Submitted by Robert Felt on June 22, 2007 - 9:12am.

The problem of acupoint contraindications in pregnancy

Stephen Birch PhD, LicAc (USA), MBAcC (UK), lid NVA (Holland)

Stichting (Foundation) for the Study of Traditional East Asian Medicine

W.G. Plein 330

1054 SG Amsterdam

The Netherlands

Introduction

Today we find many modern textbooks recommending the uses of acupoints for certain conditions and contraindicating their uses in other conditions [Qiu 1993]. One of the best known examples of the contraindications is the prohibition against needling LI-4 and SP-6 during pregnancy [Qiu 1993]. There are however questions about the validity of these statements [Birch, Felt 1999]. This paper will discuss the points that are usually said to be contraindicated for treatment during pregnancy and trace the history of these ideas and contradictions in the literature about them. What remains are serious questions concerning the validity of the claims.

To do this I shall first list the points that are contraindicated during pregnancy, by examining thirty five historical and modern texts and all the point contraindications during pregnancy each makes. This allows a contrast of statements about point contraindications during pregnancy between modern and historical Chinese sources, modern and historical Japanese sources and modern western sources. To understand these variations and their contradictions I shall then examine changes in the indications of needling depth for acupuncture points, comparing five historical texts with four modern Chinese texts. It will become apparent that ideas about the uses of acupuncture points have evolved over time, as should be expected [Birch, Felt, 1999]. There is not a continuous lineage of ideas, but rather discontinuity of ideas. I have documented such variation and discontinuity already for the interpretation of the six positions of the pulse in another paper [Birch, 1992]. It should not be surprising to find the same processes at work in relation to how acupuncture points are understood and used. We can speculate on the possible origins of this variation. Principally the variations that are documented are probably due to differences in how the techniques of treatment are applied. We have reasonably good evidence from modern research that the application of different techniques of stimulation to acupuncture points can elicit different responses through activating different physiological pathways [Birch, Felt, 1999, Han, 1997, Mizutani, 2004, Pomeranz, 1998, Tanaka, 1996]. It is thus quite likely that there have been variations at all levels in acupuncture practice, from textual variation in the uses of acupuncture points to methods of stimulation of the points.

My hypothesis is that the use of acupuncture points has changed significantly from historical to modern times. This should not be surprising given historical developments in and outside of East Asia wherever acupuncture has been practiced, but it does raise difficult questions about how practitioners attempt to ‘authenticate' or justify what they do. Most traditional forms of acupuncture attempt to authenticate what they do by claiming an historical lineage, for example by citing certain historical texts and/or by stating that what they do is "traditional" or "classical". The expected variations in acupuncture point uses do not eliminate historical lineages per se, but they do raise important questions about this route of justification. This paper focuses primarily on the discontinuity of ideas, highlighting major differences between historical and modern texts, and differences between "traditions". If the citing of sufficient historical documents is insufficient as a means for justifying one's modern ideas, then one should cite other relevant sources especially modern evidence for those ideas. In the absence of dependable modern sources the idea in question becomes difficult to substantiate.

Acupoint contraindications in pregnancy

To examine point contraindications in general and in pregnancy in particular I compiled all the acupuncture point contraindications or prohibitions in thirty five historical and modern sources (see table 1).

Of the following 35 sources that were compiled in this study (see Table 1), 1-28 were first compiled by Sorei Yanagiya in his text, Shinkyu Ijutsu no Mon [Yanagiya, 1948]. 1-22 are classical texts in Chinese, Japanese or Korean, 23-28 are modern Japanese authors in Japanese. Texts 29-35 were compiled from seven modern English language sources, three of which are direct translations of Chinese texts, (29, 30, 33,) one of which is a direct translation of a Japanese text, (35). Texts 31, 32, and 34 are compiled from Chinese sources. In the following list "C-" indicates a Chinese text, "J-" indicates a Japanese text, "K-" indicates a Korean text, "E-" indicates an English language text.

