
of, “I'm going to try it.” I wouldn't want the responsibility. (FGA: 158–160)

***

F6: What if I induced delivery too soon, and you just don't want that on your conscience…. What most of
us are worried about is if you apply needling, if you actually bring the pregnancy, the delivery sooner, you
don't want to be responsible for a premature baby who might not survive. Or worse still –. (FGB: 265–
270)

***

F4: There's not a lot of evidence to say that you would, but there's always a bit of a risk in the back of
your head that you could induce the labor and bring it on early for them. And that could cause
catastrophic problems for them, really. So I wouldn't want to be the person who did that kind of thing, if
there's a one-in-a-million chance it happened to be me, I wouldn't want that to happen. Not for them
and not me because I wouldn't probably practice ever again after that. (FGB: 499–505)

***

F4: Being told by someone you're free to use x, y, and z points, and it's not going to cause any problems.
But there's no definitive—as far as I'm aware, anyway—study or anything to say these are the points
that you are okay to use.

F3: I'd like to see the evidence, as well, behind those points. Because, otherwise, you still haven't got a
leg to stand on if somebody tells you in a courtroom –.

F1: And someone who would back me up in a court of law.

F5: That's right.

F6: There is that, you've got to take that into consideration. That's the fear. And leaving humanity aside
and just not wanting that on your conscience, and if it goes wrong and there's no evidence, you've not
got a cat in hell's chance of being supported.

F3: It's quite interesting, though, because we all know [name] who does it on loads of pregnant women
and never had a problem, ever. (FGB: 616–630)

Individual interviewees acknowledged this fear but believed that it could be overcome:

Getting my colleagues onside, and also getting some of the patients onside as well, because they've got
lots of access to websites and things, where they've read horror stories, or where they've read, you know,
that pregnancy is a contraindication [to acupuncture] from an ill-informed website. And they come in,
and I offer it to them, and it's more the discussing, actually, you know, the evidence, the credible
evidence that, actually, there is no risk to either yourself or the baby, and it's getting them over that
hurdle initially. (IV1:180–186)

***

I've done a number of acupuncture in women's health courses, and I know it's a subject of debate in
some of them, but, in my experience, I've used the points, and some of which would be classed as
“forbidden points,” and, you know, in all the time I've used them, I've only had success; never had—touch
wood—any adverse effects. (IV2: 133–137)

Acupuncture as an intervention choice.

In contrast to earlier concerns raised about safety, one participant clearly perceived acupuncture as safe
for pregnant women—safer, in fact, than medication, as illustrated by the first 2 quotations—and one
participant thought acupuncture also is more effective:

I would use acupuncture as a first choice of treatment, with pregnant ladies, over medication because of
the safety risks with medication. (IV1: 100–102)

***

F4: I mean, it [acupuncture] is very interesting because drugs do not seem to work for these women. You
know, talking about sort of real heavy painkillers…. We had a lady admitted last week and was
immediately put on morphine; it didn't touch her pain at all. And all that does then is make the baby
sleepy, and the mum sleepy. So, for some women, it is very difficult pain to manage. (FGC: 138–142)

***

In fact, I find my pregnant patients respond better [to acupuncture] than perhaps my standard lower
back pain. (IV1: 202–203)

Additionally, participants recognized that the one-to-one nature of acupuncture treatment, in itself,
might be more effective than managing patients as a group in back education classes:

F3: And the other dynamic that would be involved if you're giving acupuncture or any other manual
treatment, it's a one-to-one scenario, and that patient, therefore, has your isolated attention. So, if you
took each of the patients from our back class and put them in a cubicle [space] and talked to them
individually, my own hypothesis would be those would walk out feeling a bit better than if we treated
them in a class. I think, in terms of they feel that they're being listened to and their symptoms are being
dealt with, as opposed to being lost in the crowd, I think you get a better treatment outcome, which, if
that's acupuncture, or if that's completely the same as what we do here anyway, I think you'd see the
difference. (FGC: 204–212)

Some participants, even though they had not used it, also believed that acupuncture has a place in the
management of pregnancy-related LBP. This belief was related to their concern for the women's need
for pain relief. However, this raised an anxiety in therapists that the patients may then have high
expectations of acupuncture that may be unfulfilled:

F3: I think it [acupuncture] would because I do think these women get to a point at the end, they just
want something, anything.

