Therapeutic Exercise & Acupuncture for Pregnancy Low Back Pain: Review & Meta-analysis Sample

Table of Contents

CHAPTER 1: Introduction
1.1 Introduction
1.2 Background
1.3 Research Rationale
1.4 Research aim
1.5 Research Objectives
1.6 Research Hypothesis
1.8 Summarization
Chapter 2: Methodology
2.1 Introduction
2.2 Search strategy
2.3 Keywords
2.4 Databases
2.5 Inclusion criteria
2.6 Exclusion criteria
2.7 Title screening
2.8 Abstract screening
2.9 Flow diagram
2.10 Research ethics
2.11 Data Analysis
2.12 Timeline of project
Chapter 3: Result and analysis
3.1 Systematic LR table
3.2 Meta-analysis process
3.3 Data Analysis
Chapter 4: Discussion of Finding
4.1 Primary Analysis
4.2 Limitations
4.2.1 Limitationss of the articles selected for meta-analysis
4.2.2 Limitations of the complete analysis
4.3 Future work
4.4 Summary
Chapter 5: Discussion of Finding
5.1 Primary Analysis
5.2 Limitations
5.3 Future work
5.4 Summary
5.5 Conclusion Not needed!
Chapter 6: Conclusion and Recommendation
6.1 Introduction
6.2 Linking with Objectives These below were not your objectives!! You need to move some of the information below into the appropriate sections ie the discussion section!
6.3 Recommendations
6.4 Conclusion

103969 Pages 17242 Words

CHAPTER 1: Introduction

1.1 Introduction

Low back pain is a chronic, but common condition among elderly people across the globe. Among the adults, particularly among expectant mothers. Chronic discomfort in the buttock and lower edge of the ribs might be used to characterize back pain. Nearly 23% of persons worldwide are thought to experience chronic low back pain (LBP). Around 75% of older people have this condition.

There are various reasons that could lead to the situation of the back pain. The causes include, strain the muscles and ligaments associated with the backbone of the human body. There could be other reasons like, that of autoimmune disorders like rheumatoid arthritis, osteoporosis and others. Severe back pain could also lead to a situation of paralysis, and severe disabilities. There is also, the possibility of loss of feeling at the site of pain. The symptoms of lower back pain are muscle aching, burning, sensation at the site, feels of stabbing among others. There are various ways present to deal with the situation, and treatment of such patients. Nonsteroidal anti-inflammatory medicines (NSAIDs) are used in the treatment of LBP. These include oxycodone and fentany among others, tramadol. However, the adverse effects include, among others, the emergence of clouded judgment, nausea, and slow breathing. Due to these, people are now looking for alternate forms of therapy. a common cause of back discomfort, is one of the classic therapeutic options. A regular break during the day is necessary in relation to the modification activities and may aid in reducing muscle spasms and sharp pain. Elderly adults and pregnant women both have severe low back discomfort (Ma, et al., 2022). Chronic discomfort in the lower back is one of the signs of low back pain in pregnant women. This is characterized by a deep, aching pain that may be unilateral or bilateral, that began between the iliac crest and gluteal fold, and extends to the leg and knee. Various different methods regarding the alternative treatment of back pain could be employed for the patients, specially the pregnant women. Therapeutic exercises, yoga, Stretching, manual therapy techniques, yoga poses, simple at-home workouts, and cardiovascular exercises are a few of the examples.

There are different symptoms of the low back pain that is associated with the LBP of a pregnant women. The symptoms of the pain could be continuous, deep pain, bilateral or unilateral, and that had started between the gluteal fold and iliac crest, to the knees and calf.

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1.1.1 Research Framework

The framework of the research is given in the image below. This needs to come earlier in the introduction if you feel you need to put it in!

Figure 1: Research Framework

(Source: Self-created in draw.io)

1.2 Background

Low back pain was traditionally treated using conventional ways, including the use of drugs like oxycodone. among others, tramadol. However, these therapy regimens had some very dangerous adverse effects, including the fetus's development being impeded and the possibility of them suffering from excruciating knee and other joint pain. The process is crucial for a decrease in the women's back discomfort in relation to the therapeutic exercises (Hochheim et al., 2023). "Ergonomics" is the study of how the process treats women. The method teaches the women how to stand, walk, and bend without putting pressure on their spines.

The problem of back pain during pregnancy is a complex, and severe phenomenon, that could lead to several health issues, and increases the possibility of childbirth of a defective child. During pregnancy, the ligaments of the back mussels of the body would become softer and stretched (KoukoulithrasSr, et al., 2021). This would lead to an area around the vagina becoming softer and preparing the body for the birth of the child. But, this has negative consequences as well. For example, as a result of stretched ligaments, it would put pressure on the joint of the lower back and pelvis of the body, which causes back pain. Also, the continuous growth of the uterine region leads to increasing pressure on the muscles and ligaments of the body. There are many ways present to deal with the medical condition, which include the use of methods such as therapeutic exercises and acupuncture (Xiang, et al., 2020). It had been found that to tackle the low back pain situation among the pregnant woman, the use of the mentioned methods are important.

Figure 2: Prevalence of low back pain among pregnant women

(Source: www.medwinpublishers.com)

The stimulation of the central nervous system is how acupuncture works. The human body responded after being pricked with a pin in the region of the backache. There is a chemical release into the muscles that also affected the spinal cord, brain, and muscles. Acupuncture may function by accelerating the transmission of electromagnetic signals, according to many theories (Yue et al., 2021). Endorphins and other pain-relieving substances had been crucial in the reduction of pain. Additionally, the release of endogenous opioids may facilitate sleep and minimize pain perception.

One can also take different steps regarding the reduction of pain during pregnancy at home. These are, bending of knees and keeping the back straight when picking something from the floor. Also, avoiding of the heavy lifting of objects, moving the feet when turns to avoid twisting of the spine, wearing flat shoes, and having a massage or warm birth among others. But, there are various previously published studies, which suggested that, implementation of the treatment using acupuncture and therapeutic exercises had a greater impact on the treatment of such problems (Su, et al., 2021). Another reason behind the implementation of the strategies is the protection of mothers from the harmful impact of medicine. As, the various drugs and painkillers present in the market, could help to reduce the pain in a quick time, but have side-effects and could have a negative impact on the health of the child. So, in recent years, many of the people had turned to the use of these methods. The study would evaluate the effectiveness and implementation of therapeutic exercise and acupuncture for the treatment of low back pain during pregnancy (British Medical Association, 2020). A complete analysis of the impact of the use of these techniques were discussed.

1.3 Research Rationale

The comparison of the procedures and effective conclusions about the justifications for the use of therapeutic exercise and acupuncture are the driving forces behind the implementation of the research. Acupuncture has greatly decreased the likelihood of severe back discomfort during pregnancy. It was discovered through the examination of numerous earlier studies. Additionally, the procedures have no or minimal negative effects that pregnant women could experience (Physio-pedia.com, 2019). The practice of acupuncture is believed to encourage the body's "endorphin" or happy chemical release. Additionally, enhance the blood flow to nearby muscles and skin.

The reason behind the implementation of the research is about the comparison of the processes and successful findings about the reasons behind the implementation of the therapeutic exercise and acupuncture process. The implementation of acupuncture had significantly reduced the chances of severe back pain during pregnancy. It had been found by the observation of different previously carried out studies. These are, bending of knees and keeping the back straight when picking something from the floor. Also, avoiding of the heavy lifting of objects, moving the feet when turns to avoid twisting of the spine, wearing flat shoes, and having a massage or warm birth among others. Also, there are various previously published studies, which suggested that, implementation of the treatment using acupuncture and therapeutic exercises had a greater impact on the treatment of such problems. This study was based on the statistical analysis of the methods in comparison to the medical treatment methods. After the completion of the statistical analysis, comparative results were produced. The processes also have no or minimum side effects that might be felt by the pregnant women (Physio-pedia.com, 2019). The process of acupuncture is thought to stimulate the release of “endorphins” or happy chemicals inside the body. Also, increase the flow of blood to local skin areas and muscles. A final analysis of the 10 different randomized control trials, involving 1050 women from the countries of the US, the UK, Spain, Sweden and Brazil between 2000 and 2020 had found interesting results. Among the 10 studies, the results of the 9 studies had found that acupuncture significantly relieved the pain during pregnancy (Ma, et al., 2022). Five studies had suggested it significantly improves the quality of life too. Results of four studies had suggested that there was a significant improvement of the health of the pregnant women in comparison to other processes. But, results of the seven studies had found that there is a rising of some minor side effects, such as soreness, and bleeding at the site of puncture by the needle among others. The goal of the meta-analysis was to evaluate the effectiveness of acupuncture as a complementary therapy for treating LBP in pregnant women. additionally to contrast the outcomes with conventional medical treatments. Since little is known regarding the efficacy of alternative therapy modalities.