TABLE 1 - Texts used in the compilation:

1 - Shinkyu Jyu Hoki; (J - 1726)

2 - Nei Jing; (C - circa -300)

3 - Zhen Jiu Jia Yi Jing; (C - 282)

4 - Ming Tang Jing; (C - circa -300)

5 - Zhen Jiu Ju Ying,(C - 1529)

6 - Tong Ren Shu Xue Zhen Jiu Tu Jing; (C - 1026)

7 - Yi Xue Ru Men; (C - 1575)

8 - Xi Fang Zi Ming Tang Jiu Jing; (C - 1311)

9 - Zhen Jiu Zi Sheng Jing; (C - 1220)

10 - Kei Ketsu I Kai; (J - 1807)

11 - Wakan Sansai Zue; (J - 1712)

12 - Lei Jing; (C - 1624)

13 - Wai Tai Pi Yao Fang; (C - 752)

14 - To I Ho Kati; (K - 1613)

15 - Qian Jin Fang; (C - 652)

16 - Su Wen Zhu; (C - 1594)

17 - Shinkyu Setsuyaku; (J - 1812)

18 - Ryoji no Dai Gaishu; (J - 1880)

19 - Zhen Jiu Yi Xue Da Gang; (C - Qing dynasty)

20 - Shinkyu Yoho Shinan; (J - 1720)

21 - Gorui Shinkyu Basui; (J - nineteenth century)

22 - Nichiyo Kyuho; (J - nineteenth century)

23 - Mr. Yamomoto (J - twentieth century)

24 - Mr. Matsumoto (J - twentieth century)

25 - Mr. Tatsui (J - twentieth century)

26 - Mr. Tamamori (J - twentieth century)

27 - Mr. Sasagawa (J - twentieth century)

28 - Mr. Tominaga (J - twentieth century)

29 - Essentials of Chinese Acupuncture,- (C/E - 1980)

30 - Chinese Acupuncture and Moxibustion,- (C/E - 1987)

31 - Acupuncture a Comprehensive Text,- (E/C - 1983)

32 - Fundamentals of Chinese Acupuncture,- (E/C - 1988)

33 - The Book of Acupuncture Points,- (C/E - 1985)

34 - Acupuncture, Textbook and Atlas; (E - 1987)

35 - Introductory Acupuncture,- (J/E - 1977)

Table 2 lists all points that are mentioned by any of the thirty five texts as being contraindicated during pregnancy


TABLE 2 - Points contraindicated in pregnancy by 1 or more of the 35 texts

LI-4 - 2 historical Chinese (10, 19) + 5 modern Chinese (29-33)

SP-6 - 4 historical Chinese/Japanese (5, 12, 18, 19) + 3 modern Chinese (29, 30, 33)

CV-5 - 3 historical Chinese/Japanese (11, 15, 19) + 3 modern Japanese/Chinese (28, 32, 33)

GB-21 - 2 historical Chinese (12, 19) + 2 modern Chinese (32, 33)

CV-6 - 1 historical Japanese (11) + 1 modern Chinese (31)

CV- 3 - 2 historical Chinese/Japanese (9,11)

CV-4 - 2 modern Chinese (32, 33)

CV-7 - 2 historical Japanese (10,11)

SP-1 - 1 historical Chinese (3)

ST-12 - 1 historical Chinese (19)

ST-25 - 1 modern Chinese (33)

BL-60 - 1 modern Chinese (33)

BL-67 - 1 modern Chinese (33)

KI-21 - 1 historical Japanese (11)

CV-10 - 1 modern Chinese (32)

CV-11 - 1 modern Chinese (33)

Table 2 shows us that there are no universally accepted acupoint contraindications during pregnancy. Not only is there general inconsistency in the historical literature (1-22), inconsistency in the modern literature (23-35) but there is also considerable inconsistency between the historical and modern literature. Some modern Chinese books state general contraindications of needling the lower abdomen or lower back during pregnancy without specifying any points, but this too is not consistent among texts.

