Extrapolation errors in Liu et al.'s CAM integrative review of health care professionals in New Zealand.

This letter is to highlight errors made by Liu et al. in their 2020 paper in BMC Complementary Medicine and Therapies, "Complementary and alternative medicine-practice, attitudes, and knowledge among healthcare professionals in New Zealand: an integrative review". Substantial errors in their citation of the recent research and methodology by McDowell, Kohut & Betts (2019) pertaining to the practice of acupuncture in New Zealand by physiotherapists are presented. The actual results of McDowell et al.'s work and the true state of acupuncture use by their sample group is reported.

Midwifery Acupuncturists' Management of Antenatal Anxiety and Depression: Data from a Survey in Aotearoa (New Zealand).

Objective: The goal of this research was to explore how New Zealand midwifery acupuncturists manage mild-to-moderate antenatal anxiety and depression (AAD). Materials and Methods: A survey (Surveymonkey®) on midwives' perceptions of acupuncture for treating AAD was distributed late in 2019 to midwives who completed a Certificate in Midwifery Acupuncture. Data were collected on referrals and on acupuncture and complementary and alternative medicine use for AAD and associated symptoms of concern (SoC), such as low-back and pelvic pain (LBPP), sleep issues, stress, other pain, and pregnancy issues. Descriptive analysis was used to report data. Results: Of 119 midwives, 66 responded (55.5%). For AAD and SoC, midwives mostly referred patients to general practitioners and counselors, and administered acupuncture themselves. Acupuncture was most accessed for LBPP (n = 38; 70.4%), sleep (n = 31; 57.4%), anxiety (n = 27; 50.0%); stress (n = 26; 48.1%), and other pain (n = 20, 37.0%). Massage was second most-accessed for LBPP (n = 36; 66.7%), sleep (n = 25; 46.3%), and stress (n = 24; 44.4%). For depression, treatments were herbs (n = 16; 29.6%), homeopathy (n = 14; 25.9%), and acupuncture and massage (both n = 13; 24.1%). Acupuncture was most used for other pregnancy issues: birth preparation (n = 44, 88.0%); assisted labor induction (n = 43; 86.0%): nausea and vomiting (n = 43; 86.0%); breech (n = 37; 74.0%); and headaches/migraines (n = 29; 58.0%). Conclusion: Acupuncture is commonly used by midwife acupuncturists in New Zealand to treat a range of pregnancy issues, including anxiety, SoC for AAD, and other pregnancy issues. Further research would be beneficial.

The changing clinical landscape in acupuncture for women's health: a cross-sectional online survey in New Zealand and Australia.

BACKGROUND: Acupuncture is a popular treatment for women's health. Several trials and meta-analysis have been published in recent years on key women's health conditions but it is unclear if this has led to any changes in clinical practice or referrals from other health professionals. The aim of this survey was to explore if, how, and why, aspects of acupuncture practice have changed since our survey in 2013. METHOD: An online cross-sectional survey of registered acupuncturists and Chinese Medicine practitioners in Australia and New Zealand. Questions covered the practitioner demographics and training, women's health conditions commonly treated, modalities used, sources of information and continuing education (CE) (e.g. webinars), changes in clinical practice, and referral networks. RESULTS: One hundred and seventy registered practitioners responded to this survey, with 93% reporting treating women's health in the last 12 months. The majority of respondents were from Australia (60%), held a bachelors level qualification (60%), and used a traditional Chinese medicine framework (86%). Most practitioners incorporated other modalities in addition to acupuncture. Most practitioners' referral networks were predominantly based on word of mouth for menstrual, fertility and pregnancy related conditions, with referrals from medical practitioners being much less common. More than half (57%) reported having changed their women's health practice in the past 12 months; just over a quarter of those who changed treatment (27%) reported it was due to research findings. The most commonly used sources of information/CE used to inform treatment were webinars and conferences, while peer-reviewed journal articles were the least commonly used source. CONCLUSION: Acupuncture practitioners in Australia and New Zealand commonly treat women's health conditions, but this is usually the result of women seeking them out, rather than being referred from a medical practitioner. The majority of practitioners did report changing their women's health practice, but peer reviewed academic articles alone are not an ideal medium to convey this information since practitioners favour knowledge obtained from webinars and conferences. Academics and other clinician researchers should consider alternative means of disseminating knowledge beyond traditional academic publications and conferences, special interest groups may assist in this and also help improve research literacy.