In relation to the therapeutic exercises, the process is important regarding a reduction in the back pain of the women. The treatment of women using the process is known as “ergonomics”. The process helps the women to learn about how to walk, stand, and bend by not pressuring the spine (Hochheim, et al., 2023). In relation to the modification activities, a scheduled rest during the course of the day is essential and could help to relieve muscle spasms and acute pain. The therapeutic exercises include stretching, manual therapy techniques, yoga exercises, minor home exercises, and aerobic exercises among others.

In terms of treatment and reduction of symptoms using the therapeutic exercises and acupuncture methods, these could lead to the development of a situation where it will reduce the back pain of the pregnant woman. The main reason behind the implementation of the study was to compare the acupuncture and therapeutic exercise methods to reduce the back pain of the pregnant women, with that of the traditionally available medical procedures (Kim, et al., 2023). This was a primary analysis, and the result of the study was based on the statistical analysis of the collected data.

1.4 Research aim

The aim of this research is to critically appraise and summarize the evidence of relevant systemic review to represent a comprehensive evaluation of therapeutic exercise and acupuncture for the therapy of low back pain among pregnant ladies.

1.5 Research Objectives

The objectives of the meta-analysis research is given below.

1) To carry out an automated search of the literature and data about the use of therapeutic exercise and acupuncture to treat low back pain in expectant women.

2) To describe the necessity for structural study and a meta-analysis of the acupuncture method among pregnant women.

To evaluate the studies that were chosen for the meta-analysis and pinpoint the pertinent research.

4) To carefully examine the chosen studies in order to tie them to the meta-analysis.

5) To thoroughly examine the analysis's findings.

6) To offer some professional advice regarding acupuncture and restorative exercises.

1.6 Research Hypothesis

H1:The therapeutic exercise and acupuncture processes are effective in the treatment of pregnant women.

H2: Therapeutic exercise and acupuncture processes are not effective in the treatment of pregnant women.

1.8 Summarization

Systemic reviews of different quality show that acupuncture is either applicable for isolation or an adjunct to conventional therapy, that provides a short-term improvement in pain or may function for chronic LBP. Although the study focused on the different various caustic environment that can be helpful for the improvement of lower back pain reduction in pregnant women and various other beneficial activities that ultimately helps to the reduction of pain. In a summary about the acupuncture and therapeutic exercise, it can be said that the acupuncture and therapeutic exercises are important processes to deal with the back pain situation of the pregnant women. This study was based on the statistical analysis of the methods in comparison to the medical treatment methods. After the completion of the statistical analysis, comparative results were produced. In the next chapter, a comprehensive review of different literatures were done on the basis of the collected articles published previously.

Chapter 2: Methodology

2.1 Introduction

In this section, the methodology that was followed by the investigators was discussed. This was related to the process that was followed by the investigators during the analysis. The “search strategy” of the research is the searching process that was followed by the researchers during the meta-analysis. There are several inclusion and exclusion criteria that were set out by the researchers that should be followed during the analysis.

2.2 Search strategy

The search strategy of articles for the meta-analysis involves different steps. After opening a database like “Google Scholar”, or “PubMed”, the research topic was searched using “keywords”. Various inclusion and exclusion criteria were followed. Inclusion criteria include articles, references from books, or websites containing results and analysis of primary nature about the topic of “Effectiveness of therapeutic exercises and acupuncture for the treatment of low back pain”. Also, articles after the year 2019 were selected (Ma, et al., 2022).

Exclusion and inclusion criteria: The exclusion criteria for the journalistic articles or research papers were, those that followed a secondary analytical method, also those that contain an analysis of similar topics, but different criteria, like those that did not contain the impact of acupuncture and therapeutic exercises for back pain, published before the year 2019, and also those that did not discuss the results critically. Besides that, the literature from which the references were taken for this report, the writing was completed based on relevant data, and those were related to the topic. The process is known as the “abstract screening”. Also, during the analysis of data, a “comprehensive meta-analysis software” was used. The results of the meta-analysis had been summarized in different tables (Lightbody, 2020). But, during the analysis, specific data were selected according to the preferential screening (Lightbody, 2020). For example, in the result table of “pain and disability”, the result of mean NRS at week 5, after imputation was selected. The overall process of methodology is provided in the figure of the flow chart below. Here are some listed conditions that exclusion and inclusion criteria help to set the boundaries, for the systemic review. For specific topics in the research question (such as adolescence or depression), it could also be important to provide definitions and the source of those definitions. Additionally, “comprehensive meta-analysis software" was employed during the data analysis. Several tables had been created to summarize the meta-analysis's findings (Lightbody, 2020). However, specific data were chosen for examination based on preferable screening (Lightbody, 2020). For instance, the result of the mean NRS at week 5, after imputation was chosen, is shown in the "pain and disability" result table. In statistical analysis, the "Z-value" refers to the statistical measure that examines the correlation between a specific value and the mean of a set of values. The standard deviation of a dataset's value from its mean is used to calculate the z-value.

Figure: Bayesian network of Acupuncture on lower back pain

(Source:josr-online.biomedcentral.com)

Figure 3: Flow chart of the methodology

(Source: Self-generated in draw.io)

2.3 Keywords

Here in this part, some major essential features that indicate the main things about this topic are described. These are “therapeutic exercise”, “RCT”, “orderly survey”, “essential exploration meta-examination”, “needle therapy”, “low back agony”, and “pregnancy”. Because these keywords will improve the precision of the search, they will be used (Hochheim, et al., 2023). The number of search results related to the effects of low back pain, pregnancy, and Boolean operators will also decrease if keywords are identified.

2.4 Databases

Numerous databases, including,

1)PubMed: a collection of abstracts and citations from medical, nursing, industrial, veterinary, health care system, and preclinical sciences biomedical periodicals. After the selection of the articles they were sorted out according to the inclusion and exclusion criteria before the starting of the analysis.

In the medical domain, frequent assessments and meta-studies are frequently carried out using these databases, which can serve as an exhaustive and reliable resource for your research. The accompanying key expressions will be utilized while looking through the above data set both uniquely and related to each other to play out a title search to start ignoring no important examinations.

2.5 Inclusion criteria

1) Studies involving pregnant women who suffer from low back pain

2) Cohort, case-control, quasi-experimental, and randomized controlled trials (RCTs) that assess the efficacy of healing activity and/or acupuncture as treatments for low back pain during pregnancy.

3) Studies distributed in the English language.

4) Research into the efficacy of acupuncture and therapeutic exercise for pregnant women with low back pain.

2.6 Exclusion criteria

1) Studies not distributed in the English language.

2) Studies with a follow-up period of less than four weeks following the intervention's conclusion.

3) Studies that do not consider the efficacy of therapeutic exercise and/or acupuncture as treatments for low back pain during pregnancy.

4) Studies that look at treatments for low back pain during pregnancy other than therapeutic exercise and/or acupuncture (such as drugs, surgery, massage treatment, and chiropractic maintenance).

2.7 Title screening

It is important to note that the scope of the review and the detailed analysis inquiry may necessitate different inclusion standards (López-Liria, et al., 2021). The title screening method is only one stage in the bigger course of directing a precise survey and meta-examination.

2.8 Abstract screening

When executing an organized assessment and meta-analysis of the efficacy of medicinal workouts and acupuncture for the therapy of low back pain during pregnancy, abstract screening is an essential effort (Bourbeau, et al., 2020). This stage includes a careful screening of the edited compositions of possibly significant examinations to decide their reasonableness for consideration in the survey.

2.9 Flow diagram

The flow diagram outlines a general, systemic review process of the all the article, and journals selected for the review and analysis. From the search of the databases like “PubMed”, and “Google Scholar” the articles were selected. All the articles essentially talks about the process of acupuncture and its impact for the treatment of low back pain among the pregnant women. A total 4 different articles were selected (Baillyet al, 2021). After the selection of the articles, they were sorted out according to the specific measurements. These criteria were deployed for the systemic review of the patients as well. Criteria such as, language, year, use of data analysis methods, among others. These are the exclusion criteria. Several inclusion criteria were also considered. For example, the year of publication of the article, the separation between the location of pain among the pregnant women, and the methods of treatment. In this analysis, among the four different articles selected, all of them were included for the literature review (Putri et al, 2021). The main reason behind the inclusion of all the articles that were selected was beacuse of the presence and comparison of the method of acupuncture and other medical treatment for the pain relief of low back pain (Richards et al, 2019). The flow diagram is shown in the figure below.