With regards the four most commonly cited points LI-4, SP-6, CV-5 and GB-21 we find the following discrepancies:

historical texts (22) modern Chinese (6) modern Japanese (7)

LI-4 2 5 0

SP-6 4 3 0

CV-5 3 3 0

GB-21 2 2 0

What differences exist between historical, modern Chinese and modern Japanese traditions that may account for such variation? Why do none of the seven modern Japanese and many of the six modern Chinese texts contraindicate needling of these four points in pregnancy? As I have discussed elsewhere, there are major differences in the needling techniques between Japan and China [Birch, Felt 1999], perhaps this is the reason. To explore this question I examine the recommended needling depths for acupoints in the historical and modern periods and then specifically for these four acupoints.

Recommended needling depths

As the modern system of acupuncture started to become available in the West, certain modern Chinese texts were translated. The English language book Acupuncture a Comprehensive Text [O'Connor, Bensky, 1981] was one of the early influential texts in the West. It was also important in China. It is a translation of texts written in 1962 and 1974 by the Shanghai College of TCM [Op.cit p. xv]. It reflects some of the pioneering work of the Shanghai College from the 1950s and 1960s. One of the more striking changes in acupuncture described in this text is the rather large increase in the recommended depth of needling for the acupuncture points. To explore this change systematically I examined the recommended depths of insertion in "cun" for all the major acupuncture points in the following important historical acupuncture texts: Zhen Jiu Jia Yi Jing [Huang Fu-mi, 282], Tong Ren Shu Xue Zhen Jiu Tu Jing [Wang Wei-yi, 1027], Zhen Jiu Ji Sheng Jing [Wang Zhi-zhong, 1220], Zhen Jiu Ju Ying [Gao Wu, 1529], and the Zhen Jiu Da Cheng [Yang Ji-zhou, 1601]. Based upon the number of points recommended for each needle depth, it was then possible to calculate the overall mean depth of insertion and median depth of insertion as indicators of the relative depths of insertion for each text. Table 3 lists the numbers of points in each text recommended in the depth ranges given, the overall mean depth of insertion, and median depth of insertion for these five historical sources (for points that were given a range of depth of insertion, the mid point of that range is used in this table).

As a comparison the recommended depths of insertion for all the major acupuncture points in four modern Chinese textbooks on acupuncture: Essentials of Chinese Acupuncture, [Anon, 1981], Chinese Acupuncture and Moxibustion, [Cheng. 1987], Acupuncture a Comprehensive Text, [O'Connor, Bensky, 1981], Fundamentals of Chinese Acupuncture, [Ellis, Wiseman, Boss, 1988] are tabulated. The overall mean depths of insertion, and median depths of insertion are also calculated. Table 4 lists the numbers of points in each text recommended in the depth ranges given, the overall mean depths of insertion and median depths of insertion for these four modern sources (for points that were given a range of depth of insertion, the mid point of that range is used in this table).

TABLE 3

 

mean,

(median)

depths

number (%) recommended at 0.1-0.3 cun

number (%) recommended at 0.35-0.6 cun

number (%) recommended at 0.65-1.0 cun

number (%) recommended at 1.1-1.5 cun

number (%)

recommended at 1.6-3.0 cun

Jia Yi Jing

(282)

0.49 (0.4)

171 (49%)

113 (32%)

51 (15%)

5 (1%)

9 (3%)

Tong Ren Shu Xue (1027)

0.42 (0.3)

182 (56%)

94 (29%)

47 (15%)

1 (0%)

1 (0%)

Ji Sheng Jing (1220)

0.41 (0.3)

196 (58%)

89 (27%)

50 (15%)

0 (0%)

1 (0%)

Ju Ying (1529)

0.41 (0.3)

186 (56%)

99 (30%)

45 (14%)

1 (0%)

2 (0%)

Da Cheng

(1601)

0.41 (0.3)

191 (57%)

96 (29%)

48 (14%)

1 (0%)

1 (0%)

Mean (median)

0.43 (0.3)

55.2% (56%)

29.4% (29%)

14.6% (15%)

0.2% (0%)

0.6% (0%)

 

TABLE 4

 

mean,

(median)

depths

number (%) recommended at 0.1-0.3 cun

number (%) recommended at 0.35-0.6 cun

number (%) recommended at 0.65-1.0 cun

number (%) recommended at 1.1-1.5 cun

number (%)

recommended at 1.6-3.0 cun

Essentials (1980)