The Role of Research in Guiding Treatment for Women's Health: A Qualitative Study of Traditional Chinese Medicine Acupuncturists.

BACKGROUND: Surveys of acupuncture practitioners worldwide have shown an increase in the use of acupuncture to treat women's health conditions over the last ten years. Published studies have explored the effectiveness of acupuncture for various conditions such as period pain, fertility, and labor induction. However, it is unclear what role, if any, peer-reviewed research plays in guiding practice. METHODS: Acupuncturists with a significant women's health caseload were interviewed online in three small groups to explore factors that contribute to acupuncturists' clinical decision made around treatment approaches and research. RESULTS: Eleven practitioners participated in the focus groups. The overarching theme that emerged was one of 'Not mainstream but a stream.' This captured two themes relating to acupuncture as a distinct practice: 'working with what you've got' as well as 'finding the right lens', illustrating practitioners' perception of research needing to be more relevant to clinical practice. CONCLUSIONS: Acupuncture practitioners treating women's health conditions reported a disconnect between their clinical practice and the design of clinical trials, predominantly due to what they perceived as a lack of individualization of treatment. Case histories were popular as a learning tool and could be used to support increasing research literacy.

Navigating the path: a qualitative exploration of New Zealand general practitioners' views on integration of care with acupuncturists.

BACKGROUND: Increasingly, many patients believe that a combined approach of complementary and alternative medicine (CAM), including acupuncture, and conventional medicine is better than either on its own, and more patients now have the desire to discuss CAM with well-informed general practitioners (GPs). However, to our knowledge, the interaction and collaboration between GPs and acupuncturists specifically in relation to shared care have not been investigated. This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article specifically reports the GPs' viewpoints. METHODS: This study was part of a larger mixed-methods research project. Semi-structured interviews of 14 purposively sampled GP participants were conducted and analysed using thematic analysis. RESULTS: The data analysis identified both facilitators of and barriers to integrative health care. Facilitators included the willingness of GPs to engage in communication and a recognition of the importance of patient choice. Barriers included the limited opportunities for sharing information and the lack of current established pathways for communication or direct referrals. GPs also highlighted the confusion around scopes of practice in terms of the different styles of and approaches to acupuncture. CONCLUSION: This research contributes to the body of knowledge concerning interprofessional communication and collaboration between GPs and acupuncturists and suggests that while there are significant barriers to collaboration, there is also the potential to impact provider satisfaction and patient well-being. It provides context within a New Zealand health care setting and also provides additional insights regarding acupuncture, specifically through the disaggregation of specific CAM modalities.

Why are we hiding? A qualitative exploration of New Zealand acupuncturists views on interprofessional care.

BACKGROUND: In recent years more health service users are utilising complementary and alternative medicine (CAM), including acupuncture, for the management of their health. Currently general practitioners (GPs), in most cases, act as the primary provider and access point for further services and also play an important role in integrated care management. However, the interaction and collaboration between GPs and acupuncturists in relation to shared care has not been investigated. This research explored interprofessional communication between GPs and acupuncturists in New Zealand. This article reports specifically the acupuncturists' viewpoints. METHODS: This study formed part of a larger mixed methods trial investigating barriers and facilitators to communication and collaboration between acupuncturists and general practitioners in New Zealand. Semi structured interviews of 13 purposively sampled acupuncture participants were conducted and analysed using thematic analysis. RESULTS: The data analysis identified both facilitators and barriers to integrative care. Facilitators included a willingness to engage, and the desire to support patient choice. Barriers included the limited opportunities for sharing of information and the lack of current established pathways for communication or direct referrals. The role evidence played in integrative practice provided complex and contrasting narratives. CONCLUSIONS: This research contributes to the body of knowledge concerning communication and collaboration between GPs and acupuncturists, and suggests that by facilitating communication and collaboration, acupuncture can provide a significant component of integrated care packages. This research provides context within a New Zealand health care setting, and also provides insight through the disaggregation of specific provider groups for analysis, rather than a grouping together of CAM as a whole.