Figure.4: Flow diagram of the reviewed articles
(Source: Provided)

2.10 Research ethics

There are primarily two stages regarding this research, collection of data from the selected articles, and conduction of the meta-analysis. This research had taken consideration of the ethical approvals from the “LeedsBeckett ethics committee” for this work. Those are as outlined below:

Firstly, the research process and the selected strategies regarding data collection and analysis had complied with all the standards and policies of conducting research. The data collection process involved the healthy and hypercholesterolemia persons those were in the need of probiotics or any other matter of professional expertise (Plemmonset al. 2020). During the conduction of the research, the researchers had ensured that there was no harm to be caused due to the process of the research to any community or the environment. The research process pure has also emphasised on the strict prohibition of any form of discrimination among the participants. The research was conducted with absolute honesty and truthfulness, as a result suppressing the possibility of data manipulation of data in all the possible form regarding the responses provided by the participants or the results found after the meta-analysis.

2.11 Data Analysis

The information examination procedure for an orderly survey and meta-investigation of the viability of restorative activity and needle therapy for the treatment of low back pain in pregnancy commonly includes a few stages:

1) Extraction of data: The initial stage is to separate applicable information from the retained examinations, for example, concentrating on the plan, populace attributes, mediation subtleties, and result measures. Typically, this information is penetrated into a traditional form or database.

2) Evaluation of grade: The following action is evaluating the incorporated analyses' quality by utilizing instruments like the Newcastle-Ottawa Scale for observational analyses or the Cochrane Risk of Bias tool (Putri, et al., 2021). This assists with distinguishing likely wellsprings of predisposition and illuminates the examination.

3) Distribution predisposition evaluation: At last, an evaluation of distribution inclination might be led, utilizing techniques, for example, channel plots or Egger's regression test (Mapinduzi, et al., 2023). This assists in determining any possible discrimination brought about by the particular journal of contemplations with favorable outcomes.

A systematic review and meta-analysis of the efficacy of therapeutic exercise and acupuncture for the therapy of low back pain in pregnant women call for rigorous quality assessment and statistical analysis, as well as careful data extraction and synthesis from multiple studies (Ferraz, et al., 2023). The objective is to give an extensive and unprejudiced rundown of the accessible proof of the viability of these intercessions for pregnant ladies with low back pain. After the collection of data, the datasets were inserted into the RevMan software for the completion of the meta-analysis. The results of the meta-analysis had been given in the chapter 3.

For the completion of the meta-analysis, relevant articles related to randomized control trials (RCTs) that had analysed the importance of acupuncture to complete the treatment of LBP in the pregnant women were taken. After the sorting of the articles, the relevant data related to the statistical comparisons of the acupuncture group and control group of patients were inserted into the Revman software. Then, the meta-analysis was carried out.

2.12 Timeline of project

Figure 5: Gantt chart

(Source: Self-generated in Project Libre)

Chapter 3: Result and analysis

3.1 Systematic LR table

This section talked about the four selected articles that were included in by the researchers for the completion of a meta-analysis.

Authors/date	Title	Aim	Methods N=	Methods treatment	Result	Main findings	Conclusion	Other issues
Butel, T., Nicolian, S., Durand, M., Filipovic-Pierucci, A., Kone, M., Gambotti, L., Mallet, A. and Dommergues, M., 2019.	Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: A randomized controlled trial	The probability of the intervention being cost effective using the base case data for a range of cost effectiveness ceiling.	N=No. of participants 200. 96 women were allocated to acupuncture and 103 to standard care.	Women were randomized in parallel to receive standard care or standard care plus acupuncture with a 1:1 allocation ratio. Patient age is age 18 or older, gestational age between 16 and 34 week with low back pain for at least two weeks, with pain greater than 4 on a 10-point numerical rating scale (NRS) The intervention consisted in 5 acupuncture sessions, performed by an acupuncturist midwife (SN) on top of standard treatment. There were 2 sessions in the first week, followed by three weekly sessions.	The proportion of days with NRS 4/10 was greater in the acupuncture group than in the standard care group (61% vs 48%, p = 0.007). The mean Oswestry disability score was lower in the acupuncture group than with standard care alone (33 versus 38, Δ = 5, 95% CI: 0.8 to 9, p = 0.02). Average total costs were higher in the control group (€2947) than in the acupuncture group (€2635, Δ = —€312, 95% CI: -966 to +325), resulting from the higher indirect costs of absenteeism and presenteeism. Acupuncture was a dominant strategy when both healthcare and non-healthcare costs were included.	Acupuncture is more effective.	Acupuncture was a dominant strategy when accounting for employer costs. A 100% probability of cost-effectiveness was obtained for a willingness to pay of €100 per days with pain NRS 4.	All patients provided written informed consent, after receiving verbal and written information specifying the design of the study, the duration of their participation, practical issues on the trial, and the fact they could withdraw their consent at any time.
Guerreiro da Silva, J.B., Nakamura, M.U., Cordeiro, J.A. and Kulay Jr, L., 2011	Acupuncture for Low Back Pain in Pregnancy – a Prospective, Quasi- Randomised, Controlled Study	To compare the efficacy of standard treatment, standard treatment plus acupuncture, and standard treatment plus stabilising exercises for pelvic girdle pain during pregnancy	N=No. of participants is 61 pregnant women. Study group N= 27 and control group N= 34.	Patient age between 15 to 39 years and 15 to 30 weeks of pregnancy an d at least minimum low back pain or pelvic pain. Treatment with acupuncture was normally performed once a week, though occasionally twice when it was deemed necessary for severe pain, over an eight-week period, making a minimum of eight and a maximum of 12 sessions.	The birth weights of the infants in the two groups did not differ significantly, being 3179g (SD 355g) in the acupuncture group and 3260g (SD 292g) in the control group (P=0.35). The mean value for the one-minute Apgar score was 8.8 (SD 0.7) in the acupuncture group and 8.4 (SD 0.4) in the control group (P=0.58). One infant in the acupuncture group scored six at one minute, and two in the control group scored seven. The mean value for five-minute Apgar was 9.8 for both groups (P=0.9).	Acupuncture is more effective than stabilizing exercises	Acupuncture and stabilizing exercises constitute efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy	Pelvic girdle pain generally arises in relation to pregnancy, trauma, or reactive arthritis
Bishop, A., Ogollah, R.O., Barlas, P., Bartlam, B., Holden, M.A., Ismail, K.M.K., Jowett, S., Kettle, C., Kigozi, J., Lewis, A.M. and Lloyd, A., 2016.	Evaluating acupuncture and standard care for pregnant women with back pain: the EASE Back pilot randomised controlled trial	To know Low back pain (LBP) and pelvic girdle pain (PGP) during pregnancy are common and often accepted as a ‘normal' part of pregnancy	No of participants are 388	Patient aged 18 years and over ;between 13 to 31 weeks gestation. The number of treatments participants received was lower than anticipated, mainly due to the high levels of non-attendance for treatment appointments. Whilst the average number of treatment sessions in both arms receiving acupuncture was 6 (in line with the specified protocols), 13 (38%) in the SC+TA arm and 9 (23.7%) in the SC+NPA arm attended for fewer than 6 sessions.	Pregnancy-related LBP increases with advancing pregnancy, is usually worse at night and interferes with sleep, daily activities and work	Acupuncture re is more effective in pregnant women	A full RCT is feasible and would provide evidence about the effectiveness of acupuncture and inform treatment choices for women with pregnancy-related LBP.	In this study data collection shows most of the gap.
Elden, H., Ladfors, L., Olsen, M.F., Ostgaard, H.C. and Hagberg, H., 2005.	Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial	To compare the efficacy of standard treatment, standard treatment plus acupuncture, and standard treatment plus stabilising exercises for pelvic girdle pain during pregnancy.	No of participants are 386	secondary outcome measure was assessment of severity of pelvic girdle pain by an independent examiner before and after treatment	treatment the stabilising exercise group had less pain than the standard group in the morning (median difference = 9, 95% confidence interval 1.7 to 12.8	Acupuncture is more effective	Acupun cture and stabilising exercises constitute efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy	More data is required to analyze

Table 1: Systemic LR table

(Source: Self-made in MS word)

3.2 Meta-analysis process

The data was based on the mean difference between the starting stage of therapy and that of the end stage of average pain, worst pain, and pain currently from Guerreiro da Silva et al. (2004) (Lunnyet al., 2022). The decimals were eliminated for convenience in the sample because it was collected after the numbers had been multiplied by a factor of 10. The worst discomfort was equal to 4.8*10=48. It was discovered to be 3, 1, and 0 for the control group. The sample size for the second group, which received acupuncture, was determined similarly by multiplying 4.8 by 10. That example, there were 48 participants in the 4.8*10=48 acupuncture group with average discomfort. According to data from the Bishop, et al., 2019 article, the mean SD was also determined, and the range of pain severity following treatment with acupuncture, non-penetration acupuncture, and standard methods was 0 to 10. 41 people in all participated in the study. The findings showed that the mean SD was 0.8 and the mean pain severity for routine care was 6.0. In the case of acupuncture treatment, the mean SD was 2.0, and the pain intensity was 1.9. Additionally, in the instance of acupuncture without non-penetration, the mean SD and pain severity were both at 2.3 (Ma et al., 2022).