0.57 (0.5)

58 (16%)

151 (42%)

136 (38%)

12 (3%)

1 (1%)

CAM (1987)

0.60 (0.6)

25 (7%)

165 (46%)

158 (44%)

8 (2%)

2 (1%)

ACT (1981)

1.03 (0.85)

18 (5%)

41 (11%)

138 (38%)

121 (34%)

41 (11%)

Fundamentals (1988)

0.54 (0.45)

74 (21%)

156 (44%)

117 (33%)

8 (2%)

1 (0%)

Mean

0.69

12.3%

35.8%

38.3%

10.3%

3.5%

 

One can see that all the modern Chinese texts generally recommend deeper needle insertions than the historical texts. One can clearly see a shift away from use of points with shallower needling to deeper needling, with a more than 50% increase in recommended needling depth overall. While the actual measure of the "cun" can be variable as it is a relative measure for different people and on different areas of the body, it has probably not changed that significantly over time. One modern Chinese researcher has estimated that the "cun" is approximately 2.23 cm [Chen et al, 1979], while classical scholars have estimated that the "cun" was about 2.31cm [Harper, 1982].

Acupoint comparisons

If we look at the most commonly contraindicated acupoints in pregnancy LI-4, SP-6, CV-5 and GB-21 we find that they are all needled differently in modern China compared to historical texts. Table 5 shows these variations.

TABLE 5

HISTORICAL TEXTS

LI-4

SP-6

CV-5

GB-21

Jia Yi Jing (282)

0.3 cun

0.3 cun

0.5 cun

0.5 cun

Tong Ren Shu Xue (1027)

0.3 cun

0.3 cun

no needle

0.5 cun

Ji Sheng Jing (1220)

0.3 cun

0.3 cun

no needle

0.5 cun

Ju Ying (1529)

0.3 cun

0.3 cun

0.8 cun

0.5 cun

Da Cheng (1601)

0.3 cun

0.3 cun

0.8 cun

0.5 cun

MODERN TEXTS

Essentials (1980)

0.5-0.8 cun

0.5-1.0 cun

0.5-1.0 cun

0.5 cun

ACT (1981)

0.5-1.0 cun

1.5-2.0 cun

1.0-1.5 cun

0.5-1.0 cun

CAM (1987)

0.5-1.0 cun

0.5-1.0 cun

0.5-1.0 cun

0.3-0.5 cun

Fundamentals (1988)

0.5-0.8 cun

0.3-1.0 cun

0.5 -0.8 cun

0.3-0.5 cun

 

Generally LI-4 and SP-6 are needled about twice as deep in the modern Chinese texts compared to the historical Chinese texts. CV-5 and GB-21 appear to be needled around the same depths comparing historical and modern texts, but they both appear to be needled differently, probably reflecting greater anatomical knowledge in the modern period. For example CV-5 does not cause problems with fertility thus the contraindication of needling it is dropped in the modern texts. Improved anatomical knowledge of the lungs indicates the need for a generally shallower approach to needling GB-21.

Summary

The fact that there is very poor agreement between modern and historical sources on the contraindications of SP-6 and LI-4 in pregnancy and that there have been changes in the way that these points are needled in the modern Chinese texts compared to the historical texts supports the interpretation that it is not the acupoints per se that are contraindicated but rather the use of those techniques on those points that might be contraindicated. But even this interpretation may be stretching the facts. There is considerable inconsistency between historical sources, between historical and modern sources and between different modern traditions.

Further, there is no evidence from the medical literature of actual complications during pregnancy from doing acupuncture as no adverse effects were found in any of the surveys or literature reviews [Birch et al. 2004]. Many patients receive acupuncture from us while pregnant and before they realize that they are pregnant. There are no reports of complications from this even though some of the same points that are contraindicated during pregnancy are used during those treatments. Over the last 25 years I have also heard some colleagues discuss efforts to use acupuncture to trigger an abortion; in all cases these were singularly unsuccessful

Additionally, it is a routine recommended treatment in Japan to use SP-6 with moxa in pregnancy after the fifth month to help the mother and baby and in preparation for labor [Kuwahara, Boston lecture 1990]. Should we suddenly discontinue a safe and effective method because of the fears of people that are unfamiliar with the literature? This is not a good idea, our judgements should be based on an extensive knowledge of the published literature.