Using Forbidden Points in Pregnancy: Adverse Outcomes and Quality of Evidence in Randomized Controlled Trials-A Systematic Narrative Review.

Objective: Pregnancy is a complex physical and hormonal condition. Many women experience back and pelvic pain, reflux, and headaches during pregnancy. There has been a significant rise in the popularity of acupuncture for pain conditions in pregnancy, wherein nonpharmacologic options are important. Concerns have been raised by both traditional and medical acupuncturists about using "forbidden points" during pregnancy and the risk of preterm contractions (PTC), as this could limit women's and practitioners' willingness to continue treatment during pregnancy. There is also a risk of bias introduced into clinical trials when participants are highly selected or they drop out of studies due to adverse outcomes. This review examined randomized controlled trials (RCTs) of acupuncture using forbidden points prior to 37 weeks of pregnancy to treat pain conditions, with the primary outcome of PTC. Methods: A database search identified RCTs, including trials of penetrating acupuncture that used forbidden points in their protocols to treat pregnancy-related pain conditions. STRICTA [Standards for Reporting Interventions in Clinical Trials of Acupuncture] and GRADE [Grades of Recommendation, Assessment, Development, and Evaluation] criteria were used to assess the quality of evidence. This review includes 8 RCTs reporting on 713 women. Results: Only 2 studies reported on the primary outcome of PTC, and there were insufficient data to perform a primary analysis. In these 2 studies, 6 participants withdrew due to PTC. No study was at a low risk of bias for all GRADE domains, and 3 studies were at high or unclear risk of bias in all domains. Conclusions: PTC is an important clinical outcome and should be reported routinely. The strength of evidence to date is insufficient to recommend using forbidden points prior to 37 weeks of pregnancy. Highly selected patient populations, risk of bias in study design, and participant withdrawal rates, suggest that high-quality trials are required.

U.K. Support Network for Maternity Acupuncture: Survey of Acupuncturists on the Acupuncture (for Conception to) Childbirth Team.

Objective: In the United Kingdom, a professional acupuncture network, the Acupuncture (for Conception to) Childbirth Team (ACT), provides education and support for practitioners using maternity acupuncture. However, the nature of treatments their members provide has been unknown. The aim of this survey was to explore how ACT members used acupuncture for maternity care within their women's health practices. Materials and Methods: An anonymous self-completion questionnaire, hosted by Survey Monkey, was completed by practitioners from 10 ACT branches. Questions covered demographic information, type and frequency of treatment provided in the previous year, and referral networks. Descriptive statistics were used to report the data. Results: Of 114 survey forms sent, 99 replies were received, a response rate of 86.8%. In addition to fertility and menstrual conditions, the majority of the practitioners (87 [87.8%]) had treated at least 1 pregnant woman each. The most-common maternity situations encountered were: birth preparation (84 [96.5%]); nausea & vomiting (82 [94.2%]); and inducing labor (79 [90.8%]). More than 50% of the practitioners were also treating lower-back and pelvic pain (77 [88.5%]), breech presentations (74 [85.0%]), threatened miscarriages (55 [63.2%]), and headaches/migraines (46 [52.8%]). Only a minority (8 [9.1%]) attended births. A greater number of referrals were received from medical health professionals for pregnancy (54 [65.8%]) than for fertility (16 [19.5%]) or menstrual conditions (8 [9.7%]). Conclusions: ACT practitioners were treating a wide range of maternity conditions. Referrals from Western medical practitioners were more common for maternity acupuncture than for fertility or menstrual health. It may be that this professional network approach would be beneficial in other countries to support practitioners interested in providing maternity acupuncture.

Safe acupuncture and dry needling during pregnancy: New Zealand physiotherapists' opinion and practice.