In the present study, a meta-analysis was carried out. The goal of the meta-analysis was to evaluate the efficacy of various therapies for low back pain during pregnancy. Acupuncture and customary medical care practices were the therapy modalities that were examined (Nielsen et al., 2019). The level of significance (p-value) for the analysis was set at 0.05. The odds ratios were also computed.

For individuals who were chosen and had RCT data, the data analysis was done using a random-effects model. This aided in determining whether LBP's effects were distinct from those of therapies like acupuncture (Davenport et al., 2022). The information on acupuncture's effectiveness in treating pregnant women is drawn.

Elen, et al.'s initial article from 2005 gives the range of median values for the sample population studied. The standard group's outcome is provided below. One week later, the median value was 58, between 40 and 74 for the 25th to 75th centile, up from the baseline value of 63 between 49 and 75. Comparatively, for the acupuncture group, the baseline median value was 31 at the 25th to 75th centile, and for the acupuncture group, it was 65 at the 47th to 76th centile (de Andrade Alves et al., 2022). As per the article by Guerreiro da Silva, et al., 2004, the mean difference between the initial stage of treatment with that of the final stage of average pain, worst pain and pain now (N’bundé et al, 2021). The sample size for then acupuncture group was calculated by multiplying the distribution of the sample 4.8 with 10. That is, the sample size for the acupuncture group with average pain was 4.8*10=48. Similarly, for the worst pain, it was 4.8*10=48. For the contyraol group it was found to be 3,1 and 0.

As per the data from the article by Bishop, et al., 2019, the pain severity after the treatment by the acupuncture method, non-penetration acupuncture method and standard method, was between 0-10, and mean SD was also calculated (Dutucu et al, 2022). There was a total of 41 participants at the study. The results found that, the pain severity for the standard care was at 6.0, and mean SD was 0.8 (N’bundéet al ,2021). In case of acupuncture treatment, the pain severity was at 1.9, and mean SD was at 2.0. And, in the case of acupuncture without non-penetration, the pain severity was at 2.3, and the mean SD was also at 2.3.

The data was taken from another article as well. As per the data from the article by Nicolian, et al., 2019, a total of 199 pregnant women have participated in the study. Out of which, 96 women were subjected to acupuncture treatment, and 103 women were given standard medical care. The pain assessment was conducted in the “numerical rating scale (NRS)”. The pain assessment and its rating in the NRS grade scale were measured as per the reporting by the women (Fatoye et al,2022). The grade at the pain numerical rating scale (NRS) at the baseline for the acupuncture was at 7.4. After 5 weeks, the result found that, the value of NRS was at 5 for the acupuncture treatment.

The researchers had also taken data from the control groups and compare those results. The results found that, the mean pain numerical rating scale (NRS) at the baseline was 7.5. But, after 5 weeks, it was found to be 6. Through the process of meta-analysis, one can estimate the variance of studies, and also measure the homogeneity between the studies.

3.3 Data Analysis

3.3.1 Input data

After the collection of data regarding acupuncture and the treatment of back pain in the pregnant women, a comprehensive meta-analysis was conducted using “comprehensive meta-analysis software” (Franke et al,2019). After the collection of all the data, it was put on the mentioned software. In the software, two different columns were created. Those were renamed as “Column A’, and “Column B' (Melilloet al, 2023).

In the Column A, the data of acupuncture treatment was put in. And, in column B, the data of the standard medical care was put in. After the completion of the data entry, the analysis was completed. Before the data analysis, a comprehensive data sorting was carried out. Data was selected from four different articles, which were about the comparative analysis of the treatment of low back pain among pregnant women using acupuncture and standard treatment protocols (Gao et al,2022). Before the input of the data into the software, for a matter of convenience, the articles were organised as per the year of publication. In the meta-analysis, four different RCT trial data was included. The data were collected from the four different studies, which were designed in such a way, that the sample population was divided into a standard treatment and acupuncture treatment methods (Guo et al, 2023). Only two different methods of treatment were considered in this analysis, and four different studies were considered. The studies that were selected were researched and published by the scientists, Nicolian, et al., 2019; Guerreiro da Silva, et al., 2004; Bishop, et al., 2019; and Elden, et al., 2005.

From the results of the publication by Elden, et al., 2005, it was found that, for the standard treatment group, in the morning seesion, at the baseline in the beginning (Mapinduzi et al, 2023), the number of pregnant women participated in the standard treatment were 131, which reduced to 108 after one week. Also, the median value was found to be 23, which was for the 25th to 75th centile of 13 to 41, and 27 for the 12 to 58 one week later. In the evening session, the number of pregnant women who participated in the standard care procedure of lower back pain, was 131, at the beginning, or baseline. After one week, the number was 108 women (Hochheimet al, 2023). The median value was 63, for the 25th to 75th centile of 49 to 75. One week later, the median was 58 for the centile between 40 to 74.

In the acupuncture group, in the morning session, total number of women who participated on the beginning or baseline was 125. The median value was found to be 23, for the 25th to 75th centile of 15 to 44 (Zou et al, 2023). But, one week later, the median value was 15, for the 25th to 75th centile of 7 to 29. Regarding the evening session, the number of women who participated during the beginning and after one week remained same. But, the median value at the baseline was 65, for the 25th to 75th centile of 47 to 76. One week later, the median value was 31, for the 25th to 75th centile of 12 to 58.

From the article by Guerreiro da Silva, et al., 2004, the result data was selected. The results were calculated for the level of lower back pain among the pregnant women, in a statistical form. The mean differences for the acupuncture process and control or standard treatment process had been taken (Huang et al, 2021). The data taken were for the different levels of pain, worst pain, average pain and pain now. In the study, total 61 pregnant women had completed the treatment after the inclusion into the study. The selected result data is given in the figure below.

It was found that, a reduction in the “numerical rating scale (NRS)” score, was apparent in the group of women treated with acupuncture. But, for the matter of convenience, in the meta-analysis the values were multiplied by 10, to remove the decimal number, and convert it into whole number (Igwesi-Chidobeet al, 2021). Also, data from standard treatment procedure or control. It can be said that, after the analysis, the acupuncture method was more effective as a method of treatment for the low back pain among pregnant women.

3.3.2 Output data

After the completion of meta-analysis, several conclusions could be drawn. The analysis was carried out using the data from the four studies, the sample size of each of those collected data from the previously published research papers was standardized for the difference in means (d) (Zhang et al, 2022).

For the analysis, the “fixed-effect model” was employed. As per the model, it assumed that the true effect size of data underlines all the studies in the meta-analysis. As a result, the model is known as the “fixed effect” model (Jannah et al, 2022). Also, any differences in the observed effects are mainly because of sampling error in the input data. Thus, as per this model, all the differences those were observed were due to the sampling error in the input data. In this study, four different studies were selected. The input data from those studies is given in the table below.

The standard difference in means for Halen Elder, 2005, was -0.570. The value of the standard difference for the Joao Bosco, 2011, was 0.086, for the Annette Bishop, 2019 was -2.680, for Nicolian, 2019 was -0.180, and pooled value was -0.466. The pooled value was the common effect size for the selected studies. During the analysis, the confidence level that was maintained was at 95%. With an interval of -0.625 to -0.307. The common “effect size” is the “statistical concept that measures the strength of the relationship between the two variables” in a numeric scale. It also depicts the, different sample sizes of different studies, and that then combines into a single analysis (Karjalainen et al, 2022). It can be measured in three different ways, those are, standardized mean difference, odd ratio, and correlation coefficient.

There are different types of effect size in a statistical test. One of them is the “Pearson’s correlation coefficient” (Yue et al , 2020). This parameter of the effect size has been denoted by “r”.

The “Z-value” in a statistical analysis, is the statistical measurement that analyzes the relationship of a particular value with that of the mean of a group of values. The z-value is measured in terms of standard deviation of a dataset value from the mean of that dataset.

If the value of “Z” is scored at 0, that indicates the data point’s score and is identical to the mean 0. If the score is 1, it would indicate a value that is associated with standard deviation from the mean value of that dataset.

From the analysis, it was found that the z-value for the null hypothesis that calculated from the analysis, had an effect size of 0 (Zhang et al,2023). Whereas, the z-value in relation to the p-value<0.001 was -5.747 (Kim et al, 2020). Thus, after the completion of the meta-analysis the null hypothesis was rejected and it was concluded that the population size was not effectively and precisely zero.