Recommendations:

My feeling is that it is perhaps better not to try to make firm policy statements about contraindications of acupuncture during pregnancy, especially as they pertain to the use of specific acupuncture points. The issues involved are complex and, more importantly, there are no reported adverse effects associated with acupuncture in relation to pregnancy.

 

References

- Anon (1980). Essentials of Chinese Acupuncture. Beijing; Foreign Languages Press.

- Birch S. (1992). Naming the unnameable: A historical study of radial pulse six position diagnosis. Traditional Acupuncture Society Journal; 12: 2-13. Also in: Journal of the Acupuncture Society of New York; 1994, 1, 3-4: 19-32.

- Birch S, Felt R. (1999). Understanding Acupuncture. London, Churchill Livingstone.

- Birch S, Keppel Hesselink J, Jonkman FAM, Hekker TAM, Bos A. (2004). Clinical research of acupuncture: Part one - what have reviews of the efficacy and safety of acupuncture told us so far? J Alt Complem Med.

- Chen WC, et al. (1979). The determination of the depth of puncture for the development of needling sensation. National Symposia of Acupuncture and Moxibustion and Acupuncture Anesthesia. Beijing, June 1-5, 1979, pages 113-114.

- Cheng XN. (1987). Chinese Acupuncture and Moxibustion. Beijing; Foreign Languages Press.

- Ellis A, Wiseman N, Boss K. (1988). Fundamentals of Chinese Acupuncture; Brookline, Massachusetts, Paradigm Publications.

- Gao Wu. (1529). Zhen Jiu Ju Ying, Taipei, Hong Ye Bookshop Publishing Company, 1983.

- Han JS. (1997). Physiology of acupuncture: a review of thirty years research. J Alt Complem Med. 3, suppl 1: S-101-108.

- Harper D. (1982). The "Wu Shi Erh Ping Fang": Translation and Prolegomena. Doctoral Thesis, University of California, Berkeley.

- Huang Fu-mi. (282). Zhen Jiu Jia Yi Jing. From Zhen Jiu Jia Yi Jing Shu Xue Zhong Ji. Shandong, Science and Technology Publishing Company, 1982.

- Manaka Y, Itaya K, Birch S. (1995). Chasing the Dragon's Tail, Brookline, Paradigm Publications.

- Mizutani J. (2004). Practical moxibustion therapy (28). NAJOM, 11, 30:34-35.

- O'Connor J, Bensky D. (1981). Acupuncture a Comprehensive Text; Seattle, Eastland Press.

- Pomeranz B. (1998). Scientific basis of acupuncture. In: G Stux, B Pomeranz. Basics of Acupuncture. Berlin, Springer-Verlag, fourth edition, pp. 6-72.

- Qiu ML. (1993). Chinese Acupuncture and Moxibustion, Edinburgh, Churchill Livingstone.

- Tanaka TH. (1996). Professor Nishijo's research-acupuncture and the autonomic nervous system. N Amer J Orien Med. 3, 8:6-10.

- Wang Wei-yi. (1027). Tong Ren Shu Xue Zhen Jiu Tu Jing. Taipei, Wu Zhou Publishing Company, 1976.

- Wang Zhi-zhong. (1220). Zhen Jiu Ji Sheng Jing. In Zhen Jiu Ji Sheng Jing; Shi Si Jing Fa Hui. Taipei, Xuan Feng Publishing Company, 1980.

- Yanagiya S. (1948). Shinkyu Ijutsu no Mon; Yokosuka, Ido no Nippon Publishing company.

- Yang Ji-zhou. (1601). Zhen Jiu Da Cheng. Taipei, Da Zhong Guo Tu Shu Publishing Company, 1982.

 

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