OBJECTIVE: Acupuncture guidelines have advised caution when treating women during pregnancy, because historical "forbidden" acupuncture points are believed to stimulate miscarriage or early labor. Despite recent research demonstrating that acupuncture is a useful and safe treatment tool for pregnancy-related low-back pain (LBP) and pelvic girdle pain (PGP), it is postulated that fear of miscarriage and subsequent blame by association, restricts its provision. More recently, an increase in dry needling (DN) courses for physiotherapists has potentiated the rapid growth in DN practice in New Zealand (NZ). Many dry needlers do not consider DN to be a form of acupuncture; it is unknown if they have similar safety concerns. METHODS: NZ registered physiotherapists practicing acupuncture and/or DN were invited to participate in an electronic survey to examine their practice and level of understanding in regard to safe needling during pregnancy. RESULTS: Of 124 respondents, only 60 (48%) would needle pregnant women, with a further 66% of those still expressing safety concerns. NZ physiotherapists practicing DN only, were more likely to needle areas related to "forbidden" points in all trimesters. However, overall, NZ physiotherapists were less likely to needle "forbidden" points than their UK peers. CONCLUSION: Conflicting literature and a "fear of blame" influences NZ physiotherapists' decisions to offer needling (both acupuncture and DN) during pregnancy. Further training in this field is recommended to ensure safe practice and adequate provision of acupuncture treatment options for pregnant women suffering musculoskeletal pain, such as LBP and PGP. Further research, particularly into DN, for women during pregnancy, is warranted.

Treating Pain in Pregnancy with Acupuncture: Observational Study Results from a Free Clinic in New Zealand.

INTRODUCTION: Clinic-based acupuncturists, midwives, and physiotherapists have reported using acupuncture to treat lumbopelvic pain in pregnancy, a common condition that may affect functioning and quality of life. To contribute to the emerging evidence on treatment outcomes, we collected patient-reported pain reduction data from women treated during pregnancy in a no-pay, hospital-based acupuncture service in New Zealand. METHODS: Observational study of patient-reported symptom reduction.The main outcome measure was the MYMOP (Measure Your Medical Outcome Profile), a brief, validated self-report instrument. Open-ended questions on treatment experiences and adverse events were included. RESULTS: Of the 81 women on whom we had complete treatment data, the majority (N = 72, 89%) reported clinically meaningful symptom reduction. Patient-reported adverse events were infrequent and mild. DISCUSSION: Patient-reported and treatment-related lumbopelvic pain symptom reduction findings provide further evidence that acupuncture in pregnancy is safe and beneficial in a field setting. We discuss this study's unique contributions in providing guidance for clinicians who practice acupuncture in pregnancy, including midwives, physiotherapists, and physicians.

Does acupuncture have a role in the treatment of threatened miscarriage? Findings from a feasibility randomised trial and semi-structured participant interviews.

BACKGROUND: Threatened miscarriage is a common complication of early pregnancy increasing the risk of miscarriage or premature labour. Currently there is limited evidence to recommend any biomedical pharmacological or self-care management, resulting in a 'watchful waiting' approach. The objective of this study was to examine the feasibility of offering acupuncture as a therapeutic treatment for women presenting with threatened miscarriage. METHODS: A mixed methods study involving a randomised controlled trial and semi structured interviews. A pragmatic acupuncture protocol including medical self-care advice was compared to an active control receiving touch intervention and medical self-care advice. Descriptive statistics were used to examine the demographic and baseline characteristics. Endpoints were analysed between groups using a mean t-test and chi-square tests with P < 0.05 considered statistically significant. Dichotomous data was expressed as Risk Ratio with 95 % confidence intervals. Eleven participants were purposively interviewed about their experiences on exiting the trial with interviews analysed using thematic analysis. RESULTS: Forty women were successfully randomised. For women receiving acupuncture there was a statically significant reduction with threatened miscarriage symptoms including bleeding, cramping and back pain compared with the control (p = 0.04). Thematic analysis revealed women were dissatisfied with the medical support and advice received. An overarching theme emerged from the data of 'finding something you can do.' This encompassed the themes: 'they said there was nothing they could do,' 'feeling the benefits' and 'managing while marking time.' CONCLUSION: Acupuncture was a feasible intervention and reduced threatened miscarriage symptoms when compared to a touch intervention. Further research is required to further explore acupuncture use for this common complication and whether it can reduce the incidence of miscarriage. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12610000850077 . Date of registration 12/10/2010. Retrospectively registered, with first participant enrolled 11/10/2012.