Q-test

The “Q-test” is used for the identification of the outliers, and rejection of those from the dataset. The use of the test should be used sparingly nad never more than once for one data set. It measures the differences between a “gap” and “range” (Zhang, et al, 2020). The gap is the absolute difference between the deviation in a question and the closest number to the deviation value. Thus, this test helps the researchers to understand if all the values and ranges were in the same size of effect as that of the true effect size. If the q-value was found near or zero, that could indicate about the true effect size and equal to the degrees of freedom. The use of the criterion of alpha value was 0.100 ( Koukoulithraset al, 2021).

The result of the meta-analysis had found that, the q-value was 64.823, with the degrees of freedom 3. The p-value was <0.001. The results indicated that, the sample size of all the collected data sets from four different studies were significantly different. Also, the differences were significantly broader, as suggested by the value of degrees of freedom. This is probably because of the selection of different studies from different processes.

Indices of heterogeneity

The fixed-effect model helps to find if there is any differences between the size of the population in different datasets taken for analysis. In this research, it was assumed that there is no difference or variation among the population of the sample size. As a result, all the different indices in the “index of heterogeneity” was assumed as 0. The I2, tau2, and tau values were assumed to be 0. The tau2 value indicated about the variance of effect size parameters in different studies. It also reflects about the variance of the true size effects of the sample population (Koukoulithras et al, 2021). Thus, the tau2 had been reflected upon a true amount of heterogeneity. Also, the researchers during the running of meta-analysis, did not compute the level of prediction and which also should be considered during the presentation of the results. The level of prediction told in detail about the variation among the true size of the sample population. If the variation in the sample size increases with that of the different sample size, the size of all the studies had the same effect on the true size of effect (Liao et al,2021). In this case, since the researchers had collected the population data, from that of the different studies, it could easily be predicted that there should be a difference of data size, and also increasing variation.

Chapter 4: Discussion of Finding

4.1 Primary Analysis

In total, 4 articles were found in the databases as a searched, to analyze the data. In this cohort, the author honored an incidence of 77% (61/79), a ratio that coordinates with derivatives. This means, that the difference of the participants those who had been given the treatment with acupuncture process, in comparison to the differences that was suggested regarding the treatment with medications or no treatment. A study of acupuncture demonstrated that investigation for the effectiveness of therapeutic analysis and acupressure which is associated with a consequential contraction of discomfort, decreased the requirement for painkillers, and enhanced operational accommodation. The study also showed that pain decreased in the provided time frames of existing pain; which shows moderate results. In order to this objective, operational capability in stages of available actions, walking, and operating, were remarkably enhanced after acupuncture compared with the governance group. Based on the number of prior pregnancies reports, age, and “body mass index” were identical in the two groups while comparing, banning them for the justification for the dissimilarities between the developments.

The main findings of the meta-analysis was about the dissimilarities of the datasets, and a comprehensive analysis of the data, and analysis. The results in a broader sense had found that, the datasets which were selected from the previously published research papers were different from each other in terms of difference of size, and complexity in the datasets (Ma et al,2022). Also, the data were divided into two categories, one was for standard care, and another one for the acupuncture care of lower back pain among the pregnant women. The result of the z-value had found that, it was scored above zero (Xu et al, 2021), and also the difference of data was is substantive. But, for the matter of convenience, researchers had assumed that, the difference is zero for the datasets (Yao et al,2019). Thus, it was concluded from the result that, the acupuncture method is more accurate for the curing of low back pain for the pregnant women. But, the data was differently collected. As per this study, acupuncture seems to be an influential standard for diminishing the symptoms and enhancing the “quality of life” of pregnant women. The study supports that this approach should be additionally researched in forthcoming randomized studies of big populations to ensure the conclusions in effectiveness and the scarcity of unfavorable effects. It is straightforward to involve matters in a reasonable technique that can reduce the condition of medications (Su et al. 2021). This “quasi-randomized” study of 61 women counts as additional proof of the impact and security of acupuncture in the low back and “pelvic pain during pregnancy”.

In addition to this it can be stated that the meta-analysis process was completed without the glitch of much of the process, there were some limitations regarding the datasets of the selected articles that were used for the analysis of the report. First of all, the articles that were selected contained datasets regarding pregnant women with LBP issues. But, the datasets were inconsistent and incomplete. There were also issues regarding the different protocols of acupuncture treatment followed. But, since all kinds of articles were selected for the analysis, the section for the analysis gets complicated (Butelet al. 2019). That causes some doubts regarding the work. It's essential to acknowledge any limitations of the systematic review, such as the availability of a limited number of high-quality studies or potential biases in the included studies. In summary, a systematic review of therapeutic exercise and acupuncture for low back pain during pregnancy requires a meticulous and impartial approach to examining existing research. It aims to provide a comprehensive understanding of the topic, enabling healthcare professionals and policymakers to make informed decisions about the use of these interventions in clinical practice for pregnant women experiencing low back pain. With the broad explanation of this, it can be merged that complete detail on the items in systematic reviews could provide researchers with a fair and innovative assessment of clinical heterogeneity and give medical professionals more confirmation when applying the appropriate proof in their everyday practice. Where there is little harmony, it may also create it additionally effortless to position embodiments for assessing the effectiveness of acupuncture.

Strength overview

Researchers made their full effort to reduce the chance of prejudice in each and every stage for this overview. To identify the literature, researchers used comprehensive, systemic independent research strategies with valuable databases without the restriction of languages and date of publication. Although, data synthesis that researchers confirmed by the LBP chronicity, as well as control comparisons, and outcome measures for addressing the heterogeneity influence.

Explain the need for meta-analysis

In this study, it is clearer that “Therapeutic exercises” and “Acupuncture” are two extremely varied prospects for alleviating pains, toughening the strengths of muscles, and enhancing mobility in the patient's body (Butelet al. 2019). It can also be stated that therapeutic exercise is a state of physical treatment in which a patient is specified typical exercises which are required for their distinguishing particular needs. The practices obliged a detailed explanation for the enhancement of critical exploration. The main findings of the study are entails the major parameters that are the key findings of the basic proportion of the scale of back pain.

Implications for Practice and Research

Researchers were unable to draw definite conclusions about the efficacy to maintain the process. Consistent evidence for chronic LBP reveals that acupuncture is superior to no treatment or when combined with other conventional therapies for pain alleviation and functional improvement at short-term follow-ups, these outcomes had medium to substantial clinical impact (Butelet al. 2019). According to these results, it is heartening to highlight that acupuncture has been shown to be an efficient clinical alternative for patients with chronic LBP and should be promoted in regular clinical practice, whether it is used alone or as an addition to other interventions. Considering the frequent intractable of LBP should be nature of favorable in the practice. In general, it may be said that "Low back pain" refers to a localized discomfort that affects the lower back and lasts from the time of conception until delivery. According to the study, women who had experienced "low back pain" in the past when pregnant will experience more severe discomfort for roughly 6-7 months of their pregnancy. In addition, the patient's gender, occupation, age, and parity result in a risk of low back discomfort during or after subsequent pregnancies, which appears to be a cause for concern. Although there is evidence to suggest that "low back pain" during pregnancy is discomfort in the "lumbar region," which is situated above the sacrum and may radiate towards the legs. Precautions must be taken at all times throughout pregnancy in order to carry out the essential tasks for caring for the baby. Pregnancy-related alterations to the body include posture abnormalities, weight increase, and musculoskeletal dysfunctions, according to doctors and therapists. Some additional posture is incredibly useful for them to reduce the pain that has formed in their body at this time because pelvic discomfort and low back pain are both fairly common. This study is so enlightening that it aids in comprehending the fundamental needs of the human body. Working with an experienced practitioner to develop the best course of action to manage the situation safely and successfully is the last and most satisfying option.

Relative comparison between the two processes of therapeutic exercises and acupuncture

These entail physical exercises and activities intended to build muscles, increase flexibility, and improve all-around physical performance (Su et al. 2021). Exercises are frequently customized to the demands and conditions of the individual. Therapeutic exercises are usually accessible and economically priced because they can be performed at home or in a physical therapy center. Acupuncture sessions may include greater initial charges and regular follow-up consultations. These usually place a more holistic emphasis on overall physical health and fitness. focuses on particular meridians and places to provide more individualized pain relief (Su et al. 2021). It is thought to ease pain or discomfort and balance the flow of energy (qi). These help to relieve low back pain by strengthening the muscles that support the spine, boosting blood circulation, and enhancing posture.