F1: I think it could have a role for pain relief, but I think it's as an adjunct to the other things…. I think
ladies are going to be very much for it because they're desperate for help, but I think they may well
expect possible instant relief and cure, and that would be the only thing. (FGC: 147–159)

***

F2: I think if their expectation, if they've not got any knowledge in it, the same as a lot of them don't
have any knowledge of physio [physical therapy], they come for a physio appointment expecting to be
cured of their pain, and I think probably they would have a very similar expectation with acupuncture
particularly if they've maybe had physio and it's taken away some of the pain but it's not made them
symptom free, then I think a lot of them will maybe expect acupuncture to be the thing that will take
away their pain and make them pain-free. (FGC: 194–200)

Practitioners who used acupuncture in the management of pregnancy-related LBP considered when
acupuncture may be most beneficial during the pregnancy, which seemed to be guided by factors such
as pain severity, the source of the pain, and the frequency of treatments:

We generally try to leave it [acupuncture] until later in the pregnancy simply because they tend to need a
regular top-up once they start it because it is purely pain relief, so we would try to eliminate the
underlying problem initially if it's a misalignment; if it's a postural problem, we'll tend to work on that
first. If, by correcting that, we don't get anywhere, then we will offer acupuncture as pain relief, but it
tends to be that they're coming weekly then until the end of their pregnancy…but it's really the patients'
decision once we've discussed it with them when they want to make that level of commitment and how
bad the pain is. (IV2: 115–124)

***

If the pain is really severe, then it [acupuncture] is something I would think of more quickly, if that makes
sense, because I find that it can be really helpful at kind of managing pain, and then I can almost create
myself a window of opportunity to look at other things and sort of treat in other ways, particularly if I
can't even complete an assessment because the pain is so high that it would be something to try and
think of to try and lessen that so the pain would probably be the biggest influence. (IV3: 82–87)

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Discussion

This qualitative study explored the perceptions, views, and experiences of physical therapists involved in
treating women with pregnancy-related LBP, with the aim of eliciting data to inform the EASE Back pilot
trial (Bartlam et al, unpublished research).

Although the participants in this study shared several perceptions, they also expressed some divergent
views. This finding, in part, may reflect the fact that the individual interviewees, by virtue of the national
survey sample,17 came from clinical interest groups likely to manage women with pregnancy-related LBP
and the fact that members of the women's health focus group were experienced in women's health
generally but not specifically in using acupuncture.

However, a fundamental issue emerging from the wider findings of this study seems to be that some
physical therapists who may be referred women with pregnancy-related LBP have little knowledge of
pregnancy and low confidence in treating women who are pregnant. They specifically lacked confidence
in the safety of acupuncture in pregnancy, which made them reluctant to offer it as part of their
treatment. Even some of those participants who felt more confident about treating women who are
pregnant were still not confident to use acupuncture. The EASE Back survey findings showed that
physical therapists reported using a variety of interventions as part of usual care,17 but some of the
interviewees felt insufficiently competent in using these interventions for pregnancy-related LBP.
Participants seemed almost more willing to reinforce their patients' view that pregnancy-related LBP is
something to “go through” and will be self-limiting. A few therapists, in contrast, were very happy to use
acupuncture in the management of this patient group.
Lack of clinical experience with pregnancy-related LBP seems to be linked to working in a general
musculoskeletal outpatient setting, where few women who are pregnant are treated. Nonetheless, a
concern for the profession from the findings of this study is that of therapists either not referring
patients to others who are experienced in managing pregnancy-related LBP or applying interventions
that they do not feel competent or confident to deliver, raising questions concerning clinical judgment
and professional practice.15 Additionally, physical therapists are required to act within their scope of
practice yet fulfill a duty of care to service users; understanding a condition—be it pregnancy-related
LBP or any other condition—and how it influences management, therefore, is a professional
responsibility.31,32 The findings of this study suggest that both personal concerns and the professional
fear of litigation threaten this practice.

Many of the participants had previously received acupuncture education. Despite this education and
evidence to support the safety of acupuncture in the second and third trimesters,12–14 there was
reluctance to use it. Evidence from the literature and interviews with women who were pregnant
(Bartlam et al, unpublished research) indicate that if women are fully informed, they are happy to have
acupuncture, especially given that for some the pain can be debilitating and that they are more fearful
of potential side effects of drugs in pregnancy. Although some participants in this study expressed a fear
of harming the fetus, there is strong evidence that acupuncture is safe, with no evidence of adverse
effects on either the fetus or neonate or the mother.13,33–35 Nonetheless, physical therapists remained
distrustful of the evidence. This distrust might be reinforced within clinics or hospitals that do not permit
physical therapists to use acupuncture in the treatment of women who are pregnant, such as for the
participants in FGC in this study.