"Well I'm safe because " - acupuncturists managing conflicting treatment recommendations when treating threatened miscarriage: a mixed-methods study.

OBJECTIVE: To explore how contraindications to the use of acupuncture during pregnancy are managed in clinical practice. DESIGN: Acupuncturists' views on their management of threatened miscarriage were sought by using a mixed-methods design involving a self-completed questionnaire and semi-structured interviews. An online survey was distributed through the Australian and New Zealand acupuncture associations requesting practitioners' to access an online link to a questionnaire hosted by Survey Monkey. This questionnaire examined acupuncturist's views on safety and the use of Traditional Chinese Medicine treatment modalities. Descriptive and bivariate statistics were used to analyze data. Thirteen participants were purposefully selected from the survey responses to further explore treatment management. These interviews were recorded via Skype, transcribed, and analyzed by using thematic analysis. RESULTS: Of 370 respondents, 214 (58%) had treated women for threatened miscarriage within the previous year. Approximately half (58%) had treated four or fewer women, while a minority (14%) had treated 15 or more. The use of abdominal and blood invigorating points reflected diverse treatment strategies within acupuncture textbooks. While the majority avoided acupuncture points traditionally cautioned against in pregnancy, 13% would use LI 4, 22% would use SP 6, and 31% would use BL 32. Two safety themes emerged: "Well I'm safe because…justifying diverse approaches" and "A limited knowledge base-sorting it out for yourself," illustrating how practitioners justified safe practice and had difficulty obtaining trustworthy treatment knowledge. CONCLUSION: Practitioners demonstrated interest in treating threatened miscarriage. All practitioners saw themselves as providing safe treatment. Those using historically contraindicated points justified their use on the basis of personal opinion, advice from trusted others, and clinical experience with a small number of women. In treating at-risk pregnancies, these justifications may be inadequate. Further research exploring the views of practitioners who are experienced in this specialized area would inform clinical practice for this common complication of early pregnancy.

Treatment of women's reproductive health conditions by Australian and New Zealand acupuncturists.

BACKGROUND: Acupuncture is used by nine percent of the Australian population; however, we know relatively little about the practice of acupuncture to treat women's reproductive health in Australia and New Zealand. METHODS: This study surveyed acupuncturists to examine their practice with treating women's reproductive health complaints. A cross sectional survey of 3406 Australian and New Zealand acupuncturists was conducted. A self-completion questionnaire explored the areas of acupuncture treatment for gynaecological pregnancy and fertility complaints. RESULTS: Questionnaires were completed by 377 acupuncturists. Ninety-six percent of practitioners reported treating women's reproductive health conditions within the previous year. All three areas of women's reproductive health were commonly treated with 96% treating gynaecological health, 91% treating pregnancy conditions, and 90% fertility conditions. The most commonly treated gynaecological conditions were premenstrual syndrome (90.1%, 95% CI 86.2-93.0), menopause (89.4%, 95% CI 85.4-92.4) and primary dysmenorrhea (89.1%, 95% CI 85.1-92.2). Participants reported treating general fertility not related to assisted reproduction (93%, 95% CI 89.4-95.5), treatment for a diagnosed fertility related conditions (85.8%, 95% CI 81.1-89.4), and to decrease infertility related stress (86%, 95% CI 81.5-89.7). The most common pregnancy related conditions treated were nausea (90.3%, 95% CI 86.3-93.3), back or pelvic pain (89.3%, 95% CI 85.1-92.4), and prebirth labour preparation (86.8%, 95% CI 82.3-90.3). CONCLUSION: Treating women's reproductive health complaints was commonly reported among the groups of acupuncturists in Australia and New Zealand responding to this survey; however, our findings cannot be generalised to the wider acupuncture communities in these two countries.