Acupuncture may relieve low back pain by modulating pain signals, releasing endorphins, and promoting the body's natural healing processes. Therapeutic activities depending on the patient's condition and demands can be highly personalized, with particular exercises being suggested. Although acupuncture points can be adjusted to the patient's condition, the overall procedure is less customized and adheres to traditional principles. Exercises are generally safe during pregnancy when recommended and overseen by licensed healthcare experts. However, faulty execution can cause harm. When administered by qualified, certified professionals with experience treating pregnant patients, acupuncture is regarded as safe. This indicates a distinction between the individuals who received therapy through the acupuncture method and the suggested differences regarding medication-based treatment or no treatment at all. An examination of acupuncture revealed research on the efficacy of therapeutic analysis and acupressure, which is linked to a reduction in discomfort, a reduction in the need for painkillers, and an improvement in operational accommodations. Additionally, the study demonstrated a reduction in pain within the specified time limits for pre-existing pain, indicating modest outcomes. To achieve this goal, compared to the governance group, operational capability in the stages of available actions walking, and operating was noticeably improved following acupuncture. The reports of previous pregnancies, age, and "body mass index" were direct to make the matter highlighted that Therapeutic exercises are usually accessible and economically priced because they can be performed at home or in a physical therapy center. Acupuncture sessions may include greater initial charges and regular follow-up consultations. These usually place a more holistic emphasis on overall physical health and fitness. Focuses on particular meridians and places to provide more individualized pain relief.

A large body of research has been done to support the efficacy of particular exercises in relieving low back pain during pregnancy. Although some studies have indicated that acupuncture may help with low back pain, the evidence is not as strong as it is for therapeutic exercises. Exercises for therapeutic purposes can frequently be done at home or in a physical therapy setting, making them reasonably accessible and affordable.

Consistent follow-up consultations and higher initial costs are possible with acupuncture sessions. These frequently focus on general physical fitness and well-being with a more holistic approach. Targets pain relief at a more localized level by concentrating on specific sites and meridians. These help to relieve low back pain by strengthening the muscles that support the spine, boosting blood circulation, and enhancing posture. Acupuncture may relieve low back pain by modulating pain signals, releasing endorphins, and promoting the body's natural healing processes. Therapeutic activities depending on the patient's condition and demands can be highly personalized, with particular exercises being suggested. Although acupuncture points can be adjusted to the patient's condition, the overall procedure is less customized and adheres to traditional principles. Exercises are generally safe during pregnancy when recommended and overseen by licensed healthcare experts. However, faulty execution can cause harm. When administered by qualified, certified professionals with experience treating pregnant patients, acupuncture is regarded as safe. This indicates a distinction between the individuals who received therapy through the acupuncture method and the suggested differences regarding medication-based treatment or no treatment at all. An examination of acupuncture revealed research on the efficacy of therapeutic analysis and acupressure, which is linked to a reduction in discomfort, a reduction in the need for painkillers, and an improvement in operational accommodations. Additionally, the study demonstrated a reduction in pain within the specified time limits for pre-existing pain, indicating modest outcomes. To achieve this goal, compared to the governance group, operational capability in the stages of available actions walking, and operating was noticeably improved following acupuncture. The reports of previous pregnancies, age, and "body mass index" were direct to make the matter highlighted that Therapeutic exercises are usually accessible and economically priced because they can be performed at home or in a physical therapy center. Acupuncture sessions may include greater initial charges and regular follow-up consultations. These usually place a more holistic emphasis on overall physical health and fitness. Focuses on particular meridians and places to provide more individualized pain relief. A large body of research has been done to support the efficacy of particular exercises in relieving low back pain during pregnancy. Although some studies have indicated that acupuncture may help with low back pain, the evidence is not as strong as it is for therapeutic exercises. Exercises for therapeutic purposes can frequently be done at home or in a physical therapy setting, making them reasonably accessible and affordable. Consistent follow-up consultations and higher initial costs are possible with acupuncture sessions. These frequently focus on general physical fitness and well-being with a more holistic approach. Targets pain relief at a more localized level by concentrating on specific sites and meridians.

From a critical point of view can explore that decision to use acupuncture or therapeutic exercises for low back pain during pregnancy should take into account the patient's preferences, the severity of the condition, and advice from a healthcare professional. To attain the best possible pain management and general well-being throughout pregnancy, some people may profit from combining the two methods.

This study makes it more apparent that "Therapeutic exercises" and "Acupuncture" are two very different options for reducing pain, boosting muscle strength, and improving patient mobility. It is also possible to define therapeutic exercise as a form of physical therapy in which a patient is given instructions on standard exercises that are necessary for their unique set of needs. In order to improve a patient's level of physical and muscular function and lessen discomfort, certain techniques are required. Pulling, supporting, and various balance exercises are included in the list of possible workouts. These may involve the use of bands, foam rollers, or weight lifters.

In contrast to it, acupuncture is a traditional Chinese medical practice that was founded on the idea of energy flow. An acupuncturist can stimulate certain spots on the body to stimulate or impede the body's inherent healing process using needles, force, heat, or laser stimulators. There are some similarities and some differences when comparing therapeutic activities and acupuncture as treatments. Both procedures enhance mobility and biological function while supporting a reduction in pain intensity. Both methods can improve quality of life and be used to treat a variety of medical conditions, from severe arthritis damage to sports injuries. The difference is that each method uses a separate strategy to accomplish the same task.

In the article of Nicolian 2019, the major gap is shown in the 1:1 randomization method to calculate standard care or acupuncture procedure. This was the major cause of the failure to calculate the findings in this study.

The article of João, 2004 shows the data insufficiency in the calculation procedure which would be helpful for indepth analysis of the pain measurements in pregnent women. As per the view of this article researchers can offer pregnant women and healthcare professionals strong data on the effectiveness, safety, and best practises for acupuncture in addressing low back pain during pregnancy by filling this literature gap (Bourbeauet al,2020). This would make it possible to make an educated judgement about whether to include acupuncture as a therapy option in the all-encompassing care of pregnant women with low back pain. This item has been examined for a variety of needs and groups, such as non-pregnant people with low back pain, however pregnant women frequently have special physiological and safety concerns that call for particular examination (Buzasiet al,2022).

4.2 Limitations

4.2.1 Limitationss of the articles selected for meta-analysis

The study design of Bosco et al. 2004 has certain limitations in their station. The management of patients has shown that it could not support the acupuncture intervention. In order to reduce bias researcher minimized the contact between the therapist and interviewer, and talked to the pregnant women about bias (Bosco et al. 2004). The acupuncture group received more attention.

The lack which is highlighted in the article by Butelet al. 2019, expressed that the “Oswestry score” had the benefit of protecting a politely wide spectrum of movements, including individual care, pinching, walking, standing, social life, sitting, and traveling (Butelet al. 2019). Although this study has shown that pregnant women with severe to moderate “low back pain” along with the additional features like those selected to participate in the process of meta-analysis have shown different psychological tendencies to profit from acupuncture than those who did not display that.

4.2.2 Limitations of the complete analysis

Although, the meta-analysis process was completed without the glitch of much of the process, there were some limitations regarding the datasets of the selected articles that were used for the analysis of the report. First of all, the articles those were selected had contained datasets regarding the pregnant women with LBP issues. But, the datasets were inconsistent, and incompleted. There was also issues regarding the different protocol of acupuncture treatment followed. But, since all kinds of articles were selected for the analysis, the section for the analysis gets complicated. That causes some doubts regarding the work.

4.3 Future work

In this study, future analysis should concentrate on investigating the effectiveness of various sorts of therapeutic exercises specially customized for the therapy of “low back pain” during pregnancy. In-depth illustration, it may be valuable to correspond and compare the significance of aerobic exercises such as jogging, swimming, walking, and yoga for treating “low back pain” in pregnant women (Sultana et al. 2022). Moreover, the investigation should also be accomplished on the effectiveness of integrating therapeutic movement with acupuncture for the therapy of pregnant women with low back pain. This could deliver significant insight into how these two modalities can connect and support each other in furnishing reassurance for low back pain. Here, large-scale clinical trials must be performed in terms to define any additional generalizable effects of these treatments. Furthermore, it is important to investigate to what extent certain pre-existing factors, such as overall physical fitness and age, may influence the efficacy of therapeutic exercise and acupuncture for the treatment of low back pain during pregnancy (Sultana et al. 2022). Finally, additional research should concentrate on investigating the long-term effects of these two modalities for treating low back pain in pregnant women, and how the relief provided during the course of pregnancy might translate to benefits after the birth of the child.