So, as Cummings inferred from his case studies, physical therapists seem to be facing a dilemma: “Is it
ethically defensible to withhold treatment on purely medicolegal grounds (ie, the concern about being
blamed for a coincidental adverse event in the pregnancy)?”36(p46) This fear is expressed by physical
therapists as not wanting to be blamed, or indeed sued, by the woman, and as feeling unsupported by
peers, the profession, and employers. It seems here that the available research on acupuncture safety is
interpreted through the lens of both the individual's values and a professional culture of caution.
Specifically, therapists appear to adhere to a type of precautionary principle, whereby the possibility of
harm takes precedence over a countervailing probability of benefit.37 If advocates of an intervention,
such as acupuncture for pregnancy-related LBP, fail to engage with practitioners' adherence to such a
principle, more research evidence alone is unlikely to alter this perception of acupuncture, and practice
is unlikely to change.38

Many interventions carry risks, and good clinical reasoning involves balancing information about
benefits and risks to reach a responsible clinical decision. Bredin et al39 looked at risk related to physical
activity in women who are pregnant and suggested using a decision tree; this approach may be a useful
tool to develop for acupuncture in the context of pregnancy.40 Without being alarmist or protectionist,
these tools may enable practitioners to ensure that patients are fully informed about intervention risks
and benefits, and thereby satisfy personal ethical concerns41 and allow them to be more confident in
their decision making.

Strengths and Limitations

In an attempt to ensure rigor in the study, participants were sampled purposively, 2 methods of data
collection were used, and, in the data analysis, saturation was sought and cross-coding of transcripts
was carried out within the research team. However, these findings represent the experiences and
perceptions of a sample of UK physical therapists; it cannot be assumed that they represent physical
therapist practice internationally. Additionally, although the majority of the participants had some
experience in treating this patient group and some did use acupuncture as an intervention for
pregnancy-related LBP, it became evident during data collection that not all participants were practicing
under the same treatment philosophy. This is an issue that warrants further research. Therapists' use of
acupuncture, in many instances, was linked to issues of confidence in their knowledge and training and
to fears of litigation. However, local policy around service provision of acupuncture may determine the
use of acupuncture, regardless of therapists' perceptions of their competence in its use. Such policy
constraints on practitioners' autonomous practice deserve further exploration.

Implications

The findings from the physical therapists' interviews in phase 1 were used to direct the training program
for participating physical therapists in phase 2 and in the pilot randomized trial and to refine the
interventions that would be used. The training program, therefore, focused on incorporating the existing
good evidence about the safety of even strong acupuncture. In an attempt to improve therapists'
knowledge and confidence in assessing and treating women who are pregnant, some of these women
were invited to be models during the training program so that therapists could practice using
acupuncture just as they would within the trial. Additionally, teaching sessions were led by a women's
health specialist physical therapist, an experienced acupuncturist confident in the use of this treatment
for pregnancy-related LBP, and an obstetrician. Throughout the program, therapists were encouraged to
voice any concerns about acupuncture and had the opportunity to address pregnancy symptoms and
signs—including their perceptions of the safety of acupuncture in pregnancy—as well as to practice
technique. It is hoped, therefore, that the therapists' lack of confidence and fears were thereby
addressed.42 Moreover, as a result of these qualitative findings, we measured the clinicians' confidence
in the diagnosis and management of pregnancy-related LBP before and after the training program. In
addition, once the trial began, therapists utilized opportunities for ongoing mentorship and support.43

Despite many physical therapists in the United Kingdom using acupuncture for musculoskeletal pain
problems and evidence that acupuncture is effective and safe for women with pregnancy-related LBP,
the findings of this study suggest that therapists are reluctant to use acupuncture in the treatment of
this patient group. The explanations for this reluctance include perceived lack of knowledge and
confidence and a pervasive professional culture of caution—in particular, fears of inducing early labor
and of litigation. These qualitative findings have been key to informing the content of the training
program for physical therapists delivering acupuncture within our pilot EASE Back trial
(ISRCTN49955124).44

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Footnotes

Dr Waterfield, Dr Bartlam, Dr Bishop, Dr Barlas, and Professor Foster provided concept/idea/research

design. Dr Waterfield, Dr Bartlam, Dr Bishop, Dr Holden, and Professor Foster provided writing. Dr
Bartlam and Dr Holden provided data collection. Dr Waterfield, Dr Bartlam, and Dr Barlas provided data
analysis. Dr Bartlam, Dr Holden, and Professor Foster provided project management. Professor Foster,
Dr Bishop, and Dr Barlas provided fund procurement. Dr Bartlam provided participants and institutional
liaisons. Dr Waterfield, Dr Bartlam, and Dr Barlas provided consultation (including review of manuscript
before submission).

This study was approved by Greater Manchester North Research Ethics Committee 12/NW/0227, and
the EASE Back trial is registered with the ISRCTN database Ref: ISRCTN49955124.

Aspects of this work were presented at Physiotherapy UK 2014 Conference & Trade Exhibition; October
10–11, 2014; Birmingham, United Kingdom.

The EASE Back study is funded by the National Institute for Health Research's (NIHR's) Health
Technology Assessment Programme. This article presents independent research funded by the NIHR
under its Health Technology Assessment (Grant Reference Number 10/69/05) and is supported by an
NIHR Research Professorship to Dr Foster (NIHR-RP-011-015). The views expressed are those of the
authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.