A search for hope and understanding: an analysis of threatened miscarriage internet forums.

OBJECTIVE: threatened miscarriage is a common complication of early pregnancy, which increases the risk of miscarriage or pregnancy complications such as premature birth. Currently there is limited evidence to recommend beneficial medical treatments or lifestyle changes, resulting in a 'watchful waiting' approach. The aim of this study was to describe women's experiences of threatened miscarriage through examining postings to Internet discussion forums. DESIGN: a Goggle alert for threatened miscarriage was created with emails containing hyperlinks sent to the first author and collected over a seven month period (April to November 2011). Data was analysed using thematic analysis. FINDINGS: one hundred and twenty one discussion threads were collected. The overarching theme that emerged was one of 'a search for hope and understanding'. Within this there were four sub themes that illustrated this search. 'A reason for hope: stories and real life experiences' illustrated how women sought hope for a viable pregnancy through others. 'Becoming the expert,' captures how women gave advice from their own experiences. 'A safe place to share' and 'connecting to empathic support' illustrates how women used this medium for long distance support. KEY CONCLUSION: internet discussion forums were used by women to seek hope and support they were not receiving from their health professionals. Women urged each other to remain hopeful despite a negative medical prognosis. There was an acceptance of a lay expertise within the forums that was valid enough to challenge medical expertise. IMPLICATIONS FOR PRACTICE: health practitioners may need education that helps them balance their delivery of medical information with hope in order to increase feelings of trust. With women seeing the Internet as a useful form of support, it may be relevant for practitioners to consider recommending relevant Internet sites and discuss this with women.

Acupuncture as a therapeutic treatment option for threatened miscarriage.

BACKGROUND: Threatened miscarriage involves vaginal bleeding in a pregnancy that remains viable. This is a common early pregnancy complication with increased risk factors for early pregnancy loss, preterm premature rupture of membranes (PPROM), preterm delivery, low birth weight babies and maternal antepartum haemorrhage. Currently there are no recommended medical treatment options, rather women receive advice that centres on a 'wait and see' approach. For women with a history of unexplained recurrent miscarriage providing supportive care in a subsequent pregnancy improves live birthing outcomes, but the provision of supportive care to women experiencing threatened miscarriage has to date not been examined. DISCUSSION: While it is known that 50-70% of miscarriages occur due to chromosomal abnormalities, the potential for therapeutic intervention amongst the remaining percentage of women remains unknown. Complementary and alternative medicine (CAM) therapies have the potential to provide supportive care for women presenting with threatened miscarriage. Within fertility research, acupuncture demonstrates beneficial hormonal responses with decreased miscarriage rates, raising the possibility acupuncture may promote specific beneficial effects in early pregnancy. With the lack of current medical options for women presenting with threatened miscarriage it is timely to examine the possible treatment benefits of providing CAM therapies such as acupuncture. SUMMARY: Despite vaginal bleeding being a common complication of early pregnancy there is often reluctance from practitioners to discuss with women and medical personal how and why CAM may be beneficial. In this debate article, the physiological processes of early pregnancy together with the concept of providing supportive care and acupuncture are examined. The aim is to raise awareness and promote discussion as to the beneficial role CAM may have for women presenting with threatened miscarriage.

Forbidden points' in pregnancy: historical wisdom?

Within the acupuncture literature there is debate on the safety of using specific acupuncture points during pregnancy. Termed 'forbidden' or contraindicated, they refer to acupuncture points that can be used to induce labour but may also include points with no known inducing or labour-enhancing effects. Recommendations range from avoiding these acupuncture points at any time in pregnancy to statements that despite the warnings in the literature, these points are not contraindicated during a normal pregnancy. This discussion paper examines the historical use of contraindicated points, the physiology of the pregnant body and the effect of these points during research trials. It is hoped that this will encourage further discussion and provide a background for practitioners to make informed choices about how they use these points in clinical practice.