4.4 Summary

In summation, this study aimed to estimate the significance and effectiveness of “therapeutic exercise” as well as “acupuncture” in facilitating a rating of severe to moderate levels of the treatment of low back pain in pregnant women. The study assembled and investigated data from numerous prior studies to supply a comprehensive overview of this matter. Although it is prominent that low back pain is a common complaint during pregnancy, affecting a significant number of women. It can have a negative impact on their quality of life and daily activities. Therefore, finding effective treatment options is crucial. For the initiation of meta-analysis, there are four different articles selected, those should be related to the acupuncture and therapeutic exercise treatments. From those selected articles, relevant data about the acupuncture and therapeutic exercise. The meta-analysis included studies that compared therapeutic exercise or acupuncture with control groups (such as no treatment or placebo) in pregnant women experiencing low back pain (Wang et al. 2023). The researchers assessed the outcomes by measuring pain intensity, functional disability, and overall improvement. The results of the meta-analysis indicated that both therapeutic exercise and acupuncture showed significant effectiveness in reducing low back pain during pregnancy. The studies were those that were selected for the completion of meta-analysis. Therapeutic exercise interventions included a variety of exercises targeting the lower back and pelvic muscles, aiming to improve strength, flexibility, and posture.

Women who were at high risk of miscarriage (those who had previously experienced three or more recurrent miscarriages; those who had cervix abnormalities considered to increase miscarriage risk; those who had antiphospholipid syndrome; those who had lupus anticoagulant); and those who were at high risk of pre-term labor (those who had previously delivered before 37 weeks) (Zhang et al. 2023). Additionally, subgroup analyses were performed to look at the outcomes of various acupuncture and exercise regimens. It was discovered that a number of exercise regimens, including supervised group exercise, aquatic exercise, and home exercise, all had a positive impact on the reduction of low back pain. Similarly to this, several acupuncture methods, such as manual and electroacupuncture, were successful in relieving pain. Overall, this meta-analysis offers compelling evidence in favor of acupuncture and therapeutic exercise as effective treatments for low back pain during pregnancy. These non-pharmacological methods for treating pain offer secure and reliable substitutes for drug therapy while avoiding potential side effects. To guarantee the best results for pregnant women, it is crucial to remember that individualized treatment regimens should be created in conjunction with medical experts.

Acupuncture is said to benefit expectant mothers by enhancing the balance of the body's connection, which is essential for the healthy growth of the fetus and the improvement of the mother's health. Thus, acupuncture offers pregnant women several advantages by easing the frequent aches associated with pregnancy-related disorders like headaches, nausea, and exhaustion. Acupuncture can also force expectant mothers to recognize the good changes in their bodies that result from pregnancy, such as improved circulation and relaxed muscles (Karjalainen et al., 2022). In contrast, therapeutic exercise is a vitally important component of any comprehensive prenatal care strategy. Therapeutic activities, therefore, improved the posture, balance, awareness, and muscle strength of pregnant women's bodies.

In conclusion, it can be said that the method of acupuncture and therapeutic exercise are easy, and impactful methods of treatment for the pregnanat women. The literature review section had evaluated four different articles that examined the impact of acupuncture and therapeutic exercises for the treatment of pregnant women (Nitalessy, 2023. It was found that the methods are almost 45% more impactful over the traditional medical processes. In this section, a flow diagram of the selected articles were also created, and which also mentioned about different inclusion and exclusion criteria. Thus, conducting research on pregnant women involves ethical considerations due to the potential risks to both the mother and the developing fetus (Chiarottoet al, 2022). These ethical concerns may contribute to the scarcity of studies focusing on acupuncture for low back pain during pregnancy. Researchers must ensure that study designs adhere to rigorous ethical standards and prioritize the well-being of both the pregnant participants and their unborn children. The results of the q-test, z-test, and mean differences for the statistical analysis indicated that, the acupuncture was proven to be more effective for the treatment of the pregnant women, in comparison to the traditional medication treatments.

Chapter 5: Discussion of Finding

5.1 Primary Analysis

In total, 4 articles were found in the databases as a searched, to analyze the data. In this cohort, the author honored an incidence of 77% (61/79), a ratio that coordinates with derivatives. What do you mean?? A study of acupuncture demonstrated that investigation for the effectiveness of therapeutic analysis and acupressure which is associated with a consequential contraction of discomfort, decreased the requirement for painkillers, and enhanced operational accommodation. The study also showed that pain decreased in the provided time frames of existing pain; which shows moderate results. In order to this objective, operational capability in stages of available actions, walking, and operating, were remarkably enhanced after acupuncture compared with the governance group. Based on the number of prior pregnancies reports, age, and “body mass index” were identical in the two groups while comparing, banning them for the justification for the dissimilarities between the developments. None of this makes sense!

You need to start off this chapter by mentioning the main findings of your results! And then discussing in detail what the main findings mean!

As per this study, acupuncture seems to be an influential standard for diminishing the symptoms and enhancing the “quality of life” of pregnant women. The study supports that this approach should be additionally researched in forthcoming randomized studies of big populations to ensure the conclusions in effectiveness and the scarcity of unfavorable effects. It is straightforward to involve matters in a reasonable technique that can reduce the condition of medications (Su et al. 2021). This “quasi-randomized” study of 61 women counts as additional proof of the impact and security of acupuncture in the low back and “pelvic pain during pregnancy”.

In this article by Butelet al. 2019, pregnant women who are suffering from pelvic girdle pain and “low back pain” engaged with acupuncture in development to systematic care expressed less pain and disability than those patients who received systematic care independently. Acupuncture with routine care overwhelmed “(cheaper and more effective)” routine care independently from the attitude of the organization and costs an additional for the individual with a pain score of 4 from the philosophy of the clinic (Butelet al. 2019). From the societal attitude, the more elevated healthcare expenses of acupuncture exist counterbalanced by lower avoiding costs from their work. The result of the systemic review showed the application of physical therapy like therapeutic exercise or acupressure during pregnancy low back pain relief.

The article by Elden et al. 2005 shows the main findings of this study which highlighted that the exercises were planned to influence especially the regional strength approach, on the basis of transnational stabilizing muscle exercises which could have furnished the same consequence in this study. Still, the study highlighted that there were no significant discrepancies exist between present suggestions about stabilization pieces of training and the activities given in the study. This study demonstrates that processes of structured physiotherapy may be influential in dining pelvic girdle pain in the time of pregnancy and that acupuncture illustrates an influential alternative. In a similar way to this exercise were found to be very common practices that are used to decline the LBP and the majority of the relative study category shows that meta-analysis has a significant study or analysis in the participants.

Most of this section does not make sense! You need to clear about what the main findings of your SR and meta analysis were! What did the SR findings show? What did the meta analysis of the data show? What were the main things you found out? What do they mean? How does other literature support/ not support what you found? What are the clinical implications of your findings?

5.2 Limitations

Organise the above into limitations of the studies in the SR and then the limitations of what you did!

5.3 Future work

5.4 Summary

In summation, this study aimed to estimate the significance and effectiveness of “therapeutic exercise” as well as “acupuncture” in facilitating a rating of severe to moderate levels of the treatment of low back pain in pregnant women. The study assembled and investigated data from numerous prior studies to supply a comprehensive overview of this matter. Although it is prominent that low back pain is a common complaint during pregnancy, affecting a significant number of women. It can have a negative impact on their quality of life and daily activities. Therefore, finding effective treatment options is crucial. What did you do for the SR? The meta-analysis included studies that compared therapeutic exercise or acupuncture with control groups (such as no treatment or placebo) in pregnant women experiencing low back pain (Wang et al. 2023). The researchers assessed the outcomes by measuring pain intensity, functional disability, and overall improvement. The results of the meta-analysis indicated that both therapeutic exercise and acupuncture showed significant effectiveness in reducing low back pain during pregnancy. (Which studies? References) Therapeutic exercise interventions included a variety of exercises targeting the lower back and pelvic muscles, aiming to improve strength, flexibility, and posture. Acupuncture involved the insertion of thin needles into specific points on the body to stimulate pain relief and restore balance.remove

Your summary needs to be aim, what you did and the main methods, main results, main findings and their clinical implications! The information above does not belong in the summary!!

5.5 Conclusion Not needed!

The chapter provides solid evidence where data analysis of this chapter is interpreted and depicted in a good manner.” The input data of data analysis shows that common effect size is the statistical concept that measures the muscle of the relationship between the two variables on a numeric scale”. It also depicts the different sample sizes of various studies, which integrate into a single analysis. it was discovered that the “z-value” for the null hypothesis calculated from the analysis, had an effect size of 0. Whereas, the “z-value” in connection to the “p-value<0.001” was “-5.747”. Thus this study is highly significant to investigate more deeply to obtain the desired result for relief from low back pain. Move this to the results section for the meta analysis!

Chapter 6: Conclusion and Recommendation

6.1 Introduction

The conclusion of the entire chapter is provided in this chapter. Also, the chapter comprises linking with objectives, and recommendations to improve the appropriate therapeutic application process that is helpful in reducing low back pain the pregnant women and also depending on the limitation or gaps in the research in the purpose of development in the relief process as corresponding find outs. Not clear!

6.2 Linking with Objectives These below were not your objectives!! You need to move some of the information below into the appropriate sections ie the discussion section!

Impact of acupressure in comparison to medical treatment processes.

The influence of modern advanced therapies for the purpose of medical treatment procedures and natural remedies for low back pain in pregnancy cannot be ignored although the effectiveness of each approach will vary in each individual case (Koukoulithraset al. 2021). Medical therapy for low back pain in gestation generally consists of prescription, physical therapy, and, in some matters, surgery. Medication is normally prescribed to reduce inflammation or to address pain, while physical therapy can help address underlying issues and help with postural correction. In more severe cases, surgery may be recommended to repair any damaged tissue or alignment issues in the lower back (Nielsen and Wieland 2019). In contrast to medical treatment, using natural remedies for low back pain during pregnancy is becoming increasingly popular. These remedies include exercises that improve flexibility, posture, and core strength; maintaining a healthy weight; stress reduction; and proper hydration, nutrition, and sleep. These methods are beneficial for both preventing and treating low back pain, and they empower pregnant women to take an active role in managing their own pain. It is important to note that no single approach is a "one size fits all" solution for low back pain in pregnancy. While many women find relief from medical treatments such as medication and physical therapy, others may achieve greater relief from natural remedies (Koukoulithraset al. 2021). Ultimately, the most satisfactory path of action is to work with a skilled practitioner to create the most suitable plan of action to safely and effectively manage the low back pain of pregnant women. In addition to medical and natural treatments, women should also practice self-care, including taking breaks from activities that may worsen the pain and increasing the comfort of their resting position. By addressing the underlying issues causing the pain, pregnant women can find relief from their low back pain and maximize their physical and emotional health.

During the time of pregnancy, it is a more elevating time when precautions are a must to take all the primary actions for taking care of babies. Doctors and therapists generally suggest that several changes like postural adjustments, weight gain, and musculoskeletal dysfunctions are very common in the pregnant woman's body. At this time pelvic pains and low back are very frequent some extra posture is really helpful for them to control the pain that has arisen in their body. This research is very much informative that it helps to understand the basic requirement of the body. Finally, the most satisfactory path of action is to work with a skilled practitioner to create the most suitable plan of action to safely and effectively manage the low back pain of pregnant women. In order to explore medical and biological treatments, pregnant women must also rehearse self-care, including enduring vacations from movements that may lead to deteriorating pain levels and supplementing the consolation of their resting position.

Relative comparison between the two processes of therapeutic exercises and acupuncture

In this study, it is clearer that “Therapeutic exercises” and “Acupuncture” are two extremely varied prospects for alleviating pains, toughening the strengths of muscles, and enhancing mobility in the patient's body. It can also be stated that therapeutic exercise is a state of physical treatment in which a patient is specified typical exercises which are required for their distinguishing particular needs. These practices oblige to enhance a patient's level of physical and muscular function in terms of reducing pain. Exercises can incorporate pulling, supporting, and different balancing exercises, which may include the usage of, bands, foam rollers, or weights lifter.

Similarly, in comparison with it, acupuncture is an ancient form of Chinese medicine, developed on the basis of the concept of energy flow. Through the application of needles, force, warmth, or laser stimulators, an acupuncturist can promote distinctive points on the body that promote or capitulate the body's biological healing process. In the cases of comparing therapeutic exercises and acupuncture as medicines, there are some resemblances and some distinctions. Both procedures support diminishing pain intensity and improve mobility and biological function. Both techniques can enhance the quality of life, and they can both be utilized to treat an assortment of medical situations like major damages from arthritis to sports injuries. The distinction is that each procedure takes a distinguishable technique to perform an identical result. Therapeutic exercise is more easy, fine, and more comfortable, which involves a physical therapist directly manipulating the patient to perform specific exercises. Similarly, it can also be stated that acupuncture is slightly complicated, which concerns the usage of needles inserted at specific points to stimulate the body's natural healing mechanisms. Ultimately, the decision of which approach to take should come down to the individual needs of the patient. Each approach has its own benefits and drawbacks, so it is important to get a medical professional's opinion before deciding. Additionally, some patients may benefit more from one approach than another, so it is important to keep an open mind when considering both options. For example, some patients may see better results from therapeutic exercises, while others may experience better results from acupuncture. In the end, the decision should be tailored to the specific individual needs of the patient.

Evaluation of the acupuncture process

Acupuncture and therapeutic exercises are two of the most common types of non-invasive and drug-free treatments used to help pregnant women identify both positives and negatives in their bodies. This study explores that acupuncture and therapeutic exercises both are evolving rapidly with a special reference to pregnant women to treat hurting situations viz lower back pain, pelvic pain, and musculoskeletal pain. Furthermore, acupuncture and therapeutic exercises can support one another in aiding pregnant women to identify the way by which their body is transforming throughout the procedure of their pregnancy. Acupuncture or acupressure affects the insertion of syringes into specific areas throughout the body in order to promote healing and balance of the body’s energy (Karjalainenet al. 2022). It is believed that acupuncture can help pregnant women by heightening the balance of the body’s connection which is necessary for the healthy development of the fetus and the better health of the mother. Acupuncture thus provides multiple benefits to pregnant women relieving the common aches attending pregnancy issues such as headaches, nausea, and fatigue. Besides this, acupuncture can oblige pregnant women to identify the positive transformations that happen in their body during pregnancy, such as increased circulation as well as relaxation of the musculoskeletal system (Karjalainenet al. 2022). In comparison with this therapeutic exercises is a critically influential part of any extensive prenatal care plan. Therapeutic exercises thus influenced pregnant women’s bodies to improve their posture, physical balance, physical awareness, and muscle strength to decrease low back pain. It can correspondingly support pregnant women to determine absolute postural and structural modifications that happen in their bodies during the period of pregnancy.

Positive and Negative Outcomes of Acupressure and therapeutic exercises

In broadly it can be stated that “Low back pain” is the regional ache that is supposed for the lower back region and will endure throughout the pregnancy period until the postnatal period. The study demonstrated that pregnant women with a record of “low back pain” will encounter more intense discomfort during the time of almost 6-7 months of their pregnancy (Guoet al. 2023). Additional risk characteristics or key factors viz the patient’s gender, occupation, age, and parity outcome in the risk of low back pain during or future pregnancies time which seems to be a concern. Although various supporting evidence stated that “low back pain” in pregnancy is represented as discomfort in the “lumbar region”, which is located at the above portion of the sacrum and may be radiated to the legs. Sometimes this pain is periodical and is aggravated by accomplishing movements in the identical assignment for a long time, usually happening within 30 minutes of those movements viz walking, standing, and sitting.

6.3 Recommendations

Evaluating various limitations in the patient’s body there are some recommendations or suggestions that are needed or required to be improved in terms of achieving the best result in the patient’s body. Firstly, depending on the patient’s condition “therapeutic exercise” delivers effective comfort from continuous low back pain which is caused by the suitable engagement of the posterior back muscles as well as the strengthening of the body muscles. In terms of achieving the highest advantage of these medicinal exercises, pregnant women should consult a professional physical therapist for applying appropriate exercise selection and proper form of execution. Acupuncture or exercises should improve posture, take pressure off the ligaments and muscles of the lower back, and increase strength and balance. It is also important to accomplish muscle stretches for the hamstrings, hip flexors, and glutes, as this will reduce tension in the lower back or pelvis and alleviate discomfort.

Secondly, acupuncture should be applied with the help of an acupuncture specialist as it totally depends on the patient’s current physical condition. In that case, acupressure can be applied as a, method of supplementation.

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6.4 Conclusion

A summary of the entire chapter is provided in this chapter. The evaluations have been strategically comprised to compare and contrast the research questions and objectives that are applicable to the analysis of this chapter. Here, linking with objectives determined how the effectiveness of acupressure and therapeutic exercise can stimulate the reduction of the low in pregnant women’s body. The research also emphasizes the different aspects of the application of different viewpoints regarding therapeutic exercise and acupressure which help to decide the effectiveness of one particular thing that is more suitable in a patient’s body. Moreover, the required recommendations for further investigation have also been furnished in this chapter to obtain the best and most suitable result. This is not a conclusion! A conclusion is you main finding! What was the main finding? And what does it mean and what are the clinical implications and what else needs to be done?

You need to pay attention to what you are writing and the structure and flow of information n the sections! A lot of the information is in the wrong places and you need to remove conclusions from every chapter. Please organize your work properly and pay attention to the feedback